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Issue 13, March 28, 2023

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CDC Science Clips: Volume 15, Issue 13, March 28, 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.
    • Chronic Diseases and Conditions
      1. The World Trade Center Health Program: Cancer screening and cancer care best practices
        Calvert GM, Lilly G, Cochran J.
        Arch Environ Occup Health. 2023 :1-7.
        The events of September 11, 2001 (9/11) exposed nearly a half million persons to many carcinogenic chemicals and dusts, as well as psychological and physical stressors. Subsequent epidemiologic studies of 9/11-exposed persons have suggested elevated risks for some cancers, e.g., prostate cancer, thyroid cancer, and melanoma. To detect cancer at an early stage, the US Preventive Services Task Force recommends screening certain asymptomatic persons for lung, colorectal, cervical and breast cancer, but not for other cancers. High quality cancer diagnosis and treatment guidelines are available from the National Comprehensive Cancer Network and the National Cancer Institute. For enrolled members, the WTC Health Program provides coverage for cancer screening and diagnosis, and covers medically necessary treatment costs for all types of cancer, assuming 9/11-exposure and minimum latency requirements are met, and a Program-affiliated physician attests that 9/11 exposures were substantially likely to have been a significant factor in aggravating, contributing to, or causing the enrolled WTC member's cancer.

      2. Variation in early anakinra use and short-term outcomes in multisystem inflammatory syndrome in children
        Chang JC, Young CC, Muscal E, Sexson Tejtel SK, Newhams MM, Kucukak S, Crandall H, Maddux AB, Rowan CM, Halasa NB, Harvey HA, Hobbs CV, Hall MW, Kong M, Aguiar CL, Schuster JE, Fitzgerald JC, Singh AR, Wellnitz K, Nofziger RA, Cvijanovich NZ, Mack EH, Schwarz AJ, Heidemann S, Newburger JW, Zambrano LD, Campbell AP, Patel MM, Randolph AG, Son MB.
        Arthritis Rheumatol. 2023 .
        OBJECTIVE: Evidence regarding effectiveness of interleukin-1 receptor antagonism in Multisystem Inflammatory Syndrome in Children (MIS-C) is lacking. We characterized variation in initial treatment with anakinra and evaluated cardiovascular outcomes associated with adding anakinra to standard initial therapy. METHODS: We conducted a retrospective cohort study of MIS-C cases in a U.S. surveillance registry November 2020-December 2021. Day 0 was the first calendar day of immunomodulatory treatment. Factors associated with initial anakinra use (days 0-1) were identified. We compared cases ages 2-20 years receiving intravenous immunoglobulin (IVIG) and glucocorticoids vs. anakinra plus IVIG and/or glucocorticoids (days 0-1), using inverse probability weighting to balance severity. Primary outcomes were vasopressor requirement (day 3) and impaired left ventricular ejection fraction (days 3-4). The secondary outcome was 50% reduction in C-reactive protein (day 3). RESULTS: Among 1516 MIS-C cases (44 sites), 193 (13%) received anakinra alone or with other immunomodulators as initial treatment (range 0-74% by site). Site accounted for 59% of residual variance in anakinra use. After balancing severity, initial treatment with anakinra plus IVIG and/or glucocorticoids (N=121) vs. IVIG and glucocorticoids (N=389) was not associated with significant differences in vasopressor requirement (25.6% vs. 20.1%; RR 1.27, 95% CI [0.88-1.84]), ventricular dysfunction (33.7% vs. 25.7%; RR 1.31, 95% CI [0.98-1.75]), or C-reactive protein reduction. CONCLUSIONS: We identified substantial variation in initial anakinra use in a real-world population of children with MIS-C, but no average short-term improvement in cardiovascular outcomes associated with early addition of anakinra to IVIG and/or glucocorticoids compared to IVIG and glucocorticoids alone.

    • Communicable Diseases
      1. Evidence of mpox virus infection among persons without characteristic lesions or rash presenting for first dose of JYNNEOS vaccine-District of Columbia, August 2022
        Ogale YP, Baird N, Townsend MB, Berry I, Griffin I, Lee M, Ashley P, Rhodes T, Notigan T, Wynn N, Kling C, Smith T, Priyamvada L, Carson WC, Navarra T, Dawson P, Weidle PJ, Willut C, Mangla AT, Satheshkumar PS, Hutson CL, Jackson DA, Waltenburg MA.
        Clin Infect Dis. 2023 .
        We assessed mpox virus prevalence in blood, pharyngeal, and rectal specimens among persons without characteristic rash presenting for JYNNEOS vaccine. Our data indicate that the utility of risk-based screening for mpox in persons without skin lesions or rash via pharyngeal swabs, rectal swabs, and/or blood is likely limited.

      2. Uptake and continuation of HIV pre-exposure prophylaxis among women of reproductive age in two health facilities in Kisumu County, Kenya
        Ogolla M, Nyabiage OL, Musingila P, Gachau S, Odero TM, Odoyo-June E, Ochanda B, Appolonia A, Katiku E, Joseph R, Ogolla C, Otieno L, Odhiambo F, Truong HM.
        J Int AIDS Soc. 2023 ;26(3):e26069.
        INTRODUCTION: In 2020, Kenya had 19,000 new HIV infections among women aged 15+ years. Studies have shown sub-optimal oral pre-exposure prophylaxis (PrEP) use among sub-populations of women. We assessed the uptake and continuation of oral PrEP among women 15-49 years in two health facilities in Kisumu County, Kenya. METHODS: A retrospective cohort of 262 women aged 15-49 years, initiated into oral PrEP between 12 November 2019 and 31 March 2021, was identified from two health facilities in the urban setting of Kisumu County, Kenya. Data on baseline characteristics and oral PrEP continuation at months 1, 3 and 6 were abstracted from patient records and summarized using descriptive statistics. Missing data in the predictor variables were imputed within the joint modelling multiple imputation framework. Using logistic regression, we evaluated factors associated with the discontinuation of oral PrEP at month 1. RESULTS: Of the 66,054 women screened, 320 (0.5%) were eligible and 262 (82%) were initiated on oral PrEP. Uptake was higher among women 25-29 years as compared to those 15-24 years (77% vs. 33%). Oral PrEP continuation declined significantly with increasing duration of follow-up; 37% at month 1, 21% at month 3 and 12% at month 6 (p<0.05). In the adjusted analysis, women 15-24 years had lower adjusted odds of continuing at month 1 than women ≥25 years (adjusted odds ratio [aOR]: 0.41, 95% CI: 0.21-0.82). There was no association between being sero-discordant and continuation of oral PrEP at month 1 (aOR; 1.21, 95% CI 0.59-2.50). Women from the sub-county hospital were more likely to continue at month 1 of follow-up compared to women enrolled in the county referral hospital (aOR 5.11; 95% CI 2.24-11.70). CONCLUSIONS: The low eligibility for oral PrEP observed among women 15-49 years in an urban setting with high HIV prevalence calls for a review of the screening process to validate the sensitivity of the screening tool and its proper application. The low uptake and continuation among adolescent girls and young women underscores the need to identify and address specific patient- and facility-level barriers affecting different sub-populations at risk for HIV acquisition.

      3. Automating case reporting of chlamydia and gonorrhea to public health authorities in Illinois clinics: Implementation and evaluation of findings
        Mishra N, Grant R, Patel MT, Guntupalli S, Hamilton A, Carr J, McKnight E, Wise W, deRoode D, Jellison J, Collins NV, Pérez A, Karki S.
        JMIR Public Health Surveill. 2023 ;9:e38868.
        BACKGROUND: Chlamydia and gonorrhea cases continue to rise in Illinois, increasing by 16.4% and 70.9% in 2019, respectively, compared with 2015. Providers are required to report both chlamydia and gonorrhea, as mandated by public health laws. Manual reporting remains a huge burden; 90%-93% of cases were reported to Illinois Department of Public Health (IDPH) via electronic laboratory reporting (ELR), and the remaining were reported through web-based data entry platforms, faxes, and phone calls. However, cases reported via ELRs only contain information available to a laboratory facility and do not contain additional data needed for public health. Such data are typically found in an electronic health record (EHR). Electronic case reports (eCRs) were developed and automated the generation of case reports from EHRs to be reported to public health agencies. OBJECTIVE: Prior studies consolidated trigger criteria for eCRs, and compared with manual reporting, found it to be more complete. The goal of this project is to pilot standards-based eCR for chlamydia and gonorrhea. We evaluated the throughput, completeness, and timeliness of eCR compared to ELR, as well as the implementation experience at a large health center-controlled network in Illinois. METHODS: For this study, we selected 8 clinics located on the north, west, and south sides of Chicago to implement the eCRs; these cases were reported to IDPH. The study period was 52 days. The centralized EHR used by these clinics leveraged 2 of the 3 case detection scenarios, which were previously defined as the trigger, to generate an eCR. These messages were successfully transmitted via Health Level 7 electronic initial case report standard. Upon receipt by IDPH, these eCRs were parsed and housed in a staging database. RESULTS: During the study period, 183 eCRs representing 135 unique patients were received by IDPH. eCR reported 95% (n=113 cases) of all the chlamydia cases and 97% (n=70 cases) of all the gonorrhea cases reported from the participating clinical sites. eCR found an additional 14 (19%) cases of gonorrhea that were not reported via ELR. However, ELR reported an additional 6 cases of chlamydia and 2 cases of gonorrhea, which were not reported via eCR. ELR reported 100% of chlamydia cases but only 81% of gonorrhea cases. While key elements such as patient and provider names were complete in both eCR and ELR, eCR was found to report additional clinical data, including history of present illness, reason for visit, symptoms, diagnosis, and medications. CONCLUSIONS: eCR successfully identified and created automated reports for chlamydia and gonorrhea cases in the implementing clinics in Illinois. eCR demonstrated a more complete case report and represents a promising future of reducing provider burden for reporting cases while achieving greater semantic interoperability between health care systems and public health.

      4. Mpox respiratory transmission: the state of the evidence
        Beeson A, Styczynski A, Hutson CL, Whitehill F, Angelo KM, Minhaj FS, Morgan C, Ciampaglio K, Reynolds MG, McCollum AM, Guagliardo SA.
        Lancet Microbe. 2023 .
        The relative contribution of the respiratory route to transmission of mpox (formerly known as monkeypox) is unclear. We review the evidence for respiratory transmission of monkeypox virus (MPXV), examining key works from animal models, human outbreaks and case reports, and environmental studies. Laboratory experiments have initiated MPXV infection in animals via respiratory routes. Some animal-to-animal respiratory transmission has been shown in controlled studies, and environmental sampling studies have detected airborne MPXV. Reports from real-life outbreaks demonstrate that transmission is associated with close contact, and although it is difficult to infer the route of MPXV acquisition in individual case reports, so far respiratory transmission has not been specifically implicated. Based on the available evidence, the likelihood of human-to-human MPXV respiratory transmission appears to be low; however, studies should continue to assess this possibility.

      5. Gaps and disparities in chronic hepatitis B monitoring and treatment in the United States, 2016-2019
        Pham TT, Toy M, Hutton D, Thompson W, Conners EE, Nelson NP, Salomon JA, So S.
        Med Care. 2023 ;61(4):247-253.
        BACKGROUND: Chronic hepatitis B (CHB) carries an increased risk of death from cirrhosis and hepatocellular carcinoma (HCC). The American Association for the Study of Liver Diseases recommends patients with CHB receive monitoring of disease activity, including ALT, hepatitis B virus (HBV) DNA, hepatitis B e-antigen (HBeAg), and liver imaging for patients who experience an increased risk for HCC. HBV antiviral therapy is recommended for patients with active hepatitis and cirrhosis. METHODS: Monitoring and treatment of adults with new CHB diagnoses were analyzed using Optum Clinformatics Data Mart Database claims data from January 1, 2016, to December 31, 2019. RESULTS: Among 5978 patients with new CHB diagnosis, only 56% with cirrhosis and 50% without cirrhosis had claims for≥1 ALT and either HBV DNA or HBeAg test, and among patients recommended for HCC surveillance, 82% with cirrhosis and 57% without cirrhosis had claims for≥1 liver imaging within 12 months of diagnosis. Although antiviral treatment is recommended for patients with cirrhosis, only 29% of patients with cirrhosis had≥1 claim for HBV antiviral therapy within 12 months of CHB diagnosis. Multivariable analysis showed patients who were male, Asian, privately insured, or had cirrhosis were more likely (P<0.05) to receive ALT and either HBV DNA or HBeAg tests and HBV antiviral therapy within 12 months of diagnosis. CONCLUSION: Many patients diagnosed with CHB are not receiving the clinical assessment and treatment recommended. A comprehensive initiative is needed to address the patient, provider, and system-related barriers to improve the clinical management of CHB.

      6. Notes from the field: Increase in pediatric invasive group A streptococcus infections - Colorado and Minnesota, October-December 2022
        Barnes M, Youngkin E, Zipprich J, Bilski K, Gregory CJ, Dominguez SR, Mumm E, McMahon M, Como-Sabetti K, Lynfield R, Chochua S, Onukwube J, Arvay M, Herlihy R.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(10):265-267.

      7. Public health response to clusters of rapid HIV transmission among Hispanic or Latino gay, bisexual, and other men who have sex with men - metropolitan Atlanta, Georgia, 2021-2022
        Saldana C, Philpott DC, Mauck DE, Hershow RB, Garlow E, Gettings J, Freeman D, France AM, Johnson EN, Ajmal A, Elimam D, Reed K, Sulka A, Adame JF, Andía JF, Gutierrez M, Padilla M, Jimenez NG, Hayes C, McClung RP, Cantos VD, Holland DP, Scott JY, Oster AM, Curran KG, Hassan R, Wortley P.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(10):261-264.
        During February 2021-June 2022, the Georgia Department of Public Health (GDPH) detected five clusters of rapid HIV transmission concentrated among Hispanic or Latino (Hispanic) gay, bisexual, and other men who have sex with men (MSM) in metropolitan Atlanta. The clusters were detected through routine analysis of HIV-1 nucleotide sequence data obtained through public health surveillance (1,2). Beginning in spring 2021, GDPH partnered with health districts with jurisdiction in four metropolitan Atlanta counties (Cobb, DeKalb, Fulton, and Gwinnett) and CDC to investigate factors contributing to HIV spread, epidemiologic characteristics, and transmission patterns. Activities included review of surveillance and partner services interview data,(†) medical chart reviews, and qualitative interviews with service providers and Hispanic MSM community members. By June 2022, these clusters included 75 persons, including 56% who identified as Hispanic, 96% who reported male sex at birth, 81% who reported male-to-male sexual contact, and 84% of whom resided in the four metropolitan Atlanta counties. Qualitative interviews identified barriers to accessing HIV prevention and care services, including language barriers, immigration- and deportation-related concerns, and cultural norms regarding sexuality-related stigma. GDPH and the health districts expanded coordination, initiated culturally concordant HIV prevention marketing and educational activities, developed partnerships with organizations serving Hispanic communities to enhance outreach and services, and obtained funding for a bilingual patient navigation program with academic partners to provide staff members to help persons overcome barriers and understand the health care system. HIV molecular cluster detection can identify rapid HIV transmission among sexual networks involving ethnic and sexual minority groups, draw attention to the needs of affected populations, and advance health equity through tailored responses that address those needs.

      8. COVID-19 mortality and progress toward vaccinating older adults - World Health Organization, Worldwide, 2020-2022
        Wong MK, Brooks DJ, Ikejezie J, Gacic-Dobo M, Dumolard L, Nedelec Y, Steulet C, Kassamali Z, Acma A, Ajong BN, Adele S, Allan M, Cohen HA, Awofisayo-Okuyelu A, Campbell F, Cristea V, De Barros S, Edward NV, Waeber A, Guinko TN, Laurenson-Schafer H, Mahran M, Carrera RM, Mesfin S, Meyer E, Miglietta A, Mirembe BB, Mitri M, Nezu IH, Ngai S, Ejoh OO, Parikh SR, Peron E, Sklenovská N, Stoitsova S, Shimizu K, Togami E, Jin YW, Pavlin BI, Novak RT, Le Polain O, Fuller JA, Mahamud AR, Lindstrand A, Hersh BS, O'Brien K, Van Kerkhove MD.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(5):113-118.
        After the emergence of SARS-CoV-2 in late 2019, transmission expanded globally, and on January 30, 2020, COVID-19 was declared a public health emergency of international concern.* Analysis of the early Wuhan, China outbreak (1), subsequently confirmed by multiple other studies (2,3), found that 80% of deaths occurred among persons aged ≥60 years. In anticipation of the time needed for the global vaccine supply to meet all needs, the World Health Organization (WHO) published the Strategic Advisory Group of Experts on Immunization (SAGE) Values Framework and a roadmap for prioritizing use of COVID-19 vaccines in late 2020 (4,5), followed by a strategy brief to outline urgent actions in October 2021.(†) WHO described the general principles, objectives, and priorities needed to support country planning of vaccine rollout to minimize severe disease and death. A July 2022 update to the strategy brief(§) prioritized vaccination of populations at increased risk, including older adults,(¶) with the goal of 100% coverage with a complete COVID-19 vaccination series** for at-risk populations. Using available public data on COVID-19 mortality (reported deaths and model estimates) for 2020 and 2021 and the most recent reported COVID-19 vaccination coverage data from WHO, investigators performed descriptive analyses to examine age-specific mortality and global vaccination rollout among older adults (as defined by each country), stratified by country World Bank income status. Data quality and COVID-19 death reporting frequency varied by data source; however, persons aged ≥60 years accounted for >80% of the overall COVID-19 mortality across all income groups, with upper- and lower-middle-income countries accounting for 80% of the overall estimated excess mortality. Effective COVID-19 vaccines were authorized for use in December 2020, with global supply scaled up sufficiently to meet country needs by late 2021 (6). COVID-19 vaccines are safe and highly effective in reducing severe COVID-19, hospitalizations, and mortality (7,8); nevertheless, country-reported median completed primary series coverage among adults aged ≥60 years only reached 76% by the end of 2022, substantially below the WHO goal, especially in middle- and low-income countries. Increased efforts are needed to increase primary series and booster dose coverage among all older adults as recommended by WHO and national health authorities.

      9. Screening and testing for hepatitis B virus infection: CDC recommendations - United States, 2023
        Conners EE, Panagiotakopoulos L, Hofmeister MG, Spradling PR, Hagan LM, Harris AM, Rogers-Brown JS, Wester C, Nelson NP.
        MMWR Recomm Rep. 2023 ;72(1):1-25.
        Chronic hepatitis B virus (HBV) infection can lead to substantial morbidity and mortality. Although treatment is not considered curative, antiviral treatment, monitoring, and liver cancer surveillance can reduce morbidity and mortality. Effective vaccines to prevent hepatitis B are available. This report updates and expands CDC's previously published Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection (MMWR Recomm Rep 2008;57[No. RR-8]) regarding screening for HBV infection in the United States. New recommendations include hepatitis B screening using three laboratory tests at least once during a lifetime for adults aged ≥18 years. The report also expands risk-based testing recommendations to include the following populations, activities, exposures, or conditions associated with increased risk for HBV infection: persons incarcerated or formerly incarcerated in a jail, prison, or other detention setting; persons with a history of sexually transmitted infections or multiple sex partners; and persons with a history of hepatitis C virus infection. In addition, to provide increased access to testing, anyone who requests HBV testing should receive it, regardless of disclosure of risk, because many persons might be reluctant to disclose stigmatizing risks.

      10. Progress in scale up of HIV viral load testing in select sub-Saharan African countries 2016-2018
        Fonjungo PN, Lecher S, Zeh C, Rottinghaus E, Chun H, Adje-Toure C, Lloyd S, Mwangi JW, Mwasekaga M, Eshete YM, Pati R, Mots'oane T, Mitruka K, Beukes A, Mwangi C, Bowen N, Hamunime N, Beard RS, Kabuje A, Nabadda S, Auld AF, Balachandra S, Zungu I, Kandulu J, Alemnji G, Ehui E, Alexander H, Ellenberger D.
        PLoS One. 2023 ;18(3):e0282652.
        INTRODUCTION: We assessed progress in HIV viral load (VL) scale up across seven sub-Saharan African (SSA) countries and discussed challenges and strategies for improving VL coverage among patients on anti-retroviral therapy (ART). METHODS: A retrospective review of VL testing was conducted in Côte d'Ivoire, Kenya, Lesotho, Malawi, Namibia, Tanzania, and Uganda from January 2016 through June 2018. Data were collected and included the cumulative number of ART patients, number of patients with ≥ 1 VL test result (within the preceding 12 months), the percent of VL test results indicating viral suppression, and the mean turnaround time for VL testing. RESULTS: Between 2016 and 2018, the proportion of PLHIV on ART in all 7 countries increased (range 5.7%-50.2%). During the same time period, the cumulative number of patients with one or more VL test increased from 22,996 to 917,980. Overall, viral suppression rates exceeded 85% for all countries except for Côte d'Ivoire at 78% by June 2018. Reported turnaround times for VL testing results improved in 5 out of 7 countries by between 5.4 days and 27.5 days. CONCLUSIONS: These data demonstrate that remarkable progress has been made in the scale-up of HIV VL testing in the seven SSA countries.

    • Community Health Services
      1. K-medoids clustering of hospital admission characteristics to classify severity of influenza virus infection
        Leis AM, McSpadden E, Segaloff HE, Lauring AS, Cheng C, Petrie JG, Lamerato LE, Patel M, Flannery B, Ferdinands J, Karvonen-Gutierrez CA, Monto A, Martin ET.
        Influenza Other Respir Viruses. 2023 ;17(3):e13120.
        BACKGROUND: Patients are admitted to the hospital for respiratory illness at different stages of their disease course. It is important to appropriately analyse this heterogeneity in surveillance data to accurately measure disease severity among those hospitalized. The purpose of this study was to determine if unique baseline clusters of influenza patients exist and to examine the association between cluster membership and in-hospital outcomes. METHODS: Patients hospitalized with influenza at two hospitals in Southeast Michigan during the 2017/2018 (n = 242) and 2018/2019 (n = 115) influenza seasons were included. Physiologic and laboratory variables were collected for the first 24 h of the hospital stay. K-medoids clustering was used to determine groups of individuals based on these values. Multivariable linear regression or Firth's logistic regression were used to examine the association between cluster membership and clinical outcomes. RESULTS: Three clusters were selected for 2017/2018, mainly differentiated by blood glucose level. After adjustment, those in C(17)1 had 5.6 times the odds of mechanical ventilator use than those in C(17)2 (95% CI: 1.49, 21.1) and a significantly longer mean hospital length of stay than those in both C(17)2 (mean 1.5 days longer, 95% CI: 0.2, 2.7) and C(17)3 (mean 1.4 days longer, 95% CI: 0.3, 2.5). Similar results were seen between the two clusters selected for 2018/2019. CONCLUSION: In this study of hospitalized influenza patients, we show that distinct clusters with higher disease acuity can be identified and could be targeted for evaluations of vaccine and influenza antiviral effectiveness against disease attenuation. The association of higher disease acuity with glucose level merits evaluation.

      2. Use of a negative pressure containment pod within ambulance-workspace during pandemic response
        Pena M, Neu DT, Feng HA, Hammond DR, Mead KR, Banerjee RK.
        J Med Device. 2023 ;17(1):011009.
        Emergency medical service (EMS) providers have a higher potential exposure to infectious agents than the general public (Nguyen et al., 2020, "Risk of COVID-19 Among Frontline Healthcare Workers and the General Community: A Prospective Cohort Study," Lancet Pub. Health, 5(9), pp. e475-e483; Brown et al., 2021, "Risk for Acquiring Coronavirus Disease Illness Among Emergency Medical Service Personnel Exposed to Aerosol-Generating Procedures," Emer. Infect. Disease J., 27(9), p. 2340). The use of protective equipment may reduce, but does not eliminate their risk of becoming infected as a result of these exposures. Prehospital environments have a high risk of disease transmission exposing EMS providers to bioaerosols and droplets from infectious patients. Field intubation procedures may be performed causing the generation of bioaerosols, thereby increasing the exposure of EMS workers to pathogens. Additionally, ambulances have a reduced volume compared to a hospital treatment space, often without an air filtration system, and no control mechanism to reduce exposure. This study evaluated a containment plus filtration intervention for reducing aerosol concentrations in the patient module of an ambulance. Aerosol concentration measurements were taken in an unoccupied research ambulance at National Institute for Occupational Safety and Health (NIOSH) Cincinnati using a tracer aerosol and optical particle counters (OPCs). The evaluated filtration intervention was a containment pod with a high efficiency particulate air (HEPA)-filtered extraction system that was developed and tested based on its ability to contain, capture, and remove aerosols during the intubation procedure. Three conditions were tested (1) baseline (without intervention), (2) containment pod with HEPA-1, and (3) containment pod with HEPA-2. The containment pod with HEPA-filtered extraction intervention provided containment of 95% of the total generated particle concentration during aerosol generation relative to the baseline condition, followed by rapid air cleaning within the containment pod. This intervention can help reduce aerosol concentrations within ambulance patient modules while performing aerosol-generating procedures.

      3. This Viewpoint describes new recommendations from the CDC regarding universal screening of adults for hepatitis B virus infection. eng

      4. Perceived benefits and barriers of a COVID-19 test to stay program in a school district serving Black or African American people with low income, December 2021
        Kamitani E, Holman EJ, Philpott D, Parasram VD, Ruth LJ, Onyeuku C, Carter B, Gwynn E, Beck TW, Regan K, Hagler LR, Clark A, Shelley G, Thomas ES.
        Public Health Rep. 2023 :333549231155472.
        OBJECTIVES: Quarantine after exposure to COVID-19 has resulted in substantial loss of in-person learning in schools from prekindergarten through grade 12. Test to Stay (TTS), a strategy that limits the spread of SARS-CoV-2 while prioritizing in-person learning, requires substantial investment in resources. The objective of this study was to assess the perceived benefits, barriers, and facilitators of implementing TTS in an urban school district in the Midwest serving primarily Black or African American people with low income. METHODS: In December 2021, we used a concurrent mixed-methods approach to understand perceived benefits, barriers, and facilitators of implementing TTS by combining quantitative analysis of telephone surveys conducted with parents (n = 124) and a qualitative inquiry involving key informants from the school district and local health department (n = 22). We analyzed quantitative data using descriptive statistics. We used thematic analysis to analyze qualitative data. RESULTS: Quantitative findings showed that parents supported TTS because it was convenient (n = 83, 97%) and effective (n = 82, 95%) in keeping students learning in person (n = 82, 95%) and preventing the spread of COVID-19 (n = 80, 93%). Qualitative interviews with informants found that having a clear protocol and assigning staff to specified tasks allowed for successful TTS implementation. However, insufficient staffing and testing resources, parent mistrust of testing, and lack of communication from schools were perceived barriers. CONCLUSION: The school community strongly supported TTS despite the many implementation challenges faced. This study emphasized the importance of ensuring resources for equitable implementation of COVID-19 prevention strategies and the critical role of communication.

    • Environmental Health
      1. Short- and long-term stability of aromatic amines in human urine
        Mazumder S, Ahamed RA, Seyler TH, Wang L.
        Int J Environ Res Public Health. 2023 ;20(5).
        Several aromatic amines (AAs) are established by the International Agency for Research on Cancer as carcinogenic (group 1) or probable/possible carcinogens to humans (group 2A/2B). AAs can be found in mainstream and sidestream smoke from combustible tobacco products, as well as in certain environmental pollution and occupational exposure from several chemical industry sectors. Exposure to AAs can be estimated by measuring their concentrations in urine; however, information about the short-term and long-term stabilities of AAs in urine need to be characterized before conducting large-scale population studies on AA exposure and the potentially harmful effects of AA exposure. In this report, the storage stability of o-toluidine, 2,6-dimethylaniline, o-anisidine, 1-aminonaphthalene, 2-aminonaphthalene, and 4-aminobiphenyl fortified in pooled, filtered, non-smokers' urine is analyzed by isotope dilution gas chromatography-triple quadrupole mass spectrometry (ID GC-MS/MS). The six AAs were measured in urine samples stored at ~20 °C (collection temperature), 4 °C and 10 °C (short-term transit temperatures), and -20 °C and -70 °C (long-term storage temperatures) over a 10-day period. All six analytes were stable for 10 days at transit and long-term storage temperatures but showed reduced recovery at 20 °C. The instability of the target AAs at 20 °C suggests that immediate storage of freshly voided urine at low temperatures is needed to attenuate degradation. A subset of the urine samples was analyzed following a longer storage duration at -70 °C: all AAs were stable for up to 14 months at this temperature. The stability of the six AAs in urine samples can be maintained at the various temperature levels and storage times expected in a typical study set.

      2. Invasive mold infections following Hurricane Harvey-Houston, Texas
        Toda M, Williams S, Jackson BR, Wurster S, Serpa JA, Nigo M, Grimes CZ, Atmar RL, Chiller TM, Ostrosky-Zeichner L, Kontoyiannis DP.
        Open Forum Infect Dis. 2023 ;10(3):ofad093.
        BACKGROUND: Characterizing invasive mold infection (IMI) epidemiology in the context of large flooding events is important for public health planning and clinical decision making. METHODS: We assessed IMI incidence (per 10 000 healthcare encounters) 1 year before and after Hurricane Harvey at 4 hospitals in Houston, Texas. Potential IMI cases were assigned as proven or probable cases using established definitions, and surveillance cases using a novel definition. We used rate ratios to describe IMI incidence and multivariable logistic regression to examine patient characteristics associated with IMI case status. RESULTS: IMI incidence was significantly higher posthurricane (3.69 cases) than prehurricane (2.50 cases) (rate ratio, 1.48 [95% confidence interval, 1.10-2.00]), largely driven by surveillance IMI cases. Aspergillus was the most common species cultured (33.5% prehurricane and 39.9% posthurricane). About one-quarter (25.8%) of IMI patients lacked classical IMI risk factors such as hematologic malignancy and transplantations. Overall, 45.1% of IMI patients received intensive care, and in-hospital all-cause mortality was 24.2%. CONCLUSIONS: IMI incidence likely increased following Hurricane Harvey and outcomes for IMI patients were severe. Patient and clinician education on IMI prevention and identification is warranted, particularly as the frequency of extreme weather events increases due to climate change.

    • Epidemiology and Surveillance
      1. Lessons learnt from the applying the Centers for Disease Control and Prevention (CDC) evaluation framework to the Measles Incident Management System response, USA, 2020-2021
        Jacenko S, Blough S, Grant G, Tohme R, McFarland J, Hatcher C, Goodson JL, Papania M, Pella DG, Li X, Yee SL.
        BMJ Glob Health. 2023 ;8(3).
        The functionality and performance of public health programmes at all levels of government play a critical role in preventing, detecting, mitigating and responding to public health threats, including infectious disease outbreaks. Multiple and concurrent outbreaks in recent years, such as COVID-19, Ebola and Zika, have highlighted the importance of documenting lessons learnt from public health responses of national and global agencies. In February 2020, the US Centers for Disease Control and Prevention (CDC) Center for Global Health (CGH) activated the Measles Incident Management System (MIMS) to accelerate the ability to detect, mitigate and respond to measles outbreaks globally and advance progress towards regional measles elimination goals. The activation was triggered by a global resurgence in reported measles cases during 2018-2019 and supported emergency response activities conducted by partner organisations and countries. MIMS leadership decided early in the response to form an evaluation team to design and implement an evaluation approach for producing real-time data to document progress of response activities and inform timely decision-making. In this manuscript, we describe how establishing an evaluation unit within MIMS, and engaging MIMS leadership and subject matter experts in the evaluation activities, was critical to monitor progress and document lessons learnt to inform decision making. We also explain the CDC's Framework for Evaluation in Public Health Practice applied to evaluate the dynamic events throughout the MIMS response. Evaluators supporting emergency response should use a flexible framework that can be adaptable in dynamic contexts and document response activities in real-time.

      2. Cause-specific mortality among adults aged ≥65 years in the United States, 1999 through 2020
        Kakara RS, Lee R, Eckstrom EN.
        Public Health Rep. 2023 :333549231155869.
        OBJECTIVE: Reports on recent mortality trends among adults aged ≥65 years are lacking. We examined trends in the leading causes of death from 1999 through 2020 among US adults aged ≥65 years. METHODS: We used data from the National Vital Statistics System mortality files to identify the 10 leading causes of death among adults aged ≥65 years. We calculated overall and cause-specific age-adjusted death rates and then calculated the average annual percentage change (AAPC) in death rates from 1999 through 2020. RESULTS: The overall age-adjusted death rate decreased on average by 0.5% (95% CI, -1.0% to -0.1%) per year from 1999 through 2020. Although rates for 7 of the top 10 causes of death decreased significantly, the rates of death from Alzheimer disease (AAPC = 3.0%; 95% CI, 1.5% to 4.5%) and from unintentional injuries (AAPC = 1.2%; 95% CI, 1.0% to 1.4%), notably falls (AAPC = 4.1%; 95% CI, 3.9% to 4.3%) and poisoning (AAPC = 6.6%; 95% CI, 6.0% to 7.2%), increased significantly. CONCLUSION: Public health prevention strategies and improved chronic disease management may have contributed to decreased rates in the leading causes of death. However, longer survival with comorbidities may have contributed to increased rates of death from Alzheimer disease and unintentional falls.

      3. Lessons learned from the implementation of integrated serosurveillance of communicable diseases in the Americas
        Saboyá-Díaz MI, Castellanos LG, Morice A, Ade MP, Rey-Benito G, Cooley GM, Scobie HM, Wiegand RE, Coughlin MM, Martin DL.
        Rev Panam Salud Publica. 2023 ;47:e53.
        OBJECTIVE: Systematize the experience and identify challenges and lessons learned in the implementation of an initiative for integrated serosurveillance of communicable diseases using a multiplex bead assay in countries of the Americas. METHODS: Documents produced in the initiative were compiled and reviewed. These included concept notes, internal working papers, regional meetings reports, and survey protocols from the three participating countries (Mexico, Paraguay, and Brazil) and two additional countries (Guyana and Guatemala) where serology for several communicable diseases was included in neglected tropical diseases surveys. Information was extracted and summarized to describe the experience and the most relevant challenges and lessons learned. RESULTS: Implementing integrated serosurveys requires interprogrammatic and interdisciplinary work teams for the design of survey protocols to respond to key programmatic questions aligned to the needs of the countries. Valid laboratory results are critical and rely on the standardized installment and roll-out of laboratory techniques. Field teams require adequate training and supervision to properly implement survey procedures. The analysis and interpretation of serosurveys results should be antigen-specific, contextualizing the responses for each disease, and triangulated with programmatic and epidemiological data for making decisions tailored to specific population socioeconomic and ecologic contexts. CONCLUSIONS: Integrated serosurveillance as a complementary tool for functional epidemiological surveillance systems is feasible to use and key components should be considered: political engagement, technical engagement, and integrated planning. Aspects such as designing the protocol, selecting target populations and diseases, laboratory capacities, anticipating the capacities to analyze and interpret complex data, and how to use it are key.

      4. Experiences with COVID-19 case investigation and contact tracing: A qualitative analysis
        DeLuca N, Caruso E, Gupta R, Kemmerer C, Coughlin R, Chan O, Vohra D, Oeltmann JE, Taylor MM, Moonan PK, Thorpe PG, Loosier PS, Haile G.
        SSM Qual Res Health. 2023 ;3:100244.
        Case investigation and contact tracing (CI/CT) is a critical part of the public health response to COVID-19. Individuals' experiences with CI/CT for COVID-19 varied based on geographic location, changes in knowledge and guidelines, access to testing and vaccination, as well as demographic characteristics including age, race, ethnicity, income, and political ideology. In this paper, we explore the experiences and behaviors of adults with positive SARS-CoV-2 test results, or who were exposed to a person with COVID-19, to understand their knowledge, motivations, and facilitators and barriers to their actions. We conducted focus groups and one-on-one interviews with 94 cases and 90 contacts from across the United States. We found that participants were concerned about infecting or exposing others, which motivated them to isolate or quarantine, notify contacts, and get tested. Although most cases and contacts were not contacted by CI/CT professionals, those who were reported a positive experience and received helpful information. Many cases and contacts reported seeking information from family, friends, health care providers, as well as television news and Internet sources. Although participants reported similar perspectives and experiences across demographic characteristics, some highlighted inequities in receiving COVID-19 information and resources.

    • Food Safety
      1. Development of an empirically derived measure of food safety culture in restaurants
        Kramer A, Hoover ER, Hedeen N, DiPrete L, Tuttle J, Irving DJ, Viveiros B, Nicholas D, Monroy JA, Moritz E, Brown L.
        J Food Prot. 2023 ;86(3):100043.
        A poor food safety culture has been described as an emerging risk factor for foodborne illness outbreaks, yet there has been little research on this topic in the retail food industry. The purpose of this study was to identify and validate conceptual domains around food safety culture and develop an assessment tool that can be used to assess food workers' perceptions of their restaurant's food safety culture. The study, conducted from March 2018 through March 2019, surveyed restaurant food workers for their level of agreement with 28 statements. We received 579 responses from 331 restaurants spread across eight different health department jurisdictions. Factor analysis and structural equation modeling supported a model composed of four primary constructs. The highest rated construct was Resource Availability (x¯=4.69, sd=0.57), which assessed the availability of resources to maintain good hand hygiene. The second highest rated construct was Employee Commitment (x¯=4.49, sd=0.62), which assessed workers' perceptions of their coworkers' commitment to food safety. The last two constructs were related to management. Leadership (x¯=4.28, sd=0.69) assessed the existence of food safety policies, training, and information sharing. Management Commitment (x¯=3.94, sd=1.05) assessed whether food safety was a priority in practice. Finally, the model revealed one higher-order construct, Worker Beliefs about Food Safety Culture (x¯=4.35, sd=0.53). The findings from this study can support efforts by the restaurant industry, food safety researchers, and health departments to examine the influence and effects of food safety culture within restaurants.

    • Health Behavior and Risk
      1. Prevalence of influenza-specific vaccination hesitancy among adults in the United States, 2018
        Srivastav A, Lu PJ, Amaya A, Dever JA, Stanley M, Franks JL, Scanlon PJ, Fisher AM, Greby SM, Nguyen KH, Black CL.
        Vaccine. 2023 .
        BACKGROUND: The role of vaccine hesitancy on influenza vaccination is not clearly understood. Low influenza vaccination coverage in U.S. adults suggests that a multitude of factors may be responsible for under-vaccination or non-vaccination including vaccine hesitancy. Understanding the role of influenza vaccination hesitancy is important for targeted messaging and intervention to increase influenza vaccine confidence and uptake. The objective of this study was to quantify the prevalence of adult influenza vaccination hesitancy (IVH) and examine association of IVH beliefs with sociodemographic factors and early-season influenza vaccination. METHODS: A four-question validated IVH module was included in the 2018 National Internet Flu Survey. Weighted proportions and multivariable logistic regression models were used to identify correlates of IVH beliefs. RESULTS: Overall, 36.9% of adults were hesitant to receive an influenza vaccination; 18.6% expressed concerns about vaccination side effects; 14.8% personally knew someone with serious side effects; and 35.6% reported that their healthcare provider was not the most trusted source of information about influenza vaccinations. Influenza vaccination ranged from 15.3 to 45.2 percentage points lower among adults self-reporting any of the four IVH beliefs. Being female, age 18-49 years, non-Hispanic Black, having high school or lower education, being employed, and not having primary care medical home were associated with hesitancy. CONCLUSIONS: Among the four IVH beliefs studied, being hesitant to receiving influenza vaccination followed by mistrust of healthcare providers were identified as the most influential hesitancy beliefs. Two in five adults in the United States were hesitant to receive an influenza vaccination, and hesitancy was negatively associated with vaccination. This information may assist with targeted interventions, personalized to the individual, to reduce hesitancy and thus improve influenza vaccination acceptance.

    • Health Economics
      1. Labor income losses associated with heart disease and stroke from the 2019 Panel Study Of Income Dynamics
        Luo F, Chapel G, Ye Z, Jackson SL, Roy K.
        JAMA Netw Open. 2023 ;6(3):e232658.
        IMPORTANCE: Current estimates of productivity losses associated with heart disease and stroke in the US include income losses from premature mortality but do not include income losses from morbidity. OBJECTIVE: To estimate labor income losses associated with morbidity of heart disease and stroke in the US due to missed or lower labor force participation. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used 2019 Panel Study of Income Dynamics data to estimate labor income losses associated with heart disease and stroke by comparing labor income between persons with and without heart disease or stroke, after controlling for sociodemographic characteristics and other chronic conditions and considering the situation of zero labor income (eg, withdrawal from the labor market). The study sample included individuals aged 18 to 64 years who were reference persons or spouses or partners. Data analysis was conducted from June 2021 to October 2022. EXPOSURE: The key exposure was heart disease or stroke. MAIN OUTCOMES AND MEASURES: The main outcome was labor income, measured for the year 2018. Covariates included sociodemographic characteristics and other chronic conditions. Labor income losses associated with heart disease and stroke were estimated using the 2-part model, in which part 1 is to model the probability that labor income is greater than zero and part 2 is to regress positive labor income, with both parts having the same set of explanatory variables. RESULTS: In the study sample consisting of 166 individuals (6721 [52.4%] females) representing a weighted mean income of $48 299 (95% CI, $45 712-$50 885), the prevalence of heart disease was 3.7% and the prevalence of stroke was 1.7%, and there were 1610 Hispanic persons (17.3%), 220 non-Hispanic Asian or Pacific Islander persons (6.0%), 3963 non-Hispanic Black persons (11.0%), and 5688 non-Hispanic White persons (60.2%). The age distribution was largely even, from 21.9% for the age 25 to 34 years group to 25.8% for the age 55 to 64 years group, except for young adults (age 18-24 years), who made up 4.4% of the sample. After adjustment for sociodemographic characteristics and other chronic conditions, persons with heart disease would receive an estimated $13 463 (95% CI, $6993-$19 933) less in annual labor income than those without heart disease (P < .001), and persons with stroke would receive an estimated $18 716 (95% CI, $10 356-$27 077) less in annual labor income than those without stroke (P < .001). Total labor income losses associated with morbidity were estimated at $203.3 billion for heart disease and $63.6 billion for stroke. CONCLUSIONS AND RELEVANCE: These findings suggest that total labor income losses associated with morbidity of heart disease and stroke were far greater than those from premature mortality. Comprehensive estimation of total costs of CVD may assist decision-makers in assessing benefits from averted premature mortality and morbidity and allocating resources to the prevention, management, and control of CVD.

      2. The annual direct medical cost attributable to human papillomavirus (HPV) in the United States over the period 2004-2007 was estimated at $9.36 billion in 2012 (updated to 2020 dollars). The purpose of this report was to update that estimate to account for the impact of HPV vaccination on HPV-attributable disease, reductions in the frequency of cervical cancer screening, and new data on the cost per case of treating HPV-attributable cancers. Based primarily on data from the literature, we estimated the annual direct medical cost burden as the sum of the costs of cervical cancer screening and follow-up and the cost of treating HPV-attributable cancers, anogenital warts, and recurrent respiratory papillomatosis (RRP). We estimated the total direct medical cost of HPV to be $9.01 billion annually over the period 2014-2018 (2020 U.S. dollars). Of this total cost, 55.0% was for routine cervical cancer screening and follow-up, 43.8% was for treatment of HPV-attributable cancer, and less than 2% was for treating anogenital warts and RRP. Although our updated estimate of the direct medical cost of HPV is slightly lower than the previous estimate, it would have been substantially lower had we not incorporated more recent, higher cancer treatment costs.

    • Health Equity and Health Disparities
      1. Comparing open-ended question methods to vignette methods to explore willingness to obtain pre-exposure prophylaxis access in pharmacies among black men who have sex with men
        Josma D, Morris J, Hopkins R, Quamina A, Siegler AJ, Holland D, S. Sullivan P, Harrington KR, Alohan DI, Crawford ND.
        AIDS Care. 2023 :1-8.
        Black men who have sex with men (BMSM) are at higher risk of HIV transmission than any other group; however, their uptake of the highly effective HIV prevention medication, pre-exposure prophylaxis (PrEP), is low. In collaboration with a communitybased organization in Atlanta, Georgia, we explored ten HIV-negative BMSM's willingness to obtain PrEP in pharmacies using standard open-ended and vignette qualitative methods. Three overarching themes were identified: privacy, patient-pharmacist interactions, and HIV/STI screening. While open-ended questions allowed participants to provide broad answers on their willingness to receive prevention services at a pharmacy, the vignette drew out specific responses to facilitate in-pharmacy PrEP delivery. Using both openended questions and vignette data collection strategies, BMSM reported high willingness to screen for and uptake PrEP in pharmacies. However, the vignette method allowed for greater depth. Open-ended questions elicited responses that highlighted general barriers and facilitators of PrEP dispensing in pharmacies. However, the vignette allowed participants to customize a plan of action that would best fit their needs. Vignette methods are underutilized in HIV research and may be helpful in supplementing standard open-ended interview questions to uncovering unknown challenges about health behaviors and obtain more robust data on highly sensitive research topics in HIV research.

      2. Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research priorities in health services; diversity, equity, and inclusion; and implementation science
        Byams VR, Baker JR, Bailey C, Connell NT, Creary MS, Curtis RG, Dinno A, Guelcher CJ, Kim M, Kulkarni R, Lattimore S, Norris KL, Ramirez L, Skinner MW, Symington S, Tobase P, Vázquez E, Warren BB, Wheat E, Buckner TW.
        Expert Rev Hematol. 2023 ;16(sup1):87-106.
        BACKGROUND: The National Hemophilia Foundation (NHF) conducted extensive all-stakeholder inherited bleeding disorder (BD) community consultations to inform a blueprint for future research. Sustaining and expanding the specialized and comprehensive Hemophilia Treatment Center care model, to better serve all people with inherited BDs (PWIBD), and increasing equitable access to optimal health emerged as top priorities. RESEARCH DESIGN AND METHODS: NHF, with the American Thrombosis and Hemostasis Network (ATHN), convened multidisciplinary expert working groups (WG) to distill priority research initiatives from consultation findings. WG5 was charged with prioritizing health services research (HSR); diversity, equity, and inclusion (DEI); and implementation science (IS) research initiatives to advance community-identified priorities. RESULTS: WG5 identified multiple priority research themes and initiatives essential to capitalizing on this potential. Formative studies using qualitative and mixed methods approaches should be conducted to characterize issues and meaningfully investigate interventions. Investment in HSR, DEI and IS education, training, and workforce development are vital. CONCLUSIONS: An enormous amount of work is required in the areas of HSR, DEI, and IS, which have received inadequate attention in inherited BDs. This research has great potential to evolve the experiences of PWIBD, deliver transformational community-based care, and advance health equity. Research into how people get their health care, called health services research, is important to understand if care is being delivered equitably and efficiently. This research figures out how to provide the best care at the lowest cost and finds out if everyone gets equally good care. Diversity and inclusion research focuses on whether all marginalized and minoritized populations (such as a given social standing, race, ethnicity, sex, gender identity, sexuality, age, income, disability status, language, culture, faith, geographic location, or country of birth) receive equitable care. This includes checking whether different populations are all getting the care they need and looking for ways to improve the care. Implementation science studies how to make a potential improvement work in the real world. The improvement could be a new way to diagnose or treat a health condition, a better way to deliver health care or do research, or a strategy to remove barriers preventing specific populations from getting the best available care. The National Hemophilia Foundation focuses on improving the lives of all people with bleeding disorders (BD). They brought BDs doctors, nurses, physical therapists, social workers, professors, and government and industry partners together with people and families living with BDs to discuss research in the areas described above. The group came up with important future research questions to address racism and other biases, and other changes to policies, procedures, and practices to make BD care equitable, efficient, and effective. eng

      3. Geographic variation in access to cardiac rehabilitation
        Duncan MS, Robbins NN, Wernke SA, Greevy RA, Jackson SL, Beatty AL, Thomas RJ, Whooley MA, Freiberg MS, Bachmann JM.
        J Am Coll Cardiol. 2023 ;81(11):1049-1060.
        BACKGROUND: There is marked geographic variation in cardiac rehabilitation (CR) initiation, ranging from 10% to 40% of eligible patients at the state level. The potential causes of this variation, such as patient access to CR centers, are not well studied. OBJECTIVES: The authors sought to determine how access to CR centers affects CR initiation in Medicare beneficiaries. METHODS: The authors used Medicare files to identify CR-eligible Medicare beneficiaries and calculate CR initiation rates at the hospital referral region (HRR) level. We used linear regression to evaluate the percent variation in CR initiation accounted for by CR access across HRRs. We then employed geospatial hotspot analysis to identify CR deserts, or counties in which patient load per CR center is disproportionately high. RESULTS: A total of 1,133,657 Medicare beneficiaries were eligible for CR from 2014 to 2017, of whom 263,310 (23%) initiated CR. The West North Central Census Division had the highest adjusted CR initiation rate (35.4%) and the highest density of CR programs (6.58 per 1,000 CR-eligible Medicare beneficiaries). Density of CR programs accounted for 21.2% of geographic variation in CR initiation at the HRR level. A total of 40 largely urban counties comprising 14% of the United States population age ≥65 years had disproportionately low CR access and were identified as CR deserts. CONCLUSIONS: A substantial proportion of geographic variation in CR initiation was related to access to CR programs, with a significant amount of the U.S. population living in CR deserts. These data invite further study on interventions to increase CR access.

      4. Differential performance of social communication questionnaire items in African American/Black vs. White children
        Dahl E, Moody EJ, Barger B, Rosenberg S, DiGuiseppi C, Fallin MD, Lee LC, Wiggins L.
        J Autism Dev Disord. 2023 .
        Screening for autism spectrum disorder (ASD) is an essential early step in the identification process and inaccurate screening may lead to significant delays in the onset of treatment. Past research has highlighted discrepancies in the performance of ASD screening tools such as the Social Communication Questionnaire (SCQ) among certain racial and ethnic groups. The current study explored the functioning of the SCQ among African American/Black and White respondents based on item level performance on the measure. Differential Item Functioning (DIF) analyses showed that 16 (41%) items of the SCQ functioned differently for African American/Black respondents when compared to White respondents. Implications, such as the potential for delayed diagnosis and treatment, and the influence on downstream outcomes, are discussed.

      5. Racial and ethnic differences in subjective cognitive decline - United States, 2015-2020
        Wooten KG, McGuire LC, Olivari BS, Jackson EM, Croft JB.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(10):249-255.
        Subjective cognitive decline (SCD), the self-reported experience of worsening or more frequent memory loss or confusion, might be a symptom of early-stage dementia or future serious cognitive decline such as Alzheimer disease* or a related dementia (ADRD) (1). Established modifiable risk factors for ADRD include high blood pressure, inadequate physical activity, obesity, diabetes, depression, current cigarette smoking, and hearing loss (2). An estimated 6.5 million persons aged ≥65 years in the United States live with Alzheimer disease, the most common dementia (1). This number is projected to double by 2060, with the largest increase among non-Hispanic Black or African American (Black), and Hispanic or Latino (Hispanic) adults (1,3). Using data from the Behavioral Risk Factor Surveillance System (BRFSS), CDC assessed racial and ethnic, select demographic, and geographical differences in SCD prevalence, and prevalence of health care professional conversations among those reporting SCD. The age-adjusted prevalence of SCD during 2015-2020 was 9.6% among adults aged ≥45 years (5.0% of Asian or Pacific Islander [A/PI] adults, 9.3% of non-Hispanic White [White] adults, 10.1% of Black adults, 11.4% of Hispanic adults, and 16.7% of non-Hispanic American Indian or Alaska Native [AI/AN] adults). College education was associated with a lower prevalence of SCD among all racial and ethnic groups. Only 47.3% of adults with SCD reported that they had discussed confusion or memory loss with a health care professional. Discussing changes in cognition with a physician can allow for the identification of potentially treatable conditions, early detection of dementia, promotion of dementia risk reduction behaviors, and establishing a treatment or care plan to help adults remain healthy and independent for as long as possible.

    • Healthcare Associated Infections
      1. Natural history of Clostridioides difficile colonization and infection following new acquisition of carriage in healthcare settings: A prospective cohort study
        Curry SR, Hecker MT, O'Hagan J, Kutty PK, Alhmidi H, Ng-Wong YK, Cadnum JL, Jencson AL, Gonzalez-Orta M, Saldana C, Wilson BM, Donskey CJ.
        Clin Infect Dis. 2023 .
        BACKGROUND: Limited information is available on the natural history of Clostridioides difficile colonization and infection in patients with new acquisition of C. difficile in healthcare settings. METHODS: In 3 hospitals and affiliated long-term care facilities, we collected serial perirectal cultures from patients with no diarrhea on enrollment to identify new acquisition of toxigenic C. difficile carriage and determined the duration and burden of carriage. Asymptomatic carriage was defined as transient if only 1 culture was positive with negative cultures before and after or persistent if 2 or more cultures were positive. Clearance of carriage was defined as 2 consecutive negative perirectal cultures. RESULTS: Of 1,432 patients with negative initial cultures and at least 1 follow-up culture, 39 (2.7%) developed CDI without prior detection of carriage and 142 (9.9%) acquired asymptomatic carriage with 19 (13.4%) subsequently diagnosed with CDI. Of 82 patients analyzed for persistence of carriage, 50 (61.0%) had transient carriage and 32 (39.0%) had persistent carriage, with an estimated median of 77 days to clearance of colonization (range, 14 to 133 days). Most persistent carriers had a relatively high burden of carriage and maintained the same ribotype over time, whereas most transient carriers had a low burden of carriage detected only using broth enrichment cultures. CONCLUSIONS: In 3 healthcare facilities, 9.9% of patients acquired asymptomatic carriage of toxigenic C. difficile, and 13.4% were subsequently diagnosed with CDI. Most carriers had transient rather than persistent carriage and most patients developing CDI did not have prior detection of carriage.

    • Immunity and Immunization
      1. The aim of the study was to assess barriers to Vaccines for Children (VFC) provider practices participating in the COVID-19 Vaccination Program and intentions to offer COVID-19 vaccination to children aged <5 years. We invited a random sample of 15 000 VFC provider practices in the United States to complete an online survey during February 28 to March 11, 2022. Of 2809 practices that completed the survey, 2246 (80.0%) were enrolled in the COVID-19 Vaccination Program. Concerns around staff resources, vaccine and supply storage space, and vaccine wastage from multidose vials were the most frequently reported program-enrollment barriers. Among enrolled practices that have decided whether to offer COVID-19 vaccination to the children aged <5 years, 1641 (88.8% of 1848) reported likely offering it to current patients, and 1165 reported likely offering it to children who are not current patients. Addressing participation barriers and encouraging active promotion may increase COVID-19 vaccination coverage of children.

      2. Early estimates of bivalent mRNA booster dose vaccine effectiveness in preventing symptomatic SARS-CoV-2 infection attributable to Omicron BA.5- and XBB/XBB.1.5-related sublineages among immunocompetent adults - increasing community access to testing program, United States, December 2022-January 2023
        Link-Gelles R, Ciesla AA, Roper LE, Scobie HM, Ali AR, Miller JD, Wiegand RE, Accorsi EK, Verani JR, Shang N, Derado G, Britton A, Smith ZR, Fleming-Dutra KE.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(5):119-124.
        The SARS-CoV-2 Omicron sublineage XBB was first detected in the United States in August 2022.* XBB together with a sublineage, XBB.1.5, accounted for >50% of sequenced lineages in the Northeast by December 31, 2022, and 52% of sequenced lineages nationwide as of January 21, 2023. COVID-19 vaccine effectiveness (VE) can vary by SARS-CoV-2 variant; reduced VE has been observed against some variants, although this is dependent on the health outcome of interest. The goal of the U.S. COVID-19 vaccination program is to prevent severe disease, including hospitalization and death (1); however, VE against symptomatic infection can provide useful insight into vaccine protection against emerging variants in advance of VE estimates against more severe disease. Data from the Increasing Community Access to Testing (ICATT) national pharmacy program for SARS-CoV-2 testing were analyzed to estimate VE of updated (bivalent) mRNA COVID-19 vaccines against symptomatic infection caused by BA.5-related and XBB/XBB.1.5-related sublineages among immunocompetent adults during December 1, 2022–January 13, 2023. Reduction or failure of spike gene (S-gene) amplification (SGTF) in real-time reverse transcription–polymerase chain reaction (RT-PCR) was used as a proxy indicator of infection with likely BA.5-related sublineages and S-gene target presence (SGTP) of infection with likely XBB/XBB.1.5-related sublineages (2). Among 29,175 nucleic acid amplification tests (NAATs) with SGTF or SGTP results available from adults who had previously received 2–4 monovalent COVID-19 vaccine doses, the relative VE of a bivalent booster dose given 2–3 months earlier compared with no bivalent booster in persons aged 18–49 years was 52% against symptomatic BA.5 infection and 48% against symptomatic XBB/XBB.1.5 infection. As new SARS-CoV-2 variants emerge, continued vaccine effectiveness monitoring is important. Bivalent vaccines appear to provide additional protection against symptomatic BA.5-related sublineage and XBB/XBB.1.5-related sublineage infections in persons who had previously received 2, 3, or 4 monovalent vaccine doses. All persons should stay up to date with recommended COVID-19 vaccines, including receiving a bivalent booster dose when they are eligible.

      3. Vaccine-derived poliovirus serotype 2 outbreaks and response in the Democratic Republic of the Congo, 2017-2021
        Alleman MM, Jorba J, Riziki Y, Henderson E, Mwehu A, Seakamela L, Howard W, Kadiobo Mbule A, Nsamba RN, Djawe K, Yapi MD, Mengouo MN, Gumede N, Ndoutabe M, Kfutwah AK, Senouci K, Burns CC.
        Vaccine. 2023 .
        Vaccine-derived polioviruses (VDPVs) can emerge from Sabin strain poliovirus serotypes 1, 2, and 3 contained in oral poliovirus vaccine (OPV) after prolonged person-to-person transmission where population vaccination immunity against polioviruses is suboptimal. VDPVs can cause paralysis indistinguishable from wild polioviruses and outbreaks when community circulation ensues. VDPV serotype 2 outbreaks (cVDPV2) have been documented in The Democratic Republic of the Congo (DRC) since 2005. The nine cVDPV2 outbreaks detected during 2005-2012 were geographically-limited and resulted in 73 paralysis cases. No outbreaks were detected during 2013-2016. During January 1, 2017-December 31, 2021, 19 cVDPV2 outbreaks were detected in DRC. Seventeen of the 19 (including two first detected in Angola) resulted in 235 paralysis cases notified in 84 health zones in 18 of DRC's 26 provinces; no notified paralysis cases were associated with the remaining two outbreaks. The DRC-KAS-3 cVDPV2 outbreak that circulated during 2019-2021, and resulted in 101 paralysis cases in 10 provinces, was the largest recorded in DRC during the reporting period in terms of numbers of paralysis cases and geographic expanse. The 15 outbreaks occurring during 2017-early 2021 were successfully controlled with numerous supplemental immunization activities (SIAs) using monovalent OPV Sabin-strain serotype 2 (mOPV2); however, suboptimal mOPV2 vaccination coverage appears to have seeded the cVDPV2 emergences detected during semester 2, 2018 through 2021. Use of the novel OPV serotype 2 (nOPV2), designed to have greater genetic stability than mOPV2, should help DRC's efforts in controlling the more recent cVDPV2 outbreaks with a much lower risk of further seeding VDPV2 emergence. Improving nOPV2 SIA coverage should decrease the number of SIAs needed to interrupt transmission. DRC needs the support of polio eradication and Essential Immunization (EI) partners to accelerate the country's ongoing initiatives for EI strengthening, introduction of a second dose of inactivated poliovirus vaccine (IPV) to increase protection against paralysis, and improving nOPV2 SIA coverage.

    • Injury and Violence
      1. Associations between exposure to school violence and weapon-carrying at school
        Lowry R, Parker E, Ratto J, Krause K, Hertz M.
        Am J Prev Med. 2023 .
        INTRODUCTION: Among U.S. high school students, interpersonal violence and victimizations often occur on school property. The presence of a weapon can increase the potential for injury and death resulting from an interpersonal conflict. This study examines the associations between exposure to school violence and weapon-carrying on school property among U.S. high school students. METHODS: Data from the 2017 and 2019 national Youth Risk Behavior Surveys were combined (N=28,442) and analyzed in 2022. Multivariable logistic regression models were used to calculate sex-stratified, adjusted (for race/ethnicity, grade, sexual identity, current substance use, suicidal thoughts, and history of concussion) prevalence ratios (aPRs). Prevalence ratios were considered statistically significant if 95% CIs did not include 1.0. RESULTS: Male students (4.7%) were more likely than female students (1.8%) to report carrying a weapon at school during the 30 days preceding the survey. Compared to students who did not experience school violence, weapon-carrying at school was more prevalent among students who were threatened or injured with a weapon at school (male students, aPR=3.45; female students, aPR=3.90); were involved in a physical fight at school (male students, aPR=3.44; female students, aPR=3.72); missed school because they did not feel safe (male students, aPR=1.98; female students, aPR=2.97); and among male students who were bullied at school (aPR=1.72). CONCLUSIONS: Increased emphasis on safe and supportive school environments, where all types of interpersonal violence are less likely to occur, and increased access to programs and services to promote mental health, prevent violence, and deter weapon use are needed.

    • Laboratory Sciences
      1. Effect of parental age, parity, and pairing approach on reproduction in strain 13/N guinea pigs (Cavia porcellus)
        Genzer SC, Flietstra T, Coleman-McCray JD, Tansey C, Welch SR, Spengler JR.
        Animals (Basel). 2023 ;13(5).
        Guinea pigs are important animal models for human disease, and both outbred and inbred lines are utilized in biomedical research. The optimal maintenance of guinea pig colonies, commercially and in research settings, relies on robust informed breeding programs, however, breeding data on specialized inbred strains are limited. Here, we investigated the effects of parental age, parity, and pairing approaches on mean total fetus count, percentage of female pups in the litter, and pup survival rate after 10 days in strain 13/N guinea pigs. Our analysis of colony breeding data indicates that the average litter size is 3.3 pups, with a 25.2% stillbirth rate, a failure-to-thrive outcome in 5.1% of pups, and a 10 day survival rate of 69.7%. The only variable to significantly affect the reproductive outcomes examined was parental age (p < 0.05). In comparison to adults, both juvenile and geriatric sows had lower total fetus counts; juvenile boars had a higher percentage of females in litters, and geriatric boars had a lower 10 day survival rate of pups. These studies provide valuable information regarding the reproductive characteristics of strain 13/N guinea pigs, and support a variety of breeding approaches without significant effects on breeding success.

      2. Development of an LC-MRM-MS-based candidate reference measurement procedure for standardization of serum apolipoprotein (a) tests
        Ruhaak LR, Romijn F, Begcevic Brkovic I, Kuklenyik Z, Dittrich J, Ceglarek U, Hoofnagle AN, Althaus H, Angles-Cano E, Coassin S, Delatour V, Deprez L, Dikaios I, Kostner GM, Kronenberg F, Lyle A, Prinzing U, Vesper HW, Cobbaert CM.
        Clin Chem. 2023 ;69(3):251-261.
        BACKGROUND: Medical results generated by European CE Marking for In Vitro Diagnostic or in-house tests should be traceable to higher order reference measurement systems (RMS), such as International Federation of Clinical Chemistry and Laboratory Medicine (IFCC)-endorsed reference measurement procedures (RMPs) and reference materials. Currently, serum apolipoprotein (a) [apo(a)] is recognized as a novel risk factor for cardiovascular risk assessment and patient management. The former RMS for serum apo(a) is no longer available; consequently, an International System of Units (SI)-traceable, ideally multiplexed, and sustainable RMS for apo(a) is needed. METHODS: A mass spectrometry (MS)-based candidate RMP (cRMP) for apo(a) was developed using quantitative bottom-up proteomics targeting 3 proteotypic peptides. The method was provisionally validated according to ISO 15193 using a single human serum based calibrator traceable to the former WHO-IFCC RMS. RESULTS: The quantitation of serum apo(a) was by design independent of its size polymorphism, was linear from 3.8 to 456 nmol/L, and had a lower limit of quantitation for apo(a) of 3.8 nmol/L using peptide LFLEPTQADIALLK. Interpeptide agreement showed Pearson Rs of 0.987 and 0.984 for peptides GISSTVTGR and TPENYPNAGLTR, and method comparison indicated good correspondence (slopes 0.977, 1.033, and 1.085 for LFLEPTQADIALLK, GISSTVTGR, and TPENYPNAGLTR). Average within-laboratory imprecision of the cRMP was 8.9%, 11.9%, and 12.8% for the 3 peptides. CONCLUSIONS: A robust, antibody-independent, MS-based cRMP was developed as higher order RMP and an essential part of the apo(a) traceability chain and future RMS. The cRMP fulfils predefined analytical performance specifications, making it a promising RMP candidate in an SI-traceable MS-based RMS for apo(a).

      3. Distinct in vitro and in vivo neutralization profiles of monoclonal antibodies elicited by the receptor binding domain of the ancestral SARS-CoV-2
        Kwon HJ, Zhang J, Kosikova M, Tang W, Ortega-Rodriguez U, Peng H, Meseda CA, Pedro CL, Schmeisser F, Lu J, Kang I, Zhou B, Davis CT, Wentworth DE, Chen WH, Shriver MC, Barnes RS, Pasetti MF, Weir JP, Chen B, Xie H.
        J Med Virol. 2023 .
        Broadly neutralizing antibodies against SARS-CoV-2 variants are sought to curb COVID-19 infections. Here we produced and characterized a set of mouse monoclonal antibodies (mAbs) specific for the ancestral SARS-CoV-2 receptor binding domain (RBD). Two of them, 17A7 and 17B10, were highly potent in microneutralization assay with 50% inhibitory concentration (IC(50) ) ≤ 135 ng/ml against infectious SARS-CoV-2 variants, including G614, Alpha, Beta, Gamma, Delta, Epsilon, Zeta, Kappa, Lambda, B.1.1.298, B.1.222, B.1.5 and R.1. Both mAbs (especially 17A7) also exhibited strong in vivo efficacy in protecting K18-hACE2 transgenic mice from the lethal infection with G614, Alpha, Beta, Gamma and Delta viruses. Structural analysis indicated that 17A7 and 17B10 target the tip of the receptor binding motif (RBM) in the RBD-up conformation. A third RBD-reactive mAb (3A6) although escaped by Beta and Gamma, was highly effective in cross-neutralizing Delta and Omicron BA.1 variants in vitro and in vivo. In competition experiments, antibodies targeting epitopes similar to these 3 mAbs were rarely enriched in human COVID-19 convalescent sera or post-vaccination sera. These results are helpful to inform new antibody/vaccine design and these mAbs can be useful tools for characterizing SARS-CoV-2 variants and elicited antibody responses. This article is protected by copyright. All rights reserved.

      4. Aerosolize this: Generation, collection, and analysis of aerosolized virus in laboratory settings
        Belser JA, Pulit-Penaloza JA, Maines TR.
        PLoS Pathog. 2023 ;19(3):e1011178.

      5. Advancing blood transfusion safety using molecular detection in the country of Georgia
        Alkhazashvili M, Bloch EM, Shadaker S, Kuchuloria T, Getia V, Turdziladze A, Armstrong PA, Gamkrelidze A.
        Transfus Clin Biol. 2023 .
        BACKGROUND: In 2015, the country of Georgia initiated its hepatitis C virus (HCV) elimination program. Given a high background incidence of HCV infection, centralized nucleic acid testing (NAT) of blood donations was prioritized for implementation. STUDY DESIGN AND METHODS: Multiplex NAT screening for HIV, HCV and hepatitis B virus (HBV) was launched in January 2020. An analysis was conducted of serological and NAT donor/donation data for the first year of screening (through December 2020). RESULTS: A total of 54,116 donations representing 39,164 unique donors were evaluated. Overall, 671 donors (1.7%) tested positive for at least one infectious marker by serology or NAT, with the highest prevalence among donors aged 40-49 years (2.5%; n=200), male (1.9%; n=524), replacement (2.8%; n=153) and first time (2.1%; n=642) donors. Sixty donations were seronegative but NAT positive, and therefore would not have been found by traditional serology testing alone. These were more likely among female vs. male (adjusted odds ratio [aOR] 2.06; 95% confidence interval [95%CI]: 1.05-4.05), paid (aOR 10.15; 95%CI: 2.80-36.86) or voluntary (aOR 4.30; 95%CI: 1.27-14.56) vs replacement, and repeat vs. first time (aOR 13.98; 95%CI: 4.06-48.12) donors. On repeat serological testing (including HBV core antibody [HBcAb] testing), 6 HBV+ donations, 5 HCV+ donations and 1 HIV+ donations were deemed NAT yield (detected through the implementation of NAT, and would have otherwise been missed by serology screening alone). CONCLUSION: This analysis offers a regional model for NAT implementation, demonstrating the feasibility and clinical utility in a nationwide blood program.

    • Maternal and Child Health
      1. Prevalence and descriptive epidemiology of Turner syndrome in the United States, 2000-2017: A report from the National Birth Defects Prevention Network
        Martin-Giacalone BA, Lin AE, Rasmussen SA, Kirby RS, Nestoridi E, Liberman RF, Agopian AJ, Carey JC, Cragan JD, Forestieri N, Leedom V, Boyce A, Nembhard WN, Piccardi M, Sandidge T, Shan X, Shumate CJ, Stallings EB, Stevenson R, Lupo PJ.
        Am J Med Genet A. 2023 .
        The lack of United States population-based data on Turner syndrome limits assessments of prevalence and associated characteristics for this sex chromosome abnormality. Therefore, we collated 2000-2017 data from seven birth defects surveillance programs within the National Birth Defects Prevention Network. We estimated the prevalence of karyotype-confirmed Turner syndrome diagnosed within the first year of life. We also calculated the proportion of cases with commonly ascertained birth defects, assessed associations with maternal and infant characteristics using prevalence ratios (PR) with 95% confidence intervals (CI), and estimated survival probability. The prevalence of Turner syndrome of any pregnancy outcome was 3.2 per 10,000 female live births (95% CI = 3.0-3.3, program range: 1.0-10.4), and 1.9 for live birth and stillbirth (≥20 weeks gestation) cases (95% CI = 1.8-2.1, program range: 0.2-3.9). Prevalence was lowest among cases born to non-Hispanic Black women compared to non-Hispanic White women (PR = 0.5, 95% CI = 0.4-0.6). Coarctation of the aorta was the most common defect (11.6% of cases), and across the cohort, individuals without hypoplastic left heart had a five-year survival probability of 94.6%. The findings from this population-based study may inform surveillance practices, prenatal counseling, and diagnosis. We also identified racial and ethnic disparities in prevalence, an observation that warrants further investigation.

      2. Gaps in prenatal hepatitis B screening and management of HBsAg positive pregnant persons in the U.S., 2015-2020
        Pham TT, Maria N, Cheng V, Nguyen B, Toy M, Hutton D, Conners EE, Nelson NP, Salomon JA, So S.
        Am J Prev Med. 2023 .
        BACKGROUND: The Advisory Committee for Immunization Practices (ACIP) recommends testing all pregnant women for hepatitis B surface antigen (HBsAg) and testing HBsAg-positive pregnant women for hepatitis B virus deoxyribonucleic acid (HBV DNA). HBsAg-positive pregnant persons are recommended by the American Association for the Study of Liver Diseases to receive regular monitoring, including alanine transaminase (ALT) and HBV DNA and antiviral therapy for active hepatitis and to prevent perinatal HBV transmission if HBV DNA level is >200,000 IU/mL. METHODS: Using Optum Clinformatics Data Mart Database claims data, pregnant women who received HBsAg testing and HBsAg-positive pregnant persons who received HBV DNA and alt testing and antiviral therapy during pregnancy and after delivery during January 1, 2015-December 31, 2020 were analyzed. RESULTS: Among 506,794 pregnancies, 14.6% did not receive HBsAg testing. Pregnant women more likely to receive testing for HBsAg (p<0.01) were persons aged ≥20 years, were Asian, had >1 child, or received education beyond high school. Among the 0.28% (1,437) pregnant women who tested positive for hepatitis B surface antigen, 46% were Asian. The proportion of HBsAg-positive pregnant women who received HBV DNA testing during pregnancy and in the 12 months after delivery was 44.3% and 28.6%, respectively; the proportion that received HBsAg was 31.6% and 12.7%, respectively; the proportion that received ALT testing was 67.4% and 47%, respectively; and the proportion that received HBV antiviral therapy was 7% and 6.2%, respectively. CONCLUSIONS: This study suggests that as many as half a million (∼14%) pregnant persons who gave birth each year were not tested for HBsAg to prevent perinatal transmission. More than 50% of HBsAg-positive persons did not receive the recommended HBV-directed monitoring tests during pregnancy and after delivery.

      3. Cardiac arrest during delivery hospitalization : A cohort study
        Ford ND, DeSisto CL, Galang RR, Kuklina EV, Sperling LS, Ko JY.
        Ann Intern Med. 2023 .
        BACKGROUND: Estimates of cardiac arrest occurring during delivery guide evidence-based strategies to reduce pregnancy-related death. OBJECTIVE: To investigate rate of, maternal characteristics associated with, and survival after cardiac arrest during delivery hospitalization. DESIGN: Retrospective cohort study. SETTING: U.S. acute care hospitals, 2017 to 2019. PARTICIPANTS: Delivery hospitalizations among women aged 12 to 55 years included in the National Inpatient Sample database. MEASUREMENTS: Delivery hospitalizations, cardiac arrest, underlying medical conditions, obstetric outcomes, and severe maternal complications were identified using codes from the International Classification of Diseases, 10th Revision, Clinical Modification. Survival to hospital discharge was based on discharge disposition. RESULTS: Among 10 921 784 U.S. delivery hospitalizations, the cardiac arrest rate was 13.4 per 100 000. Of the 1465 patients who had cardiac arrest, 68.6% (95% CI, 63.2% to 74.0%) survived to hospital discharge. Cardiac arrest was more common among patients who were older, were non-Hispanic Black, had Medicare or Medicaid, or had underlying medical conditions. Acute respiratory distress syndrome was the most common co-occurring diagnosis (56.0% [CI, 50.2% to 61.7%]). Among co-occurring procedures or interventions examined, mechanical ventilation was the most common (53.2% [CI, 47.5% to 59.0%]). The rate of survival to hospital discharge after cardiac arrest was lower with co-occurring disseminated intravascular coagulation (DIC) without or with transfusion (50.0% [CI, 35.8% to 64.2%] or 54.3% [CI, 39.2% to 69.5%], respectively). LIMITATIONS: Cardiac arrests occurring outside delivery hospitalizations were not included. The temporality of arrest relative to the delivery or other maternal complications is unknown. Data do not distinguish cause of cardiac arrest, such as pregnancy-related complications or other underlying causes among pregnant women. CONCLUSION: Cardiac arrest was observed in approximately 1 in 9000 delivery hospitalizations, among which nearly 7 in 10 women survived to hospital discharge. Survival was lowest during hospitalizations with co-occurring DIC. PRIMARY FUNDING SOURCE: None.

      4. BACKGROUND: Classical homocystinuria (HCU) results from deficient cystathionine β-synthase activity, causing elevated levels of Met and homocysteine (Hcy). Newborn screening (NBS) aims to identify HCU in pre-symptomatic newborns by assessing Met concentrations in first-tier screening. However, unlike Hcy, Met testing leads to a high number of false-positive and -negative results. Therefore, screening for Hcy directly in first-tier screening would be a better biomarker for use in NBS. METHODS: Dried blood spot (DBS) quality control and residual clinical specimens were used in analyses. Several reducing and maleimide reagents were investigated to aid in quantification of total Hcy (tHcy). The assay which was developed and validated was performed by flow injection analysis-tandem mass spectrometry (FIA-MS/MS). RESULTS: Interferents of tHcy measurement were identified, so selective derivatization of Hcy was employed. Using N-ethylmaleimide (NEM) to selectively derivatize Hcy allowed interferent-free quantification of tHcy by FIA-MS/MS in first-tier NBS. The combination of tris(2-carboxyethyl)phosphine (TCEP) and NEM yielded significantly less matrix effects compared to dithiothreitol (DTT) and NEM. Analysis of clinical specimens demonstrated that the method could distinguish between HCU-positive, presumptive normal newborns, and newborns receiving total parenteral nutrition. CONCLUSIONS: Here we present the first known validated method capable of screening tHcy in DBS during FIA-MS/S first-tier NBS.

      5. Sudden unexpected infant deaths: 2015-2020
        Shapiro-Mendoza CK, Woodworth KR, Cottengim CR, Erck Lambert AB, Harvey EM, Monsour M, Parks SE, Barfield WD.
        Pediatrics. 2023 .
        OBJECTIVE: Although the US infant mortality rate reached a record low in 2020, the sudden infant death syndrome (SIDS) rate increased from 2019. To understand if the increase was related to changing death certification practices or the coronavirus disease 2019 (COVID-19) pandemic, we examined sudden unexpected infant death (SUID) rates as a group, by cause, and by race and ethnicity. METHODS: We estimated SUID rates during 2015 to 2020 using US period-linked birth and death data. SUID included SIDS, unknown cause, and accidental suffocation and strangulation in bed. We examined changes in rates from 2019 to 2020 and assessed linear trends during prepandemic (2015-2019) using weighted least squares regression. We also assessed race and ethnicity trends and quantified COVID-19-related SUID. RESULTS: Although the SIDS rate increased significantly from 2019 to 2020 (P < .001), the overall SUID rate did not (P = .24). The increased SIDS rate followed a declining linear trend in SIDS during 2015 to 2019 (P < .001). Other SUID causes did not change significantly. Our race and ethnicity analysis showed SUID rates increased significantly for non-Hispanic Black infants from 2019 to 2020, widening the disparities between these two groups during 2017 to 2019. In 2020, <10 of the 3328 SUID had a COVID-19 code. CONCLUSIONS: Diagnositic shifting likely explained the increased SIDS rate in 2020. Why the SUID rate increased for non-Hispanic Black infants is unknown, but warrants continued monitoring. Interventions are needed to address persistent racial and ethnic disparities in SUID.

    • Nutritional Sciences
      1. Meeting the Healthy People 2030 added sugars target
        Stowe EW, Moore LV, Hamner HC, Park S, Gunn JP, Juan W, Kantor MA, Galuska DA.
        Am J Prev Med. 2023 .
        INTRODUCTION: Many Americans exceed the dietary recommendations for added sugars. Healthy People 2030 set a population target mean of 11.5% calories from added sugars for persons aged ≥2 years. This paper describes the reductions needed in population groups with varying added sugars intake to meet this target using 4 different public health approaches. METHODS: Data from the 2015-2018 National Health and Nutrition Examination Survey (n=15,038) and the National Cancer Institute method were used to estimate the usual percentage calories from added sugars. Four approaches investigated lowering intake among (1) the general U.S. population, (2) people exceeding the 2020-2025 Dietary Guidelines for Americans recommendation for added sugars (≥10% calories/day), (3) high consumers of added sugars (≥15% calories/day), or (4) people exceeding the Dietary Guidelines for Americans recommendation for added sugars with 2 different reductions on the basis of added sugars intake. Added sugars intake was examined before and after reduction by sociodemographic characteristics. RESULTS: To meet the Healthy People 2030 target using the 4 approaches, added sugars intake needs to decrease by an average of (1) 13.7 calories/day for the general population; (2) 22.0 calories/day for people exceeding the Dietary Guidelines for Americans recommendation; (3) 56.6 calories/day for high consumers; or (4) 13.9 and 32.3 calories/day for people consuming 10 to <15% and ≥15% calories from added sugars, respectively. Differences in added sugars intake were observed before and after reduction by race/ethnicity, age, and income. CONCLUSIONS: The Healthy People 2030 added sugars target is achievable with modest reductions in added sugars intake, ranging from 14 to 57 calories/day depending on the approach.

      2. BACKGROUND: Globally, emergency nutrition program adaptations were implemented as part of COVID-19 mitigation strategies, but the implications of the adoption of all protocol changes at scale in the context of deteriorating food security are not yet well characterized. With ongoing conflict, widespread floods, and declining food security, the secondary impacts of COVID-19 on child survival in South Sudan is of great concern. In light of this, the present study aimed to characterize the impact of COVID-19 on nutrition programming in South Sudan. METHODS: A mixed methods approach including a desk review and secondary analysis of facility-level program data was used to analyze trends in program indicators over time and compare two 15-month periods prior to the onset of COVID-19 (January 2019 - March 2020; "pre-COVID period") and after the start of the pandemic (April 2020 - June 2021; "COVID" period) in South Sudan. RESULTS: The median number of reporting Community Management of Acute Malnutrition sites increased from 1167 pre-COVID to 1189 during COVID. Admission trends followed historic seasonal patterns in South Sudan; however, compared to pre-COVID, declines were seen during COVID in total admissions (- 8.2%) and median monthly admissions (- 21.8%) for severe acute malnutrition. For moderate acute malnutrition, total admissions increased slightly during COVID (1.1%) while median monthly admissions declined (- 6.7%). Median monthly recovery rates improved for severe (92.0% pre-COVID to 95.7% during COVID) and moderate acute malnutrition (91.5 to 94.3%) with improvements also seen in all states. At the national level, rates also decreased for default (- 2.4% for severe, - 1.7% for moderate acute malnutrition) and non-recovery (- 0.9% for severe, - 1.1% for moderate acute malnutrition), with mortality rates remaining constant at 0.05-0.15%. CONCLUSIONS: Within the context of the ongoing COVID-19 pandemic in South Sudan, improved recovery, default, and non-responder rates were observed following adoption of changes to nutrition protocols. Policymakers in South Sudan and other resource-constrained settings should consider if simplified nutrition treatment protocols adopted during COVID-19 improved performance and should be maintained in lieu of reverting to standard treatment protocols.

      3. Emerging issues in probiotic safety: 2023 perspectives
        Merenstein D, Pot B, Leyer G, Ouwehand AC, Preidis GA, Elkins CA, Hill C, Lewis ZT, Shane AL, Zmora N, Petrova MI, Collado MC, Morelli L, Montoya GA, Szajewska H, Tancredi DJ, Sanders ME.
        Gut Microbes. 2023 ;15(1):2185034.
        Probiotics are used for both generally healthy consumers and in clinical settings. However, theoretical and proven adverse events from probiotic consumption exist. New probiotic strains and products, as well as expanding use of probiotics into vulnerable populations, warrants concise, and actionable recommendations on how to work toward their safe and effective use. The International Scientific Association for Probiotics and Prebiotics convened a meeting to discuss and produce evidence-based recommendations on potential acute and long-term risks, risks to vulnerable populations, the importance for probiotic product quality to match the needs of vulnerable populations, and the need for adverse event reporting related to probiotic use. The importance of whole genome sequencing, which enables determination of virulence, toxin, and antibiotic resistance genes, as well as clear assignment of species and strain identity, is emphasized. We present recommendations to guide the scientific and medical community on judging probiotic safety. What is the context? Probiotics, available to healthy consumers as both dietary supplements and foods, are also used by some patient populations. The goal of this paper is to determine if any new factors have emerged that would impact current views about probiotic safety for both these populations.What is new? The authors conclude that established practices are sensibly addressing factors important to the safety of traditional probiotics used by the general population. They also make recommendations regarding emerging safety considerations. Probiotics targeted for patient populations should undergo stringent testing to meet quality standards appropriate for that population, preferably verified by an independent third party. The safety of probiotics derived from species without a history of safe use must be considered on a case-by-case basis. Research is needed to address some gaps, for example which best animal models to use for safety assessment of live microbes, the possibility of antibiotic resistance gene transfer via transformation, and potential impact of probiotic-induced changes in microbiomes, interactions with drugs, and probiotic colonization.What is the impact? Probiotics of sufficient quality for patient populations are being developed and should be used accordingly. Long-term safety assessments for probiotics should be consistent with, and not more stringent than, current regulatory requirements for biologic drugs, including fecal microbial transplants. Rigor in collecting and reporting data on adverse events is needed. The authors confirm the need for understanding the entire genetic makeup of a probiotic as a cornerstone for assessing its safety. eng

      4. BACKGROUND: The Vitamin A Laboratory-External Quality Assessment (VITAL-EQA) program operated by the CDC provides analytical performance assessment to low-resource laboratories conducting serum vitamins A (VIA), D (VID), B-12 (B12), and folate (FOL), as well as ferritin (FER) and CRP measurements for public health studies. OBJECTIVES: We aimed to describe the long-term performance of VITAL-EQA participants from 2008 to 2017. METHODS: Participating laboratories received 3 blinded serum samples biannually for duplicate analysis over 3 d. We assessed results (n = 6) for relative difference (%) from the CDC target value and imprecision (% CV) and conducted descriptive statistics on the aggregate 10-year and round-by-round data. Performance criteria were based on biologic variation and deemed acceptable (optimal, desirable, or minimal performance) or unacceptable (less than minimal performance). RESULTS: Thirty-five countries reported VIA, VID, B12, FOL, FER, and CRP results from 2008-2017. The proportion of laboratories with acceptable performance ranged widely by round: VIA 48%-79% (for difference) and 65%-93% (for imprecision), VID 19%-63% and 33%-100%, B12 0%-92% and 73%-100%, FOL 33%-89% and 78%-100%, FER 69%-100% and 73%-100%, and CRP 57%-92% and 87%-100%. On aggregate, ≥60% of laboratories achieved acceptable differences for VIA, B12, FOL, FER, and CRP (only 44% for VID), and over 75% of laboratories achieved acceptable imprecision for all 6 analytes. Laboratories participating continuously in 4 rounds (2016-2017) showed generally similar performance compared to laboratories participating occasionally. CONCLUSIONS: Although we observed little change in laboratory performance over time, on aggregate, >50% of the participating laboratories achieved acceptable performance, with acceptable imprecision being achieved more often than acceptable difference. The VITAL-EQA program is a valuable tool for low-resource laboratories to observe the state of the field and track their own performance over time. However, the small number of samples per round and the constant changes in laboratory participants make it difficult to identify long-term improvements.

    • Occupational Safety and Health
      1. Temporal trends in occupational injuries treated in US emergency departments, 2012-2019
        Lundstrom EW, Hendricks SA, Marsh SM, Groth CP, Smith GS, Bhandari R.
        Inj Epidemiol. 2023 ;10(1):13.
        BACKGROUND: Evidence suggests that rates of occupational injuries in the US are decreasing. As several different occupational injury surveillance systems are used in the US, more detailed investigation of this trend is merited. Furthermore, studies of this decrease remain descriptive and do not use inferential statistics. The aim of this study was to provide both descriptive and inferential statistics of temporal trends of occupational injuries treated in US emergency departments (EDs) for 2012 to 2019. METHODS: Monthly non-fatal occupational injury rates from 2012 to 2019 were estimated using the national electronic injury surveillance system-occupational supplement (NEISS-Work) dataset, a nationally representative sample of ED-treated occupational injuries. Rates were generated for all injuries and by injury event type using monthly full-time worker equivalent (FTE) data from the US Current Population Survey as a denominator. Seasonality indices were used to detect seasonal variation in monthly injury rates. Trend analysis using linear regression adjusted for seasonality was conducted to quantify changes in injury rates from 2012 to 2019. RESULTS: Occupational injuries occurred at an average rate of 176.2 (95% CI =  ± 30.9) per 10,000 FTE during the study period. Rates were highest in 2012 and declined to their lowest level in 2019. All injury event types occurred at their highest rate in summer months (July or August) apart from falls, slips, and trips, which occurred at their highest rate in January. Trend analyses indicated that total injury rates decreased significantly throughout the study period (- 18.5%; 95% CI =  ± 14.5%). Significant decreases were also detected for injuries associated with contact with foreign object and equipment (- 26.9%; 95% CI =  ± 10.5%), transportation incidents (- 23.2%; 95% CI =  ± 14.7%), and falls, slips, and trips (- 18.1%; 95% CI =  ± 8.9%). CONCLUSIONS: This study supports evidence that occupational injuries treated in US EDs have decreased since 2012. Potential contributors to this decrease include increased workplace mechanization and automation, as well as changing patterns in US employment and health insurance access.

      2. Four futures for occupational safety and health
        Felknor SA, Streit JM, Edwards NT, Howard J.
        Int J Environ Res Public Health. 2023 ;20(5).
        Rapid changes to the nature of work have challenged the capacity of existing occupational safety and health (OSH) systems to ensure safe and productive workplaces. An effective response will require an expanded focus that includes new tools for anticipating and preparing for an uncertain future. Researchers at the U.S. National Institute for Occupational Safety and Health (NIOSH) have adopted the practice of strategic foresight to structure inquiry into how the future will impact OSH. Rooted in futures studies and strategic management, foresight creates well-researched and informed future scenarios that help organizations better prepare for potential challenges and take advantage of new opportunities. This paper summarizes the inaugural NIOSH strategic foresight project, which sought to promote institutional capacity in applied foresight while exploring the future of OSH research and practice activities. With multidisciplinary teams of subject matter experts at NIOSH, we undertook extensive exploration and information synthesis to inform the development of four alternative future scenarios for OSH. We describe the methods we developed to craft these futures and discuss their implications for OSH, including strategic responses that can serve as the basis for an action-oriented roadmap toward a preferred future.

    • Parasitic Diseases
      1. Molecular markers of sulfadoxine-pyrimethamine resistance in samples from children with uncomplicated plasmodium falciparum at three sites in Angola in 2019
        Rosillo SR, Dimbu PR, Cândido AL, Oh JM, Ferreira CM, Nieto Andrade B, Labuda S, Horth R, Kelley J, Morais JF, Fortes F, Martins JF, Talundzic E, Pluciński MM.
        Antimicrob Agents Chemother. 2023 :e0160122.
        Sulfadoxine-pyrimethamine (SP) is used for prevention of malaria in pregnant women in Angola. We sequenced the Plasmodium falciparum dihydrofolate reductase (pfdhfr) and dihydropteroate synthase (pfdhps) genes, implicated in SP resistance, in samples collected during a 2019 study of artemisinin-based combination therapy efficacy in Benguela, Lunda Sul, and Zaire provinces. A total of 90 day 0 and day of failure samples were individually sequenced, while 508 day 0 samples from participants without recurrent parasitemia were pooled after DNA extraction into 61 pools. The N51I, C59R, and S108N pfdhfr mutations and A437G pfdhps mutations were present at high proportions in all provinces (weighted allele frequencies, 62% to 100%). The K540E pfdhps mutation was present at lower proportions (10% to 14%). The A581G pfdhps mutation was only observed in Zaire, at a 4.6% estimated prevalence. The I431V and A613S mutations were also only observed in Zaire, at a prevalence of 2.8% to 2.9%. The most common (27% to 66%) reconstructed haplotype in all three provinces was the canonical quadruple pfdhfr pfdhps mutant. The canonical quintuple mutant was absent in Lunda Sul and Benguela and present in 7.9% of samples in Zaire. A single canonical sextuple (2.6%) mutant was observed in Zaire Province. Proportions of the pfdhps K540E and A581G mutations were well below the World Health Organization thresholds for meaningful SP resistance (prevalence of 95% for K540E and 10% for A581G). Samples from therapeutic efficacy studies represent a convenient source of samples for monitoring SP resistance markers.

      2. Effectiveness of intermittent screening and treatment of malaria in pregnancy on maternal and birth outcomes in selected districts in Rwanda: A cluster randomized controlled trial
        Uwimana A, Sethi R, Murindahabi M, Ntirandeka C, Piercefield E, Umulisa N, Abram A, Eckert E, Munguti K, Sullivan D, Uyizeye D, Mbituyumuremyi A, Gutman JR.
        Clin Infect Dis. 2023 .
        BACKGROUND: Malaria during pregnancy can cause serious consequences including maternal anemia and low birthweight (LBW). Routine antenatal care (ANC) in Rwanda includes malaria symptom screening at each ANC visit. This cluster randomized controlled trial investigated whether adding intermittent screening with a malaria rapid diagnostic test (RDT) at each routine ANC visit and treatment of positives during pregnancy (ISTp) is more effective than routine ANC for reducing malaria prevalence at delivery. METHODS: Between September 2016- June 2018, pregnant women initiating ANC at 14 health centers in Rwanda were enrolled into ISTp or control arms. All women received an insecticide-treated bed net at enrolment. Hemoglobin concentration, placental and peripheral parasitemia, newborn outcome, birthweight, and prematurity were assessed at delivery. RESULTS: 975 were enrolled in ISTp and 811 in the control. Routine ANC plus ISTp did not significantly reduce PCR-confirmed placental malaria compared to control (adjusted relative risk [aRR] 0.94, 95% confidence interval [CI] 0.59-1.50, p=0.799). ISTp had no impact on anemia (aRR 1.08, 95% CI 0.57-2.04, p=0.821). The mean birthweight of singleton newborns was not significantly different between arms (3054gm vs 3096gm, p=0.395), however women in the ISTp arm had a higher proportion of LBW (aRR = 1.59, 95% CI 1.02-2.49, p=0.042). CONCLUSIONS: This is the only study to compare ISTp to symptomatic screening at ANC in a setting where intermittent preventive treatment is not routinely provided. ISTp did not reduce the prevalence of malaria or anemia at delivery and was associated with an increased risk of LBW. CLINICAL TRIALS REGISTRATION: NCT03508349.

      3. Effect of monthly intermittent preventive treatment with dihydroartemisinin-piperaquine with and without azithromycin versus monthly sulfadoxine-pyrimethamine on adverse pregnancy outcomes in Africa: a double-blind randomised, partly placebo-controlled trial
        Madanitsa M, Barsosio HC, Minja DT, Mtove G, Kavishe RA, Dodd J, Saidi Q, Onyango ED, Otieno K, Wang D, Ashorn U, Hill J, Mukerebe C, Gesase S, Msemo OA, Mwapasa V, Phiri KS, Maleta K, Klein N, Magnussen P, Lusingu JP, Kariuki S, Mosha JF, Alifrangis M, Hansson H, Schmiegelow C, Gutman JR, Chico RM, Ter Kuile FO.
        Lancet. 2023 .
        BACKGROUND: Intermittent preventive treatment in pregnancy (IPTp) with dihydroartemisinin-piperaquine is more effective than IPTp with sulfadoxine-pyrimethamine at reducing malaria infection during pregnancy in areas with high-grade resistance to sulfadoxine-pyrimethamine by Plasmodium falciparum in east Africa. We aimed to assess whether IPTp with dihydroartemisinin-piperaquine, alone or combined with azithromycin, can reduce adverse pregnancy outcomes compared with IPTp with sulfadoxine-pyrimethamine. METHODS: We did an individually randomised, double-blind, three-arm, partly placebo-controlled trial in areas of high sulfadoxine-pyrimethamine resistance in Kenya, Malawi, and Tanzania. HIV-negative women with a viable singleton pregnancy were randomly assigned (1:1:1) by computer-generated block randomisation, stratified by site and gravidity, to receive monthly IPTp with sulfadoxine-pyrimethamine (500 mg of sulfadoxine and 25 mg of pyrimethamine for 1 day), monthly IPTp with dihydroartemisinin-piperaquine (dosed by weight; three to five tablets containing 40 mg of dihydroartemisinin and 320 mg of piperaquine once daily for 3 consecutive days) plus a single treatment course of placebo, or monthly IPTp with dihydroartemisinin-piperaquine plus a single treatment course of azithromycin (two tablets containing 500 mg once daily for 2 consecutive days). Outcome assessors in the delivery units were masked to treatment group. The composite primary endpoint was adverse pregnancy outcome, defined as fetal loss, adverse newborn baby outcomes (small for gestational age, low birthweight, or preterm), or neonatal death. The primary analysis was by modified intention to treat, consisting of all randomised participants with primary endpoint data. Women who received at least one dose of study drug were included in the safety analyses. This trial is registered with ClinicalTrials.gov, NCT03208179. FINDINGS: From March-29, 2018, to July 5, 2019, 4680 women (mean age 25·0 years [SD 6·0]) were enrolled and randomly assigned: 1561 (33%; mean age 24·9 years [SD 6·1]) to the sulfadoxine-pyrimethamine group, 1561 (33%; mean age 25·1 years [6·1]) to the dihydroartemisinin-piperaquine group, and 1558 (33%; mean age 24·9 years [6.0]) to the dihydroartemisinin-piperaquine plus azithromycin group. Compared with 335 (23·3%) of 1435 women in the sulfadoxine-pyrimethamine group, the primary composite endpoint of adverse pregnancy outcomes was reported more frequently in the dihydroartemisinin-piperaquine group (403 [27·9%] of 1442; risk ratio 1·20, 95% CI 1·06-1·36; p=0·0040) and in the dihydroartemisinin-piperaquine plus azithromycin group (396 [27·6%] of 1433; 1·16, 1·03-1·32; p=0·017). The incidence of serious adverse events was similar in mothers (sulfadoxine-pyrimethamine group 17·7 per 100 person-years, dihydroartemisinin-piperaquine group 14·8 per 100 person-years, and dihydroartemisinin-piperaquine plus azithromycin group 16·9 per 100 person-years) and infants (sulfadoxine-pyrimethamine group 49·2 per 100 person-years, dihydroartemisinin-piperaquine group 42·4 per 100 person-years, and dihydroartemisinin-piperaquine plus azithromycin group 47·8 per 100 person-years) across treatment groups. 12 (0·2%) of 6685 sulfadoxine-pyrimethamine, 19 (0·3%) of 7014 dihydroartemisinin-piperaquine, and 23 (0·3%) of 6849 dihydroartemisinin-piperaquine plus azithromycin treatment courses were vomited within 30 min. INTERPRETATION: Monthly IPTp with dihydroartemisinin-piperaquine did not improve pregnancy outcomes, and the addition of a single course of azithromycin did not enhance the effect of monthly IPTp with dihydroartemisinin-piperaquine. Trials that combine sulfadoxine-pyrimethamine and dihydroartemisinin-piperaquine for IPTp should be considered. FUNDING: European & Developing Countries Clinical Trials Partnership 2, supported by the EU, and the UK Joint-Global-Health-Trials-Scheme of the Foreign, Commonwealth and Development Office, Medical Research Council, Department of Health and Social Care, Wellcome, and the Bill-&-Melinda-Gates-Foundation.

      4. Non-falciparum malaria infection and IgG seroprevalence among children under 15 years in Nigeria, 2018
        Herman C, Leonard CM, Uhomoibhi P, Maire M, Moss D, Inyang U, Abubakar A, Ogunniyi A, Mba N, Greby SM, Okoye MI, Iriemenam NC, Maikore I, Steinhardt L, Rogier E.
        Nat Commun. 2023 ;14(1):1360.
        Plasmodium falciparum (Pf) is the dominant malaria parasite in Nigeria though P. vivax (Pv), P. ovale (Po), and P. malariae (Pm) are also endemic. Blood samples (n = 31,234) were collected from children aged 0-14 years during a 2018 nationwide HIV survey and assayed for Plasmodium antigenemia, Plasmodium DNA, and IgG against Plasmodium MSP1-19 antigens. Of all children, 6.6% were estimated to have Pm infection and 1.4% Po infection with no Pv infections detected. The highest household wealth quintile was strongly protective against infection with Pm (aOR: 0.11, 95% CI: 0.05-0.22) or Po (aOR= 0.01, 0.00-0.10). Overall Pm seroprevalence was 34.2% (95% CI: 33.3-35.2) with lower estimates for Po (12.1%, 11.6-12.5) and Pv (6.3%, 6.0-6.7). Pm seropositivity was detected throughout the country with several local government areas showing >50% seroprevalence. Serological and DNA indicators show widespread exposure of Nigerian children to Pm with lower rates to Po and Pv.

    • Public Health Leadership and Management
      1. Public and population health in U.S. medical education: A review of guidance in extraordinary times
        Maeshiro R, Jarris YS, Prunuske J, Carney JK, Strelnick AH, Townsend JM, Krane NK, Johnson SB, Howley LD, Cashman SB, Deyton LR, Ortega LA, Lebwohl B, Fair M.
        Acad Med. 2023 .
        Generations of medical educators have recommended including public and population health (PPH) content in the training of U.S. physicians. The COVID-19 pandemic, structural racism, epidemic gun violence, and the existential threats caused by climate change are currently unsubtle reminders of the essential nature of PPH in medical education and practice. To assess the state of PPH content in medical education, the authors reviewed relevant guidance, including policies, standards, and recommendations from national bodies that represent and oversee medical education for physicians with MD degrees. Findings confirm that guidance across the medical education continuum, from premedical education to continuing professional development, increasingly includes PPH elements that vary in specificity and breadth. Graduate medical education policies present the most comprehensive approach in both primary care and subspecialty fields. Behavioral, quantitative, social, and systems sciences are represented, although not uniformly, in guidance for every phase of training. Quantitative PPH skills are frequently presented in the context of research, but not in relation to the development of population health perspectives (e.g., evidence-based medicine, quality improvement, policy development). The interdependence between governmental public health and medical practice, environmental health, and the impact of structural racism and other systems of oppression on health are urgent concerns, yet are not consistently or explicitly included in curricular guidance. To prepare physicians to meet the health needs of patients and communities, educators should identify and address gaps and inconsistencies in PPH curricula and related guidance. Re-examinations of public health and health care systems in the wake of the COVID-19 pandemic support the importance of PPH in physician training and practice, as physicians can help to bridge clinical and public health systems. This review provides an inventory of existing guidance (presented in the appendices) to assist educators in establishing PPH as an essential foundation of physician training and practice.

    • Reproductive Health
      1. Voluntary medical male circumcisions for HIV prevention - 13 countries in eastern and southern Africa, 2017-2021
        Peck ME, Ong KS, Lucas T, Harvey P, Lekone P, Letebele M, Thomas VT, Maziya V, Mkhontfo M, Gultie T, Mulatu D, Shimelis M, Zegeye T, Juma AW, Odoyo-June E, Musingila PK, Njenga J, Auld A, Kapito M, Maida A, Msungama W, Canda M, Come J, Malimane I, Aupokolo M, Zemburuka B, Kankindi I, Malamba S, Remera E, Tubane E, Machava R, Maphothi N, Vranken P, Amuri M, Kazaura KJ, Simbeye D, Alamo S, Kabuye G, Chituwo O, Kamboyi R, Masiye J, Mandisarisa J, Xaba S, Toledo C.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(10):256-260.
        In 2007, voluntary medical male circumcision (VMMC) was endorsed by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS after it was found to be associated with approximately a 60% reduction in the risk for female-to-male transmission of HIV (1). As a result of this endorsement, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), through partnerships with U.S. government agencies, including CDC, the U.S. Department of Defense, and the U.S. Agency for International Development, started supporting VMMCs performed in prioritized countries in southern and eastern Africa. During 2010-2016, CDC supported 5,880,372 VMMCs in 12 countries (2,3). During 2017-2021, CDC supported 8,497,297 VMMCs performed in 13 countries. In 2020, the number of VMMCs performed declined 31.8% compared with the number in 2019, primarily because of COVID-19-related disruptions to VMMC service delivery. PEPFAR 2017-2021 Monitoring, Evaluation, and Reporting data were used to provide an update and describe CDC's contribution to the scale-up of the VMMC program, which is important to meeting the 2025 Joint United Nations Programme on HIV/AIDS (UNAIDS) target of 90% of males aged 15-59 years having access to VMMC services in prioritized countries to help end the AIDS epidemic by 2030 (4).

    • Substance Use and Abuse
      1. The World Trade Center Health Program: Smoking cessation
        Lilly G, Calvert GM.
        Arch Environ Occup Health. 2023 :1-4.
        Cigarette smoking can cause and/or worsen a variety of health conditions. The U.S. Preventive Services Task Force (USPSTF) recommends that smoking cessation services be offered to all adults who currently smoke, and governmental and non-governmental professional organizations support providing these interventions to patients who smoke. The World Trade Center (WTC) Health Program, a federal program that provides health monitoring and treatment to those directed exposed to the September 11, 2001 terrorist attacks, provides smoking cessation therapy for eligible members. This paper identifies treatment strategies for smoking cessation and references the treatment coverage policy in the WTC Health Program. In addition, this paper notes the higher smoking prevalence among those with mental health conditions such as posttraumatic stress disorder (PTSD), and the need for heightened cessation efforts given the lower quit success rates among such persons.

    • Zoonotic and Vectorborne Diseases
      1. Detection of sporadic outbreaks of Rift Valley fever in Uganda through the National Viral Hemorrhagic Fever Surveillance System, 2017-2020
        Nyakarahuka L, Whitmer S, Klena J, Balinandi S, Talundzic E, Tumusiime A, Kyondo J, Mulei S, Patel K, Baluku J, Akurut G, Namanya D, Kamugisha K, Cossaboom C, Whitesell A, Telford C, Graziano J, Montgomery J, Nichol S, Lutwama J, Shoemaker T.
        Am J Trop Med Hyg. 2023 .
        Rift Valley fever (RVF) is a zoonotic disease of public health and economic importance. Uganda has reported sporadic outbreaks of RVF in both humans and animals across the country, especially in the southwestern part of the "cattle corridor" through an established viral hemorrhagic fever surveillance system. We report 52 human cases of laboratory-confirmed RVF from 2017 to 2020. The case fatality rate was 42%. Among those infected, 92% were males and 90% were adults (≥ 18 years). Clinical symptoms were characterized by fever (69%), unexplained bleeding (69%), headache (51%), abdominal pain (49%), and nausea and vomiting (46%). Most of the cases (95%) originated from central and western districts that are part of the cattle corridor of Uganda, where the main risk factor was direct contact with livestock (P = 0.009). Other predictors of RVF positivity were determined to be male gender (P = 0.001) and being a butcher (P = 0.04). Next-generation sequencing identified the predominant Ugandan clade as Kenya-2, observed previously across East Africa. There is need for further investigation and research into the effect and spread of this neglected tropical disease in Uganda and the rest of Africa. Control measures such as promoting vaccination and limiting animal-human transmission could be explored to reduce the impact of RVF in Uganda and globally.

      2. Historical targets for country-level animal rabies testing volumes were abandoned due to ethical and welfare concerns, and interpretation challenges of testing healthy animals. To-date, no quantitative threshold has been established for evaluating adequate surveillance capacity specific to suspected rabid animals. The purpose here is to establish quantitative testing thresholds for rabies suspected animals to assess a country's rabies surveillance capacity. Animal rabies testing data was obtained from official and unofficial rabies surveillance platforms from 2010 to 2019 and supplemented with official country reports and published literature. Testing rates were determined for all-animal and domestic animals, and standardized per 100,000 estimated human population; the domestic animal rate was also standardized per 100,000 estimated dog population. There were 113 countries that reported surveillance data eligible for analysis. Countries reporting the most data were under WHO categories as having endemic human rabies or no dog rabies. The annual median all-animal testing rate for all countries was 1.53 animals/100,000 human population (IQR 0.27-8.78). Three proposed testing rate thresholds are an all-animal rate of 1.9 animals/100,000 humans, a domestic animal per human rate of 0.8 animals/100,000 humans, and a domestic animal per dog rate of 6.6 animals/100,000 dogs. These three peer-derived rabies testing thresholds for passive surveillance can be used to facilitate assessment of a country's rabies surveillance capacity.


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