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Issue 14, April 4, 2023

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CDC Science Clips: Volume 15, Issue 14, April 4, 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. Examination of prediabetes and diabetes testing among US pediatric patients with overweight or obesity using an electronic health record
        Belay B, Kraus EM, Porter R, Pierce SL, Kompaniyets L, Lundeen EA, Imperatore G, Blanck HM, Goodman AB.
        Child Obes. 2023 .
        Background: Youth with excess weight are at risk of developing type 2 diabetes (T2DM). Guidelines recommend screening for prediabetes and/or T2DM after 10 years of age or after puberty in youth with excess weight who have ≥1 risk factor(s) for T2DM. Electronic health records (EHRs) offer an opportunity to study the use of tests to detect diabetes in youth. Methods: We examined the frequency of (1) diabetes testing and (2) elevated test results among youth aged 10-19 years with at least one BMI measurement in an EHR from 2019 to 2021. We examined the presence of hemoglobin A1C (A1C), fasting plasma glucose (FPG), or oral glucose tolerance test (2-hour plasma glucose [2-hrPG]) results and, among those tested, the frequency of elevated values (A1C ≥6.5%, FPG ≥126 mg/dL, or 2-hrPG ≥200 mg/dL). Patients with pre-existing diabetes (n = 6793) were excluded. Results: Among 1,024,743 patients, 17% had overweight, 21% had obesity, including 8% with severe obesity. Among patients with excess weight, 10% had ≥1 glucose test result. Among those tested, elevated values were more common in patients with severe obesity (27%) and obesity (22%) than in those with healthy weight (8%), and among Black youth (30%) than White youth (13%). Among patients with excess weight, >80% of elevated values fell in the prediabetes range. Conclusions: In youth with excess weight, the use of laboratory tests for prediabetes and T2DM was infrequent. Among youth with test results, elevated FPG, 2hrPG, or A1C levels were most common in those with severe obesity and Black youth.

        Belay, B. Kraus, E. M. Porter, R. Pierce, S. L. Kompaniyets, L. Lundeen, E. A. Imperatore, G. Blanck, H. M. Goodman, A. B.

      2. Diabetes is a significant population health threat. Evidence-based interventions, such as the Centers for Disease Control and Prevention's National Diabetes Prevention Program and diabetes self-management education and support programs, can help prevent, delay, or manage the disease. However, participation is suboptimal, especially among populations who are at an increased risk of developing diabetes. Evaluations of programs reaching populations who are medically underserved or people with lower incomes can help elucidate how best to tailor evidence-based interventions, but it is also important for evaluations to account for cultural and contextual factors. Culturally responsive evaluation (CRE) is a framework for centering an evaluation in the culture of the programs being evaluated. We integrated CRE with implementation and outcome constructs from the Adapted Consolidated Framework for Implementation Research (CFIR) to ensure that the evaluation produced useful evidence for putting evidence-based diabetes interventions to use in real-world settings, reaching populations who are at an increased risk of developing diabetes. The paper provides an overview of how we integrated CRE and CFIR approaches to conduct mixed-methods evaluations of evidence-based diabetes interventions.

        Farris, K. D. Rutledge, G. Smith, B. D.

      3. Variation in state-level mammography use, 2012 and 2020
        Howard DH, Tangka FK, Miller J, Sabatino SA.
        Public Health Rep. 2023 :333549231155876.
        OBJECTIVES: Mammography is a screening tool for early detection of breast cancer. Uptake in screening use in states can be influenced by Medicaid coverage and eligibility policies, public health outreach efforts, and the Centers for Disease Control and Prevention-funded National Breast and Cervical Cancer Early Detection Program. We described state-specific mammography use in 2020 and changes as compared with 2012. METHODS: We estimated the proportion of women aged ≥40 years who reported receiving a mammogram in the past 2 years, by age group, state, and demographic and socioeconomic characteristics, using 2020 Behavioral Risk Factor Surveillance System data. We also compared 2020 state estimates with 2012 estimates. RESULTS: The proportion of women aged 50-74 years who received a mammogram in the past 2 years was 78.1% (95% CI, 77.4%-78.8%) in 2020. Across measures of socioeconomic status, mammography use was generally lower among women who did not have health insurance (52.0%; 95% CI, 48.3%-55.6%) than among those who did (79.9%; 95% CI, 79.3%-80.6%) and among those who had a usual source of care (49.4%; 95% CI, 46.1%-52.7%) than among those who did not (81.0%; 95% CI, 80.4%-81.7%). Among women aged 50-74 years, mammography use varied across states, from a low of 65.2% (95% CI, 61.4%-69.0%) in Wyoming to a high of 86.1% (95% CI, 83.8%-88.3%) in Massachusetts. Four states had significant increases in mammography use from 2012 to 2020, and 8 states had significant declines. CONCLUSION: Mammography use varied widely among states. Use of evidence-based interventions tailored to the needs of local populations and communities may help close gaps in the use of mammography.

        Tangka, F. K. L. Miller, J. Sabatino, S. A.

    • Communicable Diseases
      1. OBJECTIVE: Depression is prevalent among persons with HIV (PWH) and is associated with poorer adherence and lack of viral load suppression (VLS). When treated for depression, PWH are more likely to stay in HIV care and adhere to medications; however, for many PWH, depression is not adequately diagnosed or treated. We adapted Progression and Transmission of HIV (PATH 3.0), a U.S. agent-based dynamic stochastic simulation model, by incorporating a continuum of depression care and estimating the impact on VLS of an enhanced depression diagnosis and care scenario (EDC). METHODS: We compared EDC-whereby every PWH is assessed for depression, gets treatment if diagnosed, and of those, half achieve remission-to a status quo scenario (SQ) on VLS. Based on published findings, assumptions for SQ were: 34.7% depressed, 45% diagnosed, 55.3% treated and 33% of treated achieving remission. Compared to PWH without depression, we assumed the probability of being non-virally suppressed increased by 1.57 times for PWH with depression (PWH-D), and by 0.95 times for PWH with remitted depression. RESULTS: There was an average increase of 14.6% (11.5-18.5) in the proportion of PWH-D who achieved VLS in EDC compared to SQ. Among all PWH, there was a 4.7% (3.4-6.0) increase in the proportion who achieved VLS in EDC compared to SQ. CONCLUSIONS: Fully diagnosing and adequately treating depression would improve health and quality of life for a substantial proportion of PWH-D and result in a nearly 5% increase in expected rates of VLS in the United States, supporting national prevention goals.

        Koenig, L. J. Khurana, N. Islam, M. H. Gopalappa, C. Farnham, P. G.

      2. COVID-19 outcomes stratified by control status of hypertension and diabetes: Preliminary findings from PCORnet, U.S
        Jackson SL, Block JP, Rolka DB, Pavkov ME, Chevinsky JR, Lekiachvili A, Carton TW, Thacker D, Denson JL, Paranjape A, Kappelman MD, Boehmer TK, Twentyman E.
        AJPM Focus. 2022 ;1(1):100012.
        INTRODUCTION: Hypertension and diabetes are associated with increased COVID-19 severity, yet less is known about COVID-19 outcomes across levels of disease control for these conditions. METHODS: All adults aged ≥20 years with COVID-19 between March 1, 2020 and March 15, 2021 in 42 healthcare systems in National Patient-Centered Clinical Research Network were identified. RESULTS: Among 656,049 adults with COVID-19, 41% had hypertension, and 13% had diabetes. Of patients with classifiable hypertension, 35% had blood pressure <130/80 mmHg, 40% had blood pressure of 130‒139/80‒89 mmHg, 21% had blood pressure of 140‒159/90‒99 mmHg, and 6% had blood pressure ≥160/100 mmHg. Severe COVID-19 outcomes were more prevalent among those with blood pressure of ≥160/100 than among those with blood pressure of 130-139/80-89, including hospitalization (23.7% [95% CI=23.0, 24.4] vs 11.7% [95% CI=11.5, 11.9]), receipt of critical care (5.5% [95% CI=5.0, 5.8] vs 2.4% [95% CI=2.3, 2.5]), receipt of mechanical ventilation (3.0% [95% CI=2.7, 3.3] vs 1.2% [95% CI=1.1, 1.3]), and 60-day mortality (4.6% [95% CI=4.2, 4.9] vs 1.8% [95% CI=1.7, 1.9]). Of patients with classifiable diabetes, 44% had HbA1c <7%, 35% had HbA1c 7% to <9%, and 21% had HbA1c ≥9%. Hospitalization prevalence was 31.3% (95% CI=30.7, 31.9) among those with HbA1c <7% vs 40.2% (95% CI=39.4, 41.1) among those with HbA1c ≥9%; other outcomes did not differ substantially by HbA1c. CONCLUSIONS: These findings highlight the importance of appropriate management of hypertension and diabetes, including during public health emergencies such as the COVID-19 pandemic.

        Jackson, S. L. Rolka, D. B. Pavkov, M. E. Chevinsky, J. R. Lekiachvili, A. Boehmer, T. K. Twentyman, E.

      3. Behaviors associated with household transmission of SARS-CoV-2 in California and Colorado, January 2021-April 2021
        Namageyo-Funa A, Ruffin JD, Killerby ME, Jalloh MF, Scott C, Lindell K, Silver M, Matanock A, Soto RA, Donnelly MA, Schwartz NG, Chuey MR, Chu VT, Beatty ME, Totten SE, Hudziec MM, Tate JE, Kirking HL, Hsu CH.
        AJPM Focus. 2022 ;1(1):100004.
        INTRODUCTION: Mitigation behaviors are key to preventing SARS-CoV-2 transmission. We identified the behaviors associated with secondary transmission from confirmed SARS-CoV-2 primary cases to household contacts and described the characteristics associated with reporting these behaviors. METHODS: Households with confirmed SARS-CoV-2 infections were recruited in California and Colorado from January to April 2021. Self-reported behaviors and demographics were collected through interviews. We investigated behaviors associated with transmission and individual and household characteristics associated with behaviors using univariable and multivariable logistic regression with generalized estimating equations to account for household clustering. RESULTS: Among household contacts of primary cases, 43.3% (133 of 307) became infected with SARS-CoV-2. When an adjusted analysis was conducted, household contacts who slept in the same bedroom with the primary case (AOR=2.19; 95% CI=1.25, 3.84) and ate food prepared by the primary case (AOR=1.98; 95% CI=1.02, 3.87) had increased odds of SARS-CoV-2 infection. Household contacts in homes ≤2,000 square feet had increased odds of sleeping in the same bedroom as the primary case compared with those in homes >2,000 square feet (AOR=3.97; 95% CI=1.73, 9.10). Parents, siblings, and other relationships (extended family, friends, or roommates) of the primary case had decreased odds of eating food prepared by the primary case compared with partners. CONCLUSIONS: Sleeping in the same bedroom as the primary case and eating food prepared by the primary case were associated with secondary transmission. Household dimension and relationship to the primary case were associated with these behaviors. Our findings encourage innovative means to promote adherence to mitigation measures that reduce household transmission.

        Namageyo-Funa, A. Ruffin, J. D. Killerby, M. E. Jalloh, M. F. Scott, C. Lindell, K. Silver, M. Matanock, A. Soto, R. A. Donnelly, M. A. P. Schwartz, N. G. Chuey, M. R. Chu, V. T. Tate, J. E. Kirking, H. L. Hsu, C. H.

      4. Worsening spread of Candida auris in the United States, 2019 to 2021
        Lyman M, Forsberg K, Sexton DJ, Chow NA, Lockhart SR, Jackson BR, Chiller T.
        Ann Intern Med. 2023 .
        BACKGROUND: Candida auris is an emerging fungal threat that has been spreading in the United States since it was first reported in 2016. OBJECTIVE: To describe recent changes in the U.S. epidemiology of C auris occurring from 2019 to 2021. DESIGN: Description of national surveillance data. SETTING: United States. PATIENTS: Persons with any specimen that was positive for C auris. MEASUREMENTS: Case counts reported to the Centers for Disease Control and Prevention by health departments, volume of colonization screening, and antifungal susceptibility results were aggregated and compared over time and by geographic region. RESULTS: A total of 3270 clinical cases and 7413 screening cases of C auris were reported in the United States through 31 December 2021. The percentage increase in clinical cases grew each year, from a 44% increase in 2019 to a 95% increase in 2021. Colonization screening volume and screening cases increased in 2021 by more than 80% and more than 200%, respectively. From 2019 to 2021, 17 states identified their first C auris case. The number of C auris cases that were resistant to echinocandins in 2021 was about 3 times that in each of the previous 2 years. LIMITATION: Identification of screening cases depends on screening that is done on the basis of need and available resources. Screening is not conducted uniformly across the United States, so the true burden of C auris cases may be underestimated. CONCLUSION: C auris cases and transmission have risen in recent years, with a dramatic increase in 2021. The rise in echinocandin-resistant cases and evidence of transmission is particularly concerning because echinocandins are first-line therapy for invasive Candida infections, including C auris. These findings highlight the need for improved detection and infection control practices to prevent spread of C auris. PRIMARY FUNDING SOURCE: None.

        Lyman, M. Forsberg, K. Sexton, D. J. Chow, N. A. Lockhart, S. R. Jackson, B. R. Chiller, T.

      5. Characteristics of intussusception among children <24 months old before rotavirus vaccine introduction in Lao PDR
        Douangboupha V, Vorasane S, Sivixay S, Thammavong C, Vongphacachanh T, Soulithone V, Saysanasongkham S, Sisanon I, Narongsack S, Chankongsine S, Sydasak S, Yathotou V, Franzel-Sassanpour L, Parashar UD, Tate JE, Cortese M, Burnett E.
        Asian J Surg. 2023 .

      6. Factors associated with viral suppression among adults living with HIV on antiretroviral therapy in Nigeria: Analysis of a population-based survey, 2018
        Abimiku A, Ramadhani HO, Moloney M, Stafford KA, Chang JC, Patel HK, Domaoal RA, Okoye M, Jelpe T, Bronson M, Ibrahim D, Swaminathan M, Gambo A, Charurat ME.
        HIV Med. 2023 .
        OBJECTIVE: Viral load suppression (VLS) is critical in reducing morbidity and mortality associated with HIV as well as minimizing the likelihood of HIV transmission to uninfected persons. The objective of this study was to identify factors associated with VLS among people living with HIV (PLWH) on antiretroviral (ARV) therapy to inform HIV programme strategies in Nigeria. METHODS: Adult participants, aged 15-64 years, from the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS), who self-reported to be a PLWH or had detectable ARVs, were analysed to examine factors associated with VLS defined as HIV RNA <1000 copies/mL. NAIIS measured HIV prevalence, viral load, ARV and hepatitis B in PLWH. Logistic regression models were used and reported weighted prevalence. RESULTS: Of 1322 participants, 949 (68.25%) were women and 1287 (96.82%) had detectable ARVs. The median age was 39.31 [interquartile range (IQR): 31.47-47.63] years. Prevalence of VLS was 80.88%. Compared with participants with detectable ARVs, those with undetectable ARVs in their blood specimens had lower odds of VLS [adjusted odds ratio (aOR) = 0.24, 95% confidence interval (CI): 0.08-0.64). Coinfection with hepatitis B and nonnucleoside reverse transcriptase inhibitor metabolites were also associated with lower odds of VLS. Older people (45-54 vs 15-24 years) had increased odds of VLS (aOR = 2.81, 95% CI: 1.14-6.90). CONCLUSION: Young people and those with undetectable ARVs had lower odds of virological suppression. Targeted interventions focusing on young people and adherence to medication are needed to achieve the UNAIDS 95-95-95 goals for HIV epidemic control.

        Chang, J. C. Patel, H. K. Domaoal, R. A. Okoye, M. Jelpe, T. Bronson, M. Ibrahim, D. Swaminathan, M.

      7. Nationwide hepatitis C serosurvey and progress towards HCV elimination in the country of Georgia, 2021
        Gamkrelidze A, Shadaker S, Tsereteli M, Alkhazashvili M, Chitadze N, Tskhomelidze I, Gvinjilia L, Khetsuriani N, Handanagic S, Averhoff F, Cloherty G, Chakhunashvili G, Drobeniuc J, Imndaze P, Zakhashvili K, Armstrong PA.
        J Infect Dis. 2023 .
        BACKGROUND: The country of Georgia initiated its hepatitis C virus (HCV) elimination program in 2015, at which point a serosurvey showed the adult prevalence of HCV antibody (anti-HCV) and HCV RNA to be 7.7% and 5.4%, respectively. This analysis reports hepatitis C results of a follow-up serosurvey conducted in 2021, and progress towards elimination. METHODS: The serosurvey used a stratified, multi-stage cluster design with systematic sampling to include adults and children (aged 5-17 years) providing consent (or assent with parental consent). Blood samples were tested for anti-HCV and if positive, HCV RNA. Weighted proportions and 95% confidence intervals (CI) were compared with 2015 age-adjusted estimates. RESULTS: Overall, 7,237 adults and 1,473 children were surveyed. Among adults, the prevalence of anti-HCV was 6.8% (95% CI: 5.9-7.7). The HCV RNA prevalence was 1.8% (95% CI: 1.3-2.4), representing a 67% reduction since 2015. HCV RNA prevalence decreased among those reporting risk factors of ever injecting drugs (51.1% to 17.8%), and ever receiving a blood transfusion (13.1% to 3.8%) (both p < 0.001). No children tested positive for anti-HCV or HCV RNA. CONCLUSIONS: These results demonstrate substantial progress made in Georgia since 2015. These findings can inform strategies to meet HCV elimination targets.

        Shadaker, S. Khetsuriani, N. Handanagic, S. Drobeniuc, J. Armstrong, P. A.

      8. Engagement in HIV continuum of care: another step needed to close the gap towards UNAIDS 90-90-90 targets among younger men in Rwanda
        Rwibasira GN, Dzinamarira T, Remera E, Malamba SS, Fazito E, Mathu R, Matreja P, Cai H, Kayirangwa E, Nsanzimana S.
        J Med Virol. 2023 .
        In this study, we measured Rwandan men's engagement in HIV services based on the UNAIDS 90-90-90 targets and assessed factors associated with linkage to HIV services. We analyzed the Rwanda Population-based HIV Impact Assessment (RPHIA) data for 15-64-year-old males. We conducted bivariate analysis to assess the distribution and association of sociodemographic characteristics with UNAIDS 90-90-90 targets. We adjusted multi-variable models to understand the effect measurement of associated factors and determine the factors that best predict the achievement of UNAIDS 90-90-90. Of 13,780 males aged 15-64 years who participated in the RPHIA and consented to the blood draw and HIV testing, 302 had a positive HIV result while 301 had valid responses to all variables analyzed in this paper and were included in the analysis. We found that age group was an explanatory and predictive factor for achievement of UNAIDS 90-90-90. Younger men living with HIV (MLHIV) are less likely to have achieved UNAIDS 90-90-90 compared to MLHIV 50-64 years old: aOR for MLHIV aged 15-34 years was 0.21 (0.08, 0.53) and aOR for MLHIV aged 35-49 years was0.77 (0.36, 1.66). To close the UNAIDS 90-90-90 gap in Rwanda, innovative service delivery strategies are needed to support young MLHIV to reach 90-90-90. This article is protected by copyright. All rights reserved.

        Malamba, S. S.

      9. Development of treatment-decision algorithms for children evaluated for pulmonary tuberculosis: an individual participant data meta-analysis
        Gunasekera KS, Marcy O, Muñoz J, Lopez-Varela E, Sekadde MP, Franke MF, Bonnet M, Ahmed S, Amanullah F, Anwar A, Augusto O, Aurilio RB, Banu S, Batool I, Brands A, Cain KP, Carratalá-Castro L, Caws M, Click ES, Cranmer LM, García-Basteiro AL, Hesseling AC, Huynh J, Kabir S, Lecca L, Mandalakas A, Mavhunga F, Myint AA, Myo K, Nampijja D, Nicol MP, Orikiriza P, Palmer M, Sant'Anna CC, Siddiqui SA, Smith JP, Song R, Thuong Thuong NT, Ung V, van der Zalm MM, Verkuijl S, Viney K, Walters EG, Warren JL, Zar HJ, Marais BJ, Graham SM, Debray TP, Cohen T, Seddon JA.
        Lancet Child Adolesc Health. 2023 .
        BACKGROUND: Many children with pulmonary tuberculosis remain undiagnosed and untreated with related high morbidity and mortality. Recent advances in childhood tuberculosis algorithm development have incorporated prediction modelling, but studies so far have been small and localised, with limited generalisability. We aimed to evaluate the performance of currently used diagnostic algorithms and to use prediction modelling to develop evidence-based algorithms to assist in tuberculosis treatment decision making for children presenting to primary health-care centres. METHODS: For this meta-analysis, we identified individual participant data from a WHO public call for data on the management of tuberculosis in children and adolescents and referral from childhood tuberculosis experts. We included studies that prospectively recruited consecutive participants younger than 10 years attending health-care centres in countries with a high tuberculosis incidence for clinical evaluation of pulmonary tuberculosis. We collated individual participant data including clinical, bacteriological, and radiological information and a standardised reference classification of pulmonary tuberculosis. Using this dataset, we first retrospectively evaluated the performance of several existing treatment-decision algorithms. We then used the data to develop two multivariable prediction models that included features used in clinical evaluation of pulmonary tuberculosis-one with chest x-ray features and one without-and we investigated each model's generalisability using internal-external cross-validation. The parameter coefficient estimates of the two models were scaled into two scoring systems to classify tuberculosis with a prespecified sensitivity target. The two scoring systems were used to develop two pragmatic, treatment-decision algorithms for use in primary health-care settings. FINDINGS: Of 4718 children from 13 studies from 12 countries, 1811 (38·4%) were classified as having pulmonary tuberculosis: 541 (29·9%) bacteriologically confirmed and 1270 (70·1%) unconfirmed. Existing treatment-decision algorithms had highly variable diagnostic performance. The scoring system derived from the prediction model that included clinical features and features from chest x-ray had a combined sensitivity of 0·86 [95% CI 0·68-0·94] and specificity of 0·37 [0·15-0·66] against a composite reference standard. The scoring system derived from the model that included only clinical features had a combined sensitivity of 0·84 [95% CI 0·66-0·93] and specificity of 0·30 [0·13-0·56] against a composite reference standard. The scoring system from each model was placed after triage steps, including assessment of illness acuity and risk of poor tuberculosis-related outcomes, to develop treatment-decision algorithms. INTERPRETATION: We adopted an evidence-based approach to develop pragmatic algorithms to guide tuberculosis treatment decisions in children, irrespective of the resources locally available. This approach will empower health workers in primary health-care settings with high tuberculosis incidence and limited resources to initiate tuberculosis treatment in children to improve access to care and reduce tuberculosis-related mortality. These algorithms have been included in the operational handbook accompanying the latest WHO guidelines on the management of tuberculosis in children and adolescents. Future prospective evaluation of algorithms, including those developed in this work, is necessary to investigate clinical performance. FUNDING: WHO, US National Institutes of Health.

        Cain, K. P. Click, E. S.

      10. Toward a continuum of measures to mitigate primary and secondary impacts of COVID-19 and other public health emergencies
        Hakim AJ, Victory KR, Summers A, Jalloh MF, Richter P, Bennett SD, Henao OL, Marston B.
        Popul Health Manag. 2023 .
        The global COVID-19 response focused heavily on nonpharmaceutical interventions (NPIs) until vaccines became available. Even where vaccination coverage is low, over time governments have become increasingly reluctant to use NPIs. Inequities in vaccine and treatment accessibility and coverage, differences in vaccine effectiveness, waning immunity, and immune-escape variants of concern of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reinforce the long-term need for mitigation. Initially, the concept of NPIs, and mitigation more broadly, was focused on prevention of SARS-CoV-2 transmission; however, mitigation can and has done more than prevent transmission. It has been used to address the clinical dimensions of the pandemic as well. The authors propose an expanded conceptualization of mitigation that encompasses a continuum of community and clinical mitigation measures that can help reduce infection, illness, and death from COVID-19. It can further help governments balance these efforts and address the disruptions in essential health services, increased violence, adverse mental health outcomes, and orphanhood precipitated by the pandemic and by NPIs themselves. The COVID-19 pandemic response revealed the benefits of a holistic and layered mitigation approach to public health emergencies from the outset. Lessons learned can inform the next phases of the current pandemic response and planning for future public health emergencies.

        Hakim, A. J. Victory, K. R. Summers, A. Jalloh, M. F. Richter, P. Bennett, S. D. Henao, O. L. Marston, B.

      11. Characteristics of mpox vaccine recipients among a sample of men who have sex with men with presumed exposure to mpox
        Abara WE, Sullivan P, Carpino T, Sanchez T, Atkins K, Delaney K, Edwards OW, Marissa H, Baral S, Ogale Y, Galloway E, Lansky A.
        Sex Transm Dis. 2023 .
        Mpox vaccination is recommended for persons exposed to or at risk for mpox. About 25% of an online sample of MSM with presumed mpox exposure were vaccinated (≥1 dose). Vaccination was higher among younger MSM and MSM concerned about mpox or reporting sexual risk behaviors. Incorporating mpox vaccination into routine sexual health care and increasing 2-dose vaccination uptake is essential to preventing mpox acquisition, improving MSM sexual health, and averting future mpox outbreaks.

        Abara, W. E. Delaney, K. Ogale, Y. Galloway, E. Lansky, A.

      12. BACKGROUND: National guidelines recommend sexually active women under the age of 25 be screened annually for chlamydia. Our objective was to estimate the chlamydia screening rate of sexually active women aged 16-24 years from 2011-2020. METHODS: We analyzed the chlamydia screening rates among sexually active women aged 16-24 from 2011-2020 using the chlamydia measures in the Healthcare Effectiveness Data and Information Set (HEDIS) dataset. The annual national chlamydia screening rates was further stratified by census region and by patient age. RESULTS: Chlamydia screening rates among sexually active women aged 16-24 years ranged from 55.0% to 61.8% in Medicaid health plans and from 46.9% to 52.4% in commercial health plans during 2011-2020. The Northeast consistently had the highest screening rates among 4 geographic regions. The chlamydia screening rate among sexually active women aged 16-24 years decreased from 2019 to 2020: from 61.8% to 57.9% in Medicaid plans and from 52.4% to 48.4% in commercial health plans. The number of sexually active women aged 16-24 covered by commercial health plans decreased from 2019 to 2020, but the number covered by Medicaid increased from 2019 to 2020. CONCLUSION: The chlamydia screening rates in the target population have increased little from 2011-2019. The decrease in chlamydia screening rates between 2019 and 2020 could be related to the COVID-19 pandemic and the reduced use of health services during that period. With recently suboptimal chlamydia screening rates in the United States, interventions of improving and assessing chlamydia screening rates are needed.

        He, L. Patel, C. Tao, G.

    • Community Health Services
      1. Isolation and quarantine for COVID-19 in the United States, 2020-2022
        Oeltmann JE, Vohra D, Matulewicz HH, DeLuca N, Smith JP, Couzens C, Lash RR, Harvey B, Boyette M, Edwards A, Talboy PM, Dubose O, Regan P, Loosier P, Caruso E, Katz DJ, Taylor MM, Moonan PK.
        Clin Infect Dis. 2023 .
        BACKGROUND: Public health programs varied in ability to reach people with COVID-19 and their contacts to encourage separation from others. For both adult cases of COVID-19 and contacts, we estimated the impact of contact tracing activities on separation behaviors from January, 2020 until March, 2022. METHODS: We used a probability-based panel survey of a nationally representative sample to gather data for estimates and comparisons. RESULTS: An estimated 64,255,351 adults reported a positive SARS-CoV-2 test result; 79.6% isolated for >5 days, 60.2% isolated for >10 days, and 79.2% self-notified contacts. 24,057,139 (37.7%) completed a case investigation and 46.2% reported contacts to health officials. More adults who completed a case investigation isolated than adults who did not (>5 days, 82.6%; >10 days, 69.8% versus >5 days, 78.2% and >10 days 54.8%; p-values for both measures <0.05).84,946,636 adults were a contact to a COVID-19 case; 73.1% learned of their exposure directly from a case; 49.4% quarantined for >5 days, 18.7% quarantined for >14 days, and 13.5% completed a contact tracing call. More who completed a contact tracing call quarantined than those who did not (>5 days, 61.2%; >14 days, 25.2% versus >5 days, 48.5%; >14 days, 18.0%; p-values for both measures <0.05). CONCLUSIONS: Engagement in contact tracing positively correlated with isolation and quarantine. However, most adults with COVID-19 isolated and self-notified contacts regardless of whether the public health workforce was able to reach them. Identifying and reaching contacts was challenging, and limited the ability to promote quarantining, and testing.

        Oeltmann, J. E. DeLuca, N. Lash, R. R. Harvey, B. Boyette, M. Edwards, A. Talboy, P. M. Dubose, O. Regan, P. Loosier, P. Caruso, E. Katz, D. J. Taylor, M. M. Moonan, P. K.

      2. Community health workers during COVID-19: Supporting their role in current and future public health responses
        Rodriguez B, Saunders M, Octavia-Smith D, Moeti R, Ballard A, Pellechia K, Fragueiro D, Salinger S.
        J Ambul Care Manage. 2023 .
        Community health workers advance health equity and foster community-clinical linkages. By promoting culturally relevant care, sharing their own stories, and bridging gaps, they can reach populations burdened with higher rates of chronic diseases due to adverse social determinants of health and structural racism. Given the disproportionate impacts of COVID-19, lessons learned from a forum, an expert group, and a survey showed a need by community health workers for (1) training, (2) health and safety practices, (3) workplace guidance, and (4) mental health resources. Community health workers are integral to expanding access to services and require a robust infrastructure for their growth.

        Moeti, R.

      3. School-based interventions to increase student COVID-19 vaccination coverage in public school populations with low coverage - Seattle, Washington, December 2021-June 2022
        Fairlie T, Chu B, Thomas ES, Querns AK, Lyons A, Koziol M, Englund JA, Anderson EM, Graff K, Rigel S, Bell TR, Saydah S, Chatham-Stephens K, Vogt TM, Hoag S, Briggs-Hagen M.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(11):283-287.
        COVID-19 can lead to severe outcomes in children (1). Vaccination decreases risk for COVID-19 illness, severe disease, and death (2). On December 13, 2020, CDC recommended COVID-19 vaccination for persons aged ≥16 years, with expansion on May 12, 2021, to children and adolescents (children) aged 12-15 years, and on November 2, 2021, to children aged 5-11 years (3). As of March 8, 2023, COVID-19 vaccination coverage among school-aged children remained low nationwide, with 61.7% of children aged 12-17 years and approximately one third (32.7%) of those aged 5-11 years having completed the primary series (3). Intention to receive COVID-19 vaccine and vaccination coverage vary by demographic characteristics, including race and ethnicity and socioeconomic status (4-6). Seattle Public Schools (SPS) implemented a program to increase COVID-19 vaccination coverage during the 2021-22 school year, focusing on children aged 5-11 years during November 2021-June 2022, with an added focus on populations with low vaccine coverage during January 2022-June 2022.(†) The program included strategic messaging, school-located vaccination clinics, and school-led community engagement. Vaccination data from the Washington State Immunization Information System (WAIIS) were analyzed to examine disparities in COVID-19 vaccination by demographic and school characteristics and trends over time. In December 2021, 56.5% of all SPS students, 33.7% of children aged 5-11 years, and 81.3% of children aged 12-18 years had completed a COVID-19 primary vaccination series. By June 2022, overall series completion had increased to 80.3% and was 74.0% and 86.6% among children aged 5-11 years and 12-18 years, respectively. School-led vaccination programs can leverage community partnerships and relationships with families to improve COVID-19 vaccine access and coverage.

        Fairlie, T. Thomas, E. S. Saydah, S. Chatham-Stephens, K. Vogt, T. M. Briggs-Hagen, M.

    • Disaster Preparedness and Emergency Services
      1. Learning from COVID-19 to improve surveillance for emerging threats
        Jernigan DB, George D, Lipsitch M.
        Am J Public Health. 2023 :e1-e3.

    • Disease Reservoirs and Vectors
      1. Trends of insecticide resistance monitoring in mainland Tanzania, 2004-2020
        Tungu P, Kabula B, Nkya T, Machafuko P, Sambu E, Batengana B, Sudi W, Derua YA, Mwingira V, Masue D, Malima R, Kitojo C, Serbantez N, Reaves EJ, Mwalimu C, Nhiga SL, Ally M, Mkali HR, Joseph JJ, Chan A, Ngondi J, Lalji S, Nyinondi S, Eckert E, Reithinger R, Magesa S, Kisinza WN.
        Malar J. 2023 ;22(1):100.
        BACKGROUND: Insecticide resistance is a serious threat to the continued effectiveness of insecticide-based malaria vector control measures, such as long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS). This paper describes trends and dynamics of insecticide resistance and its underlying mechanisms from annual resistance monitoring surveys on Anopheles gambiae sensu lato (s.l.) populations conducted across mainland Tanzania from 2004 to 2020. METHODS: The World Health Organization (WHO) standard protocols were used to assess susceptibility of the wild female An. gambiae s.l. mosquitoes to insecticides, with mosquitoes exposed to diagnostic concentrations of permethrin, deltamethrin, lambdacyhalothrin, bendiocarb, and pirimiphos-methyl. WHO test papers at 5× and 10× the diagnostic concentrations were used to assess the intensity of resistance to pyrethroids; synergist tests using piperonyl butoxide (PBO) were carried out in sites where mosquitoes were found to be resistant to pyrethroids. To estimate insecticide resistance trends from 2004 to 2020, percentage mortalities from each site and time point were aggregated and regression analysis of mortality versus the Julian dates of bioassays was performed. RESULTS: Percentage of sites with pyrethroid resistance increased from 0% in 2004 to more than 80% in the 2020, suggesting resistance has been spreading geographically. Results indicate a strong negative association (p = 0.0001) between pyrethroids susceptibility status and survey year. The regression model shows that by 2020 over 40% of An. gambiae mosquitoes survived exposure to pyrethroids at their respective diagnostic doses. A decreasing trend of An. gambiae susceptibility to bendiocarb was observed over time, but this was not statistically significant (p = 0.8413). Anopheles gambiae exhibited high level of susceptibility to the pirimiphos-methyl in sampled sites. CONCLUSIONS: Anopheles gambiae Tanzania's major malaria vector, is now resistant to pyrethroids across the country with resistance increasing in prevalence and intensity and has been spreading geographically. This calls for urgent action for efficient malaria vector control tools to sustain the gains obtained in malaria control. Strengthening insecticide resistance monitoring is important for its management through evidence generation for effective malaria vector control decision.

        Reaves, E. J. Chan, A.

      2. Insecticide resistance compromises the control of Aedes aegypti in Bangladesh
        Al-Amin HM, Gyawali N, Graham M, Alam MS, Lenhart A, Hugo LE, Rašić G, Beebe NW, Devine GJ.
        Pest Manag Sci. 2023 .
        BACKGROUND: With no effective drugs or widely available vaccines, dengue control in Bangladesh is dependent on targeting the primary vector Aedes aegypti with insecticides and larval source management. Despite these interventions, the dengue burden is increasing in Bangladesh, and the country experienced its worst outbreak in 2019 with 101,354 hospitalized cases. This may be partially facilitated by the presence of intense insecticide resistance in vector populations. Here, we describe the intensity and mechanisms of resistance to insecticides commonly deployed against Ae. aegypti in Dhaka, Bangladesh. RESULTS: Dhaka Ae. aegypti colonies exhibited high-intensity resistance to pyrethroids. Using CDC bottle assays, we recorded 2 - 24% mortality (recorded at 24 hours) to permethrin and 48 - 94% mortality to deltamethrin, at 10x the diagnostic dose. Bioassays conducted using insecticide-synergist combinations suggested that metabolic mechanisms were contributing to pyrethroid resistance, specifically multi-function oxidases, esterases, and glutathione S-transferases. In addition, kdr alleles were detected, with a high frequency (78-98%) of homozygotes for the V1016G mutation. A large proportion (≤ 74%) of free-flying and resting mosquitoes from Dhaka colonies survived exposure to standard applications of pyrethroid aerosols in an experimental free-flight room. Although that exposure affected Ae. aegypti's immediate host-seeking behavior, the effect was transient in surviving mosquitoes. CONCLUSION: The intense resistance characterized in this study is likely compromising the operational effectiveness of pyrethroids against Ae. aegypti in Dhaka. Switching to alternative chemical classes may offer a medium-term solution, but ultimately a more sustainable and effective approach to controlling dengue vectors is required. This article is protected by copyright. All rights reserved.

        Lenhart, A.

    • Environmental Health
      1. An outbreak of acute neurological illness associated with drinking water source following a cyclone in Eluru, West Godavari district, Andhra Pradesh, India, December 2020
        Sharma S, Patel P, Kulkarni SV, Deoshatwar A, Yadav R, Tanwar S, Manohar K, Dolla JR, Jain SK, Singh SK, Dikid T.
        Clin Epidemiol Glob Health. 2023 ;20.
        Background: In December 2020, over 500 residents of Eluru City were hospitalised with seizures and sudden loss of consciousness (LOC) resembling the neurotoxic effects of organochlorine poisoning after a flooding event during the last week of November 2020. We described the epidemiological investigation of outbreak and identified risk factors. Methods: We performed descriptive analysis followed by 1:1 unmatched case-control study. Cases were identified through house-to-house search and review of medical records at district hospital. A case defined as sudden onset LOC or new-onset seizures in an Eluru resident aged ≥1 year, December 1–15, 2020 and a control as absence of neurological symptoms in a person aged ≥1 year selected randomly from same administrative division of the case. We compared cases and controls for possible risk factors and calculated adjusted odds ratio (aOR) with 95% confidence interval (CI). Biological and environmental samples were tested for contaminants. Results: We identified 545 cases (56% males), including one death. Seizures were reported in 491 (90%) cases. Median age was 27 years (interquartile range: 17–37 years) and 480 (88%) cases resided in urban area. Cases were clustered in administrative divisions supplied by municipal water reservoirs. Cases were more likely than controls to use municipal water as primary source of drinking water (aOR = 4.6, 95% CI = 1.6–13.0). High levels (average: 14.6 mg/l) of organochlorine compounds were detected in all municipal water samples (acceptable limit: <0.001 mg/l). Conclusion: This investigation highlights water ingestion as an exposure pathway for environmental contaminants (organochlorines) in the community after largescale flooding. We recommended strengthening safe water surveillance in natural disaster response contingency plans in Eluru. © 2023 The Author(s)

        Yadav, R. Tanwar, S.

      2. OBJECTIVE: Indoor mold after flooding poses health risks including rare but serious invasive mold infections. The purpose of this study was to evaluate use of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes for mold infection and mold exposure in Houston, Texas during the year before and the year after Hurricane Harvey. METHODS: This study used data from MarketScan, a large health insurance claims database. RESULTS: The incidence of invasive mold infections remained unchanged in the year after Hurricane Harvey; however, the incidence of diagnosis codes for mold exposure nearly doubled compared with the year before the hurricane (6.3 vs. 11.0 per 100,000 enrollees, rate ratio: 1.7, 95% confidence interval 1.0-3.1). CONCLUSIONS: Diagnosis codes alone may not be sufficiently sensitive to detect changes in invasive mold infection rates within this population and timeframe, demonstrating the need for more comprehensive studies.

        Benedict, K. Jackson, B. R. Toda, M.

      3. Developing and implementing in-person and virtual SoilSHOPs in Atlanta, Georgia, as a community-engaged approach to screen and prevent soil lead exposure
        Saikawa E, Lebow-Skelley E, Hernandez R, Flack-Walker F, Bing L, Hunter CM.
        J Public Health Manag Pract. 2023 .
        Urban agriculture presents the opportunity for increased availability of local, fresh foods; however, exposure to lead soil contamination can occur through gardening in urban environments. Through a community-engaged partnership, we implemented Soil Screening, Health, Outreach and Partnerships (soilSHOPs), in-person and virtually, to screen soils for lead in Atlanta, Georgia. These soilSHOPs inform best practices for increasing awareness about lead exposure and grounding interventions in residents' lived experiences and also led the US Environmental Protection Agency to identify a Superfund site.

        Bing, L. Hunter, C. M.

      4. Mapping of cholera hotspots in Kenya using epidemiologic and water, sanitation, and hygiene (WASH) indicators as part of Kenya's new 2022-2030 cholera elimination plan
        Kiama C, Okunga E, Muange A, Marwanga D, Langat D, Kuria F, Amoth P, Were I, Gachohi J, Ganda N, Martinez Valiente M, Njenga MK, Osoro E, Brunkard J.
        PLoS Negl Trop Dis. 2023 ;17(3):e0011166.
        Cholera is an issue of major public health importance. It was first reported in Kenya in 1971, with the country experiencing outbreaks through the years, most recently in 2021. Factors associated with the outbreaks in Kenya include open defecation, population growth with inadequate expansion of safe drinking water and sanitation infrastructure, population movement from neighboring countries, crowded settings such as refugee camps coupled with massive displacement of persons, mass gathering events, and changes in rainfall patterns. The Ministry of Health, together with other ministries and partners, revised the national cholera control plan to a multisectoral cholera elimination plan that is aligned with the Global Roadmap for Ending Cholera. One of the key features in the revised plan is the identification of hotspots. The hotspot identification exercise followed guidance and tools provided by the Global Task Force on Cholera Control (GTFCC). Two epidemiological indicators were used to identify the sub-counties with the highest cholera burden: incidence per population and persistence. Additionally, two indicators were used to identify sub-counties with poor WASH coverage due to low proportions of households accessing improved water sources and improved sanitation facilities. The country reported over 25,000 cholera cases between 2015 and 2019. Of 290 sub-counties, 25 (8.6%) sub-counties were identified as a high epidemiological priority; 78 (26.9%) sub-counties were identified as high WASH priority; and 30 (10.3%) sub-counties were considered high priority based on a combination of epidemiological and WASH indicators. About 10% of the Kenyan population (4.89 million) is living in these 30-combination high-priority sub-counties. The novel method used to identify cholera hotspots in Kenya provides useful information to better target interventions in smaller geographical areas given resource constraints. Kenya plans to deploy oral cholera vaccines in addition to WASH interventions to the populations living in cholera hotspots as it targets cholera elimination by 2030.

        Brunkard, J.

      5. Dioxins and dioxin-like compounds measurements were added to polychlorinated biphenyls (PCBs) and organochlorine pesticides to expand the exposure profile in a follow-up to the Anniston Community Health Survey (ACHS II, 2014) and to study diabetes associations. Participants of ACHS I (2005-2007) still living within the study area were eligible to participate in ACHS II. Diabetes status (type-2) was determined by a doctor's diagnosis, fasting glucose ≥1 mg/dL, or being on any glycemic control medication. Incident diabetes cases were identified in ACHS II among those who did not have diabetes in ACHS I, using the same criteria. Thirty-five ortho-substituted PCBs, 6 pesticides, 7 polychlorinated dibenzo-p-dioxins (PCDD), 10 furans (PCDF), and 3 non-ortho PCBs were measured in 338 ACHS II participants. Dioxin toxic equivalents (TEQs) were calculated for all dioxin-like compounds. Main analyses used logistic regression models to calculate odds ratios (OR) and 95 % confidence intervals (CI). In models adjusted for age, race, sex, BMI, total lipids, family history of diabetes, and taking lipid lowering medication, the highest ORs for diabetes were observed for PCDD TEQ: 3.61 (95 % CI: 1.04, 12.46), dichloro-diphenyl dichloroethylene (p,p'-DDE): 2.07 (95 % CI 1.08, 3.97), and trans-Nonachlor: 2.55 (95 % CI 0.93, 7.02). The OR for sum 35 PCBs was 1.22 (95 % CI: 0.58-2.57). To complement the main analyses, we used BKMR and g-computation models to evaluate 12 mixture components including 4 TEQs, 2 PCB subsets and 6 pesticides; suggestive positive associations for the joint effect of the mixture were found but were not significant. These results add support to earlier findings for diabetes associations with PCBs, PCDDs, trans-Nonachlor and p,p'- DDE.

        Pavuk, M. Lewin, M. D. Serio, T. C. Rago, P.

    • Epidemiology and Surveillance
      1. We propose a censored quantile regression model for the analysis of relative survival data. We create a hybrid data set consisting of the study observations and counterpart randomly sampled pseudopopulation observations imputed from population life tables that adjust for expected mortality. We then fit a censored quantile regression model to the hybrid data incorporating demographic variables (e.g., age, biologic sex, calendar time) corresponding to the population life tables of demographically-similar individuals, a population versus study covariate, and its interactions with the variables of interest. These latter variables can be interpreted as relative survival parameters that depict the differences in failure quantiles between the study participants and their population counterparts.

        Williamson, J. M.

    • Food Safety
      1. Characteristics associated with successful foodborne outbreak investigations involving United States retail food establishments (2014-2016)
        Holst MM, Kramer A, Hoover ER, Dewey-Mattia D, Mack J, Hawkins T, Brown LG.
        Epidemiol Infect. 2023 :1-21.

    • Genetics and Genomics
      1. Accelerating cervical cancer screening with human papillomavirus genotyping
        Sawaya GF, Saraiya M, Soman A, Gopalani SV, Kenney K, Miller J.
        Am J Prev Med. 2023 ;64(4):552-555.
        INTRODUCTION: Selective utilization of human papillomavirus (HPV) genotyping in cervical cancer screening can accelerate clinical management, leading to earlier identification and treatment of precancerous lesions and cancer. Specifically, immediate colposcopy (instead of 1-year return) is recommended in persons with normal cytology and HPV genotypes 16 and/or 18, and expedited treatment (instead of colposcopy) is recommended in persons with high-grade squamous intraepithelial lesion (HSIL) cytology and HPV genotype 16. The effects of implementing HPV testing and genotyping into a screening program are largely unknown. METHODS: Average-risk persons aged 30-65 years screened for cervical cancer in the National Breast and Cervical Cancer Early Detection Program from 2019 to 2020 were included (N=104,991). Percentage HPV genotyping test positivity was estimated within cytology result categories. Analyses were performed in 2022. RESULTS: The most common abnormality was positive high-risk HPV testing with normal cytology, representing 40.1% (7,155/17,832) of all abnormal test result categories; HSIL cytology represented 3.0% (530/17,832) of all abnormal test result categories. In high-risk HPV‒positive persons with normal or high-grade cytology, HPV genotyping could accelerate management (immediate colposcopy and expedited treatment) in 5.4% of all persons with abnormal screening test results; if HPV genotyping had been performed in all high-risk HPV‒positive persons with normal or HSIL cytology, approximately 13.1% could have accelerated management. CONCLUSIONS: HPV genotyping in human papillomavirus‒positive persons with normal or HSIL cytology could accelerate management in a sizable percentage of persons with abnormal test results and may be particularly useful in populations with challenges adhering to longitudinal follow-up.

        Saraiya, M.


    • Health Behavior and Risk
      1. Impacts of COVID-19 on sexual behaviors, HIV prevention and care among men who have sex with men: A comparison of New York City and Metropolitan Atlanta
        Goodreau SM, Delaney KP, Zhu W, Smith DK, Mann LM, Sanchez TH, Hamilton DT, Hoover KW.
        PLoS One. 2023 ;18(3):e0282503.
        The COVID-19 pandemic has disrupted HIV prevention, care, and transmission opportunities. This likely varies by geography, given differences in COVID-19 burden and mandates over time, and by age, given different likelihoods of severe COVID-19 consequences. We consider changes in sexual behavior, HIV testing, pre-exposure prophylaxis (PrEP) use and antiretroviral therapy (ART) use among men who have sex with men (MSM) over the first year of the COVID-19 epidemic, comparing the Atlanta metropolitan area and New York City (NYC). We use two continuous time-series datasets and one panel dataset, assessing changes over time within city and comparing across cities, and disaggregate major findings by age. For clinical results, ART use showed by far the smallest reductions, and testing the largest. Disruptions occurred concurrently between cities, despite the major wave of COVID-19, and government mandates, occurring later in Atlanta. Test positivity increased in NYC only. In both cities, younger MSM saw the greatest reductions in testing and PrEP use, but the smallest in sexual behavior. Reduced clinical service usage would be unconcerning if stemming solely from reductions in exposure; however, the patterns for young MSM suggest that the COVID-19 epidemic likely generated new conditions for increased HIV transmission, especially in this cohort.

        Delaney, K. P. Zhu, W. Smith, D. K. Hoover, K. W.

    • Health Economics
      1. Cost-effectiveness of expanded hepatitis A vaccination among adults with diagnosed HIV, United States
        Abimbola TO, Van Handel M, Tie Y, Ouyang L, Nelson N, Weiser J.
        PLoS One. 2023 ;18(3):e0282972.
        Hepatitis A virus can cause severe and prolonged illness in persons with HIV (PWH). In July 2020, the Advisory Committee on Immunization Practices (ACIP) expanded its recommendation for hepatitis A vaccination to include all PWH aged ≥1 year. We used a decision analytic model to estimate the value of vaccinating a cohort of adult PWH aged ≥20 years with diagnosed HIV in the United States using a limited societal perspective. The model compared 3 scenarios over an analytic horizon of 1 year: no vaccination, current vaccine coverage, and full vaccination. We incorporated the direct medical costs and nonmedical costs (i.e., public health costs and productivity loss). We estimated the total number of infections averted, cost to vaccinate, and incremental cost per case averted. Full implementation of the ACIP recommendation resulted in 775 to 812 fewer adult cases of hepatitis A in 1 year compared with the observed vaccination coverage. The incremental cost-effectiveness ratio for the full vaccination scenario was $48,000 for the 2-dose single-antigen hepatitis A vaccine and $130,000 for the 3-dose combination hepatitis A and hepatitis B vaccine per case averted, compared with the observed vaccination scenario. Depending on type of vaccine, full hepatitis A vaccination of PWH could lead to ≥80% reduction in the number of cases and $48,000 to $130,000 in additional cost per case averted. Data on hepatitis A health outcomes and costs specific to PWH are needed to better understand the longer-term costs and benefits of the 2020 ACIP recommendation.

        Abimbola, T. O. Van Handel, M. Tie, Y. Ouyang, L. Nelson, N. Weiser, J.

    • Health Equity and Health Disparities
      1. Risk factors for reinfection with SARS-CoV-2 Omicron variant among previously infected frontline workers
        Ellingson KD, Hollister J, Porter CJ, Khan SM, Feldstein LR, Naleway AL, Gaglani M, Caban-Martinez AJ, Tyner HL, Lowe AA, Olsho LE, Meece J, Yoon SK, Mak J, Kuntz JL, Solle NS, Respet K, Baccam Z, Wesley MG, Thiese MS, Yoo YM, Odean MJ, Miiro FN, Pickett SL, Phillips AL, Grant L, Romine JK, Herring MK, Hegmann KT, Lamberte JM, Sokol B, Jovel KS, Thompson MG, Rivers P, Pilishvili T, Lutrick K, Burgess JL, Midgley CM, Fowlkes AL.
        Emerg Infect Dis. 2023 ;29(3):599-604.
        In a cohort of essential workers in the United States previously infected with SARS-CoV-2, risk factors for reinfection included being unvaccinated, infrequent mask use, time since first infection, and being non-Hispanic Black. Protecting workers from reinfection requires a multipronged approach including up-to-date vaccination, mask use as recommended, and reduction in underlying health disparities.

        Feldstein, L. R. Mak, J. Yoo, Y. M. Lamberte, J. M. Thompson, M. G. Pilishvili, T. Midgley, C. M. Fowlkes, A. L.

      2. Utilizing community based participatory research methods in Black/African American and Hispanic/Latinx communities in the US: The CDC minority HIV research initiative (MARI-Round 4)
        Evans KN, Martinez O, King H, van den Berg JJ, Fields EL, Lanier Y, Hussen SA, Malavé-Rivera SM, Duncan DT, Gaul Z, Buchacz K.
        J Community Health. 2023 :1-13.
        The Centers for Disease Control and Prevention Minority HIV Research Initiative (MARI) funded 8 investigators in 2016 to develop HIV prevention and treatment interventions in highly affected communities. We describe MARI studies who used community-based participatory research methods to inform the development of interventions in Black/African American and Hispanic/Latinx communities focused on sexual minority men (SMM) or heterosexual populations. Each study implemented best practice strategies for engaging with communities, informing recruitment strategies, navigating through the impacts of COVID-19, and disseminating findings. Best practice strategies common to all MARI studies included establishing community advisory boards, engaging community members in all stages of HIV research, and integrating technology to sustain interventions during the COVID-19 pandemic. Implementing community-informed approaches is crucial to intervention uptake and long-term sustainability in communities of color. MARI investigators' research studies provide a framework for developing effective programs tailored to reducing HIV-related racial/ethnic disparities.

        King, H.

    • Healthcare Associated Infections
      1. Whole-genome sequencing of Candida haemulonii species complex from Brazil and the United States: genetic diversity and antifungal susceptibility
        de Barros Rodrigues DK, Lockhart SR, Berkow EL, Gade L, Bonfietti LX, Gimenes VM, Ruiz LS, Macioni MB, de Souza Carvalho Melhem M.
        Med Mycol. 2023 .
        Candida haemulonii complex species can be multidrug-resistant (MDR) and cause infections such as candidemia. This study determined the genetic relationship between isolates from Brazil and the United States through whole-genome sequencing and performed antifungal susceptibility testing to investigate drug resistance. Contrary to what is widely described, most isolates were susceptible to azoles. However, an atypical susceptibility profile was found in 50% of C. pseudohaemulonii strains including resistance to the three echinocandins. Isolates from both countries formed distinct clusters with wide genetic diversity. Isolates from three hospitals in Brazil were clonal and involved in candidemia cases, pointing to the importance of improving hospital infection control measures and molecular identification. Candida haemulonii complex species is worldwide distributed and this study aimed to evaluate the resistance to antifungal drugs in cases from Brazil and the United States, and also compare their genetic relationship. Fifty strains were studied, most of them from Brazil were from cases of bloodstream infections while the strains from the United States came from cases of wounds and may be associated with diabetic patients. The vast majority of strains were resistant to amphotericin B, one of the most effective drugs, and susceptible to fluconazole. In addition, 50% of C. pseudohaemulonii strains were resistant to echinocandins. The strains from Brazil and the United States had no genetic relationship and formed two distinct groups. In 3 Brazilian hospitals, strains were clonal indicating an intrahospital transmission. Our findings contribute to guiding therapy in bloodstream fungal infections caused by Candida haemulonii species and alert for nosocomial transmission of this yeast complex species. eng

        Lockhart, S. R. Berkow, E. L. Gade, L.

    • Immunity and Immunization
      1. Immune response to co-administration of measles, mumps, and rubella (MMR), and yellow fever vaccines: a randomized non-inferiority trial among one-year-old children in Argentina
        Vizzotti C, Harris JB, Aquino A, Rancaño C, Biscayart C, Bonaventura R, Pontoriero A, Baumeister E, Freire MC, Magariños M, Duarte B, Grant G, Reef S, Laven J, Wannemuehler KA, Alvarez AM, Staples JE.
        BMC Infect Dis. 2023 ;23(1):165.
        BACKGROUND: In yellow fever (YF) endemic areas, measles, mumps, and rubella (MMR), and YF vaccines are often co-administered in childhood vaccination schedules. Because these are live vaccines, we assessed potential immune interference that could result from co-administration. METHODS: We conducted an open-label, randomized non-inferiority trial among healthy 1-year-olds in Misiones Province, Argentina. Children were randomized to one of three groups (1:1:1): Co-administration of MMR and YF vaccines (MMR(1)YF(1)), MMR followed by YF vaccine four weeks later (MMR(1)YF(2)), or YF followed by MMR vaccine four weeks later (YF(1)MMR(2)). Blood samples obtained pre-vaccination and 28 days post-vaccination were tested for immunoglobulin G antibodies against measles, mumps, and rubella, and for YF virus-specific neutralizing antibodies. Non-inferiority in seroconversion was assessed using a -5% non-inferiority margin. Antibody concentrations were compared with Kruskal-Wallis tests. RESULTS: Of 851 randomized children, 738 were correctly vaccinated, had ≥ 1 follow-up sample, and were included in the intention-to-treat population. Non-inferior seroconversion was observed for all antigens (measles seroconversion: 97.9% in the MMR(1)YF(1) group versus 96.3% in the MMR(1)YF(2) group, a difference of 1.6% [90% CI -1.5, 4.7]; rubella: 97.9% MMR(1)YF(1) versus 94.7% MMR(1)YF(2), a difference of 3.3% [-0.1, 6.7]; mumps: 96.7% MMR(1)YF(1) versus 97.9% MMR(1)YF(2), a difference of -1.3% [-4.1, 1.5]; and YF: 96.3% MMR(1)YF(1) versus 97.5% YF(1)MMR(2), a difference of -1.2% [-4.2, 1.7]). Rubella antibody concentrations and YF titers were significantly lower following co-administration; measles and mumps concentrations were not impacted. CONCLUSION: Effective seroconversion was achieved and was not impacted by the co-administration, although antibody levels for two antigens were lower. The impact of lower antibody levels needs to be weighed against missed opportunities for vaccination to determine optimal timing for MMR and YF vaccine administration. TRIAL REGISTRATION: The study was retrospectively registered in ClinicalTrials.gov (NCT03368495) on 11/12/2017.

        Harris, J. B. Grant, G. Reef, S. Laven, J.

      2. Programmatic effectiveness of a pediatric typhoid conjugate vaccine campaign in Navi Mumbai, India
        Hoffman SA, LeBoa C, Date K, Haldar P, Harvey P, Shimpi R, An Q, Zhang C, Jayaprasad N, Horng L, Fagerli K, Borhade P, Chakraborty D, Bahl S, Katkar A, Kunwar A, Yewale V, Andrews JR, Bhatnagar P, Dutta S, Luby SP.
        Clin Infect Dis. 2023 .
        BACKGROUND: The WHO recommends vaccines for prevention and control of typhoid fever, especially where antimicrobial-resistant typhoid circulates. In 2018 the Navi Mumbai Municipal Corporation (NMMC), implemented a TCV campaign. The campaign targeted all children aged 9-months through 14-years within NMMC boundaries (∼320,000 children) over 2 vaccination phases. The phase 1 campaign occurred from July 14-August 25, 2018 (71% coverage, ∼113,420 children). We evaluated the phase 1 campaign's programmatic effectiveness in reducing typhoid cases at the community level. METHODS: We established prospective, blood culture-based surveillance at 6 hospitals in Navi Mumbai, offering blood cultures to children presenting with fever ≥ 3 days. We employed a cluster-randomized (by administrative boundary) test-negative design to estimate the effectiveness of the vaccination campaign on pediatric typhoid cases. We matched test-positive, culture-confirmed typhoid cases with up to 3 test-negative, culture-negative controls by age and date of blood culture and assessed community vaccine campaign phase as an exposure using conditional logistic regression. RESULTS: Between September 1, 2018-March 31, 2021, we identified 81 typhoid cases and matched these with 238 controls. Cases were 0.44 times as likely to live in vaccine campaign communities (programmatic effectiveness, 56%, 95%CI: 25%-74%, p=0.002). Cases ≥ 5-years-old were 0.37 times as likely (95% CI: 0.19-0.70; p-value = 0.002) and cases during the first year of surveillance were 0.30 times as likely (95% CI: 0.14-0.64; p-value = 0.002) to live in vaccine campaign communities. CONCLUSIONS: Our findings support the use of TCV mass vaccination campaigns as effective population-based tools to combat typhoid fever.

        Date, K. An, Q. Zhang, C. Fagerli, K.

      3. Estimation of COVID-19 mRNA vaccine effectiveness and COVID-19 illness and severity by vaccination status during Omicron BA.4 and BA.5 sublineage periods
        Link-Gelles R, Levy ME, Natarajan K, Reese SE, Naleway AL, Grannis SJ, Klein NP, DeSilva MB, Ong TC, Gaglani M, Hartmann E, Dickerson M, Stenehjem E, Kharbanda AB, Han J, Spark TL, Irving SA, Dixon BE, Zerbo O, McEvoy CE, Rao S, Raiyani C, Sloan-Aagard C, Patel P, Dascomb K, Uhlemann AC, Dunne MM, Fadel WF, Lewis N, Barron MA, Murthy K, Nanez J, Griggs EP, Grisel N, Annavajhala MK, Akinseye A, Valvi NR, Goddard K, Mamawala M, Arndorfer J, Yang DH, Embí PJ, Fireman B, Ball SW, Tenforde MW.
        JAMA Netw Open. 2023 ;6(3):e232598.
        IMPORTANCE: Recent SARS-CoV-2 Omicron variant sublineages, including BA.4 and BA.5, may be associated with greater immune evasion and less protection against COVID-19 after vaccination. OBJECTIVES: To evaluate the estimated vaccine effectiveness (VE) of 2, 3, or 4 doses of COVID-19 mRNA vaccination among immunocompetent adults during a period of BA.4 or BA.5 predominant circulation; and to evaluate the relative severity of COVID-19 in hospitalized patients across Omicron BA.1, BA.2 or BA.2.12.1, and BA.4 or BA.5 sublineage periods. DESIGN, SETTING, AND PARTICIPANTS: This test-negative case-control study was conducted in 10 states with data from emergency department (ED) and urgent care (UC) encounters and hospitalizations from December 16, 2021, to August 20, 2022. Participants included adults with COVID-19-like illness and molecular testing for SARS-CoV-2. Data were analyzed from August 2 to September 21, 2022. EXPOSURES: mRNA COVID-19 vaccination. MAIN OUTCOMES AND MEASURES: The outcomes of interest were COVID-19 ED or UC encounters, hospitalizations, and admission to the intensive care unit (ICU) or in-hospital death. VE associated with protection against medically attended COVID-19 was estimated, stratified by care setting and vaccine doses (2, 3, or 4 doses vs 0 doses as the reference group). Among hospitalized patients with COVID-19, demographic and clinical characteristics and in-hospital outcomes were compared across sublineage periods. RESULTS: During the BA.4 and BA.5 predominant period, there were 229 eligible ED and UC encounters among patients with COVID-19-like illness (median [IQR] age, 51 [33-70] years; 49 682 [60.4%] female patients), and 19 114 patients (23.2%) had test results positive for SARS-CoV-2; among 21 007 hospitalized patients (median [IQR] age, 71 [58-81] years; 11 209 [53.4%] female patients), 3583 (17.1 %) had test results positive for SARS-CoV-2. Estimated VE against hospitalization was 25% (95% CI, 17%-32%) for receipt of 2 vaccine doses at 150 days or more after receipt, 68% (95% CI, 50%-80%) for a third dose 7 to 119 days after receipt, and 36% (95% CI, 29%-42%) for a third dose 120 days or more (median [IQR], 235 [204-262] days) after receipt. Among patients aged 65 years or older who had received a fourth vaccine dose, VE was 66% (95% CI, 53%-75%) at 7 to 59 days after vaccination and 57% (95% CI, 44%-66%) at 60 days or more (median [IQR], 88 [75-105] days) after vaccination. Among hospitalized patients with COVID-19, ICU admission or in-hospital death occurred in 21.4% of patients during the BA.1 period vs 14.7% during the BA.4 and BA.5 period (standardized mean difference: 0.17). CONCLUSIONS AND RELEVANCE: In this case-control study of COVID-19 vaccines and illness, VE associated with protection against medically attended COVID-19 illness was lower with increasing time since last dose; estimated VE was higher after receipt of 1 or 2 booster doses compared with a primary series alone.

        Link-Gelles, R. Griggs, E. P. Tenforde, M. W.

      4. Characteristics of decedents with COVID-19-related mortality in Kentucky, July 1-August 13, 2021
        Cavanaugh AM, Raparti L, Bhurgri M, Herrington A, Holladay C, Arora V, Spicer KB, Thoroughman DA, Winter K.
        Public Health Rep. 2023 :333549231155867.
        OBJECTIVE: Although vaccination reduces the risk of severe COVID-19, fatal COVID-19 cases after vaccination can occur. We examined the characteristics of decedents with COVID-19-related mortality to help inform discussions about vaccination, boosters, and mitigation strategies. METHODS: We examined COVID-19-related deaths in Kentucky resulting from infections occurring from July 1 through August 13, 2021. We used records from case investigations, medical records, the Kentucky Health Information Exchange, and the Kentucky Immunization Registry to determine demographic information, vaccination status, and underlying health conditions, including calculation of the Charlson Comorbidity Index (CCI). We calculated mortality incidence rates by vaccination status by using data for unvaccinated and fully vaccinated populations in Kentucky as of July 1, 2021. RESULTS: In total, 777 COVID-19-related deaths occurred in Kentucky during the study period; 592 (76.2%) occurred among unvaccinated people. Compared with unvaccinated decedents, fully vaccinated decedents were older (median age, 77 vs 65 years; P < .001), had higher comorbidity levels (median CCI, 3 vs 1; P < .001), and were more likely to have immunocompromised health status (26.4% vs 16.0%; P = .003). Diabetes, hypertension, heart disease, and chronic lung disease were more common among vaccinated decedents than among unvaccinated decedents. Unvaccinated adults had a significantly higher risk of death than fully vaccinated adults (incidence rate ratio for age 20-49 years: 20.5 [95% CI, 6.5-64.8]; 50-64 years: 14.6 [95% CI, 9.4-22.7]; ≥65 years: 10.2 [95% CI, 8.3-12.4]). CONCLUSIONS: Immunocompromised health status, older age, and higher comorbidity were prevalent among fully vaccinated decedents, suggesting adults with these characteristics may benefit from additional protection strategies. Further understanding of the protection of additional and booster doses is needed.

        Cavanaugh, A. M. Spicer, K. B. Thoroughman, D. A.

      5. Estimated COVID-19 vaccine effectiveness against seroconversion from SARS-CoV-2 Infection, March-October, 2021
        Plumb ID, Fette LM, Tjaden AH, Feldstein L, Saydah S, Ahmed A, Link-Gelles R, Wierzba TF, Berry AA, Friedman-Klabanoff D, Larsen MP, Runyon MS, Ward LM, Santos RP, Ward J, Weintraub WS, Edelstein S, Uschner D.
        Vaccine. 2023 .
        BACKGROUND: Monitoring the effectiveness of COVID-19 vaccines against SARS-CoV-2 infections remains important to inform public health responses. Estimation of vaccine effectiveness (VE) against serological evidence of SARS-CoV-2 infection might provide an alternative measure of the benefit of vaccination against infection. METHODS: We estimated mRNA COVID-19 vaccine effectiveness (VE) against development of SARS-CoV-2 anti-nucleocapsid antibodies in March-October 2021, during which the Delta variant became predominant. Participants were enrolled from four participating healthcare systems in the United States, and completed electronic surveys that included vaccination history. Dried blood spot specimens collected on a monthly basis were analyzed for anti-spike antibodies, and, if positive, anti-nucleocapsid antibodies. We used detection of new anti-nucleocapsid antibodies to indicate SARS-CoV-2 infection, and estimated VE by comparing 154 case-participants with new detection of anti-nucleocapsid antibodies to 1,540 seronegative control-participants matched by calendar period. Using conditional logistic regression, we estimated VE ≥ 14 days after the 2nd dose of an mRNA vaccine compared with no receipt of a COVID-19 vaccine dose, adjusting for age group, healthcare worker occupation, urban/suburban/rural residence, healthcare system region, and reported contact with a person testing positive for SARS-CoV-2. RESULTS: Among individuals who completed a primary series, estimated VE against seroconversion from SARS-CoV-2 infection was 88.8% (95% confidence interval [CI], 79.6%-93.9%) after any mRNA vaccine, 87.8% (95% CI, 75.9%-93.8%) after BioNTech vaccine and 91.7% (95% CI, 75.7%-97.2%) after Moderna vaccine. VE was estimated to be lower ≥ 3 months after dose 2 compared with < 3 months after dose 2, and among participants who were older or had underlying health conditions, although confidence intervals overlapped between subgroups. CONCLUSIONS: VE estimates generated using infection-induced antibodies were consistent with published estimates from clinical trials and observational studies that used virologic tests to confirm infection during the same period. Our findings support recommendations for eligible adults to remain up to date with COVID-19 vaccination.

        Plumb, I. D. Feldstein, L. Saydah, S. Link-Gelles, R.

    • Injury and Violence
      1. Precipitating circumstances associated with intimate partner problem related suicides
        Stanley A, Aguilar T, Holland K, Orpinas P.
        Am J Prev Med. 2023 .
        INTRODUCTION: In 2020, suicide was the 12(th) leading cause of death among adults in the United States. Prior research has shown that one common precipitating circumstance among adult suicide decedents is experiencing intimate partner problems (IPP), such as divorce, separation, romantic break-ups, arguments, conflicts, and intimate partner violence. This study examines how precipitating factors differ between IPP and non-IPP-related suicides. METHODS: In 2022, this study analyzed National Violent Death Reporting System (NVDRS) data from adult suicide decedents in 48 states and two territories between 2003 and 2020. Multivariable logistic regression models were used to compare precipitating circumstances between IPP and non-IPP-related suicides, controlling for socio-demographic characteristics. RESULTS: Of the 402,391 suicides, 20%  = 80,717) were known to be IPP-related. Circumstances that significantly increased the odds of IPP-related suicides included history of suicidal thoughts and attempts and mental health problems (depressed mood, alcohol problem, mental health diagnosis); life stressors (interpersonal violence perpetration and victimization, arguments, financial problems, job problems, family problems); and recent legal problems. Non-IPP-related suicides were more likely to occur among older individuals and to be precipitated by a physical health problem or crime. CONCLUSIONS: The findings can inform prevention strategies that build resiliency and problem-solving skills, strengthen economic support, and identify and assist people at risk for IPP-related suicides. The Centers for Disease Control and Prevention's Suicide Resource for Action and Intimate Partner Violence Prevention resource packages highlight the best available evidence for policies, programs, and practices related to preventing suicides and intimate partner problems.

        Stanley, A. Holland, K.

      2. Piloting a hospital-based road traffic injury surveillance system in Nairobi County, Kenya, 2018-2019
        Mwenda V, Yellman MA, Oyugi E, Mwachaka P, Gathecha G, Gura Z.
        Injury. 2023 .
        BACKGROUND: Kenya's estimated road traffic injury (RTI) death rate is 27.8/100,000 population, which is 1.5 times the global rate. Some RTI data are collected in Kenya; however, a systematic and integrated surveillance system does not exist. Therefore, we adopted and modified the World Health Organization's injury surveillance guidelines to pilot a hospital-based RTI surveillance system in Nairobi County, Kenya. METHODS: We prospectively documented all RTI cases presenting at two public trauma hospitals in Nairobi County from October 2018-April 2019. RTI cases were defined as injuries involving ≥1 moving vehicles on public roads. Demographics, injury circumstances, and outcome information were collected using standardized case report forms. The Kampala Trauma Score (KTS) was used to assess injury severity. RTI cases were characterized with descriptive statistics. RESULTS: Of the 1,840 RTI cases reported during the seven-month period, 73.2% were male. The median age was 29.8 years (range 1-89 years). Forty percent (n = 740) were taken to the hospital by bystanders. Median time for hospital arrival was 77 min. Pedestrians constituted 54.1% (n = 995) of cases. Of 400 motorcyclists, 48.0% lacked helmets. Similarly, 65.7% of bicyclists (23/35) lacked helmets. Among 386 motor vehicle occupants, 59.6% were not using seat belts (19.9% unknown). Seven percent of cases (n = 129) reported alcohol use (49.0% unknown), and 8.8% (n = 161) reported mobile phone use (59.7% unknown). Eleven percent of cases (n = 199) were severely injured (KTS <11), and 220 died. CONCLUSION: We demonstrated feasibility of a hospital-based RTI surveillance system in Nairobi County. Integrating information from crash scenes and hospitals can guide prevention.

        Yellman, M. A.

      3. Introduction: Research shows that a mild traumatic brain injury (mTBI) impairs a person's ability to identify driving hazards 24 h post injury and increases the risk for motor vehicle crash. This study examined the percentage of people who reported driving after their most serious mTBI and whether healthcare provider education influenced this behavior. Methods: Self-reported data were collected from 4,082 adult respondents in the summer wave of Porter Novelli's 2021 ConsumerStyles survey. Respondents with a driver's license were asked whether they drove right after their most serious mTBI, how safe they felt driving, and whether a doctor or nurse talked to them about when it was ok to drive after their injury. Results: About one in five (18.8 %) respondents reported sustaining an mTBI in their lifetime. Twenty-two percent (22.3 %) of those with a driver's license at the time of their most serious mTBI drove within 24 h, and 20 % felt very or somewhat unsafe doing so. About 19 % of drivers reported that a doctor or nurse talked to them about when it was safe to return to driving. Those who had a healthcare provider talk to them about driving were 66 % less likely to drive a car within 24 h of their most serious mTBI (APR = 0.34, 95 % CI: 0.20, 0.60) compared to those who did not speak to a healthcare provider about driving. Conclusions: Increasing the number of healthcare providers who discuss safe driving practices after a mTBI may reduce acute post-mTBI driving. Practical Applications: Inclusion of information in patient discharge instructions and prompts for healthcare providers in electronic medical records may help encourage conversations about post-mTBI driving. © 2023

        Daugherty, J. Sarmiento, K. Waltzman, D.

      4. Development of a machine learning model to estimate US firearm homicides in near real time
        Swedo EA, Alic A, Law RK, Sumner SA, Chen MS, Zwald ML, Van Dyke ME, Bowen DA, Mercy JA.
        JAMA Netw Open. 2023 ;6(3):e233413.
        IMPORTANCE: Firearm homicides are a major public health concern; lack of timely mortality data presents considerable challenges to effective response. Near real-time data sources offer potential for more timely estimation of firearm homicides. OBJECTIVE: To estimate near real-time burden of weekly and annual firearm homicides in the US. DESIGN, SETTING, AND PARTICIPANTS: In this prognostic study, anonymous, longitudinal time series data were obtained from multiple data sources, including Google and YouTube search trends related to firearms (2014-2019), emergency department visits for firearm injuries (National Syndromic Surveillance Program, 2014-2019), emergency medical service activations for firearm-related injuries (biospatial, 2014-2019), and National Domestic Violence Hotline contacts flagged with the keyword firearm (2016-2019). Data analysis was performed from September 2021 to September 2022. MAIN OUTCOMES AND MEASURES: Weekly estimates of US firearm homicides were calculated using a 2-phase pipeline, first fitting optimal machine learning models for each data stream and then combining the best individual models into a stacked ensemble model. Model accuracy was assessed by comparing predictions of firearm homicides in 2019 to actual firearm homicides identified by National Vital Statistics System death certificates. Results were also compared with a SARIMA (seasonal autoregressive integrated moving average) model, a common method to forecast injury mortality. RESULTS: Both individual and ensemble models yielded highly accurate estimates of firearm homicides. Individual models' mean error for weekly estimates of firearm homicides (root mean square error) varied from 24.95 for emergency department visits to 31.29 for SARIMA forecasting. Ensemble models combining data sources had lower weekly mean error and higher annual accuracy than individual data sources: the all-source ensemble model had a weekly root mean square error of 24.46 deaths and full-year accuracy of 99.74%, predicting the total number of firearm homicides in 2019 within 38 deaths for the entire year (compared with 95.48% accuracy and 652 deaths for the SARIMA model). The model decreased the time lag of reporting weekly firearm homicides from 7 to 8 months to approximately 6 weeks. CONCLUSIONS AND RELEVANCE: In this prognostic study of diverse secondary data on machine learning, ensemble modeling produced accurate near real-time estimates of weekly and annual firearm homicides and substantially decreased data source time lags. Ensemble model forecasts can accelerate public health practitioners' and policy makers' ability to respond to unanticipated shifts in firearm homicides.

        Swedo, E. A. Alic, A. Law, R. K. Sumner, S. A. Chen, M. S. Zwald, M. L. Van Dyke, M. E. Bowen, D. A. Mercy, J. A.

      5. Emergency department visits by incarcerated adults for nonfatal injuries - United States, 2010-2019
        Wulz A, Miller G, Navon L, Daugherty J.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(11):278-282.
        During 2010-2019, U.S. correctional authorities held 1.4-1.6 million persons in state and federal prisons annually, and 10.3-12.9 million persons were admitted to local jails each year (1,2). Incarcerated persons experience a disproportionate burden of negative health outcomes, including unintentional and violence-related injuries (3,4). No national studies on injury-related emergency department (ED) visits by incarcerated persons have been conducted, but a previous study demonstrated a high rate of such visits among a Seattle, Washington jail population (5). To examine nonfatal injury-related ED visits among incarcerated adults, CDC analyzed 2010-2019 National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) data. During 2010-2019, an estimated 733,547 ED visits by incarcerated adults occurred in the United States. The proportion of ED visits resulting from assault* and self-harm among incarcerated adults was five times as high as those among nonincarcerated adults. Among incarcerated adults, men and adult persons aged <65 years had the highest proportion of assault-related ED visits. Falls accounted for the most ED visits among incarcerated adults aged ≥65 years. A higher proportion of ED visits by incarcerated women than incarcerated men were for overdose or poisoning. These findings suggest that injuries among incarcerated adults differ from those among nonincarcerated adults and might require development and implementation of age- and sex-specific prevention strategies for this population.

        Wulz, A. Miller, G. Navon, L. Daugherty, J.

    • Laboratory Sciences
      1. Development of an equilibrium dialysis id-UPLC-MS/MS candidate reference measurement procedure for free thyroxine in human serum
        Ribera A, Zhang L, Dabbs-Brown A, Sugahara O, Poynter K, van Uytfanghe K, Shimizu E, van Herwaarden AE, Botelho JC, Danilenko U, Vesper HW.
        Clin Biochem. 2023 .
        BACKGROUND: Accurate and reliable measurement of human serum free thyroxine (FT4) is critical for the diagnosis and treatment of thyroid diseases. However, concerns have been raised regarding the performance of FT4 measurements in patient care. Centers for Disease Control and Prevention Clinical Standardization Programs (CDC-CSP) address these concerns by creating a FT4 standardization program to standardize FT4 measurements. The study aims to develop a highly accurate and precise candidate Reference Measurement Procedure (cRMP), as one key component of CDC-CSP, for standardization of FT4 measurements. METHODS: Serum FT4 was separated from protein-bound thyroxine with equilibrium dialysis (ED) following the recommended conditions in the Clinical and Laboratory Standards Institute C45-A guideline and the published RMP [23]. FT4 in dialysate was directly quantified with liquid chromatography-tandem mass spectrometry (LC-MS/MS) without derivatization. Gravimetric measurements of specimens and calibrator solutions, calibrator bracketing, isotope dilution, enhanced chromatographic resolution, and T4 specific mass transitions were used to ensure the accuracy, precision, and specificity of the cRMP. RESULTS: The described cRMP agreed well with the established RMP and two other cRMPs in an interlaboratory comparison study. The mean biases of each method to the overall laboratory mean were within ±2.5%. The intra-day, inter-day, and total imprecision for the cRMP were within 4.4%. The limit of detection was 0.90 pmol/L, which was sufficiently sensitive to determine FT4 for patients with hypothyroidism. The structural analogs of T4 and endogenous components in dialysate did not interfere with the measurements. CONCLUSION: Our ED-LC-MS/MS cRMP provides high accuracy, precision, specificity, and sensitivity for FT4 measurement. The cRMP can serve as a higher-order standard for establishing measurement traceability and provide an accuracy base for the standardization of FT4 assays.

        Ribera, A. Zhang, L. Dabbs-Brown, A. Sugahara, O. Poynter, K. Botelho, J. C. Danilenko, U. Vesper, H. W.

      2. An external quality assessment feasibility study; cross laboratory comparison of haemagglutination inhibition assay and microneutralization assay performance for seasonal influenza serology testing: A FLUCOP study
        Waldock J, Weiss CD, Wang W, Levine MZ, Jefferson SN, Ho S, Hoschler K, Londt BZ, Masat E, Carolan L, Sánchez-Ovando S, Fox A, Watanabe S, Akimoto M, Sato A, Kishida N, Buys A, Maake L, Fourie C, Caillet C, Raynaud S, Webby RJ, DeBeauchamp J, Cox RJ, Lartey SL, Trombetta CM, Marchi S, Montomoli E, Sanz-Muñoz I, Eiros JM, Sánchez-Martínez J, Duijsings D, Engelhardt OG.
        Front Immunol. 2023 ;14:1129765.
        INTRODUCTION: External Quality Assessment (EQA) schemes are designed to provide a snapshot of laboratory proficiency, identifying issues and providing feedback to improve laboratory performance and inter-laboratory agreement in testing. Currently there are no international EQA schemes for seasonal influenza serology testing. Here we present a feasibility study for conducting an EQA scheme for influenza serology methods. METHODS: We invited participant laboratories from industry, contract research organizations (CROs), academia and public health institutions who regularly conduct hemagglutination inhibition (HAI) and microneutralization (MN) assays and have an interest in serology standardization. In total 16 laboratories returned data including 19 data sets for HAI assays and 9 data sets for MN assays. RESULTS: Within run analysis demonstrated good laboratory performance for HAI, with intrinsically higher levels of intra-assay variation for MN assays. Between run analysis showed laboratory and strain specific issues, particularly with B strains for HAI, whilst MN testing was consistently good across labs and strains. Inter-laboratory variability was higher for MN assays than HAI, however both assays showed a significant reduction in inter-laboratory variation when a human sera pool is used as a standard for normalization. DISCUSSION: This study has received positive feedback from participants, highlighting the benefit such an EQA scheme would have on improving laboratory performance, reducing inter laboratory variation and raising awareness of both harmonized protocol use and the benefit of biological standards for seasonal influenza serology testing.

        Levine, M. Z. Jefferson, S. N.

    • Maternal and Child Health
      1. COVID-19 vaccine safety surveillance in early pregnancy in the United States: Design factors affecting the association between vaccine and spontaneous abortion
        Vazquez-Benitez G, Haapala JL, Lipkind HS, DeSilva MB, Zhu J, Daley MF, Getahun D, Klein NP, Vesco KK, Irving SA, Nelson JC, Williams JT, Hambidge SJ, Donahue J, Fuller CC, Weintraub ES, Olson C, Kharbanda EO.
        Am J Epidemiol. 2023 .
        In the Vaccine Safety Datalink (VSD), we previously reported no association between COVID-19 vaccination in early pregnancy and spontaneous abortion (SAB). The current study aims to understand how time since vaccine roll-out or other methodologic factors could affect results. Using a case-control design and generalized estimating equations, we estimated the odds ratios (OR) of COVID-19 vaccination in the 28 days before a SAB or last date of the surveillance period (index date) in ongoing pregnancies and occurrence of SAB, across cumulative 4-week periods from December 2020 through June 2021. Using data from a single site, we evaluated alternate methodologic approaches: increasing the exposure window to 42 days, modifying the index date from the last day to the midpoint of the surveillance period, and constructing a cohort design with a time-dependent exposure model. A protective effect (OR 0.78; 95% Confidence Interval (CI): 0.69-0.89), observed with 3-cumulative periods ending March 8, 2021, was attenuated when surveillance extended to June 28, 2021 (OR: 1.02; 95% CI: 0.96-1.08). We observed a lower OR for a 42-day as compared to a 28-day window. The time-dependent model showed no association. Timing of the surveillance appears to be an important factor affecting the observed vaccine-SAB association.

        Weintraub, E. S. Olson, C.

      2. Exome-wide assessment of isolated biliary atresia: A report from the National Birth Defects Prevention Study using child-parent trios and a case-control design to identify novel rare variants
        Sok P, Sabo A, Almli LM, Jenkins MM, Nembhard WN, Agopian AJ, Bamshad MJ, Blue EE, Brody LC, Brown AL, Browne ML, Canfield MA, Carmichael SL, Chong JX, Dugan-Perez S, Feldkamp ML, Finnell RH, Gibbs RA, Kay DM, Lei Y, Meng Q, Moore CA, Mullikin JC, Muzny D, Olshan AF, Pangilinan F, Reefhuis J, Romitti PA, Schraw JM, Shaw GM, Werler MM, Harpavat S, Lupo PJ.
        Am J Med Genet A. 2023 .
        The etiology of biliary atresia (BA) is unknown, but recent studies suggest a role for rare protein-altering variants (PAVs). Exome sequencing data from the National Birth Defects Prevention Study on 54 child-parent trios, one child-mother duo, and 1513 parents of children with other birth defects were analyzed. Most (91%) cases were isolated BA. We performed (1) a trio-based analysis to identify rare de novo, homozygous, and compound heterozygous PAVs and (2) a case-control analysis using a sequence kernel-based association test to identify genes enriched with rare PAVs. While we replicated previous findings on PKD1L1, our results do not suggest that recurrent de novo PAVs play important roles in BA susceptibility. In fact, our finding in NOTCH2, a disease gene associated with Alagille syndrome, highlights the difficulty in BA diagnosis. Notably, IFRD2 has been implicated in other gastrointestinal conditions and warrants additional study. Overall, our findings strengthen the hypothesis that the etiology of BA is complex.

        Almli, L. M. Jenkins, M. M. Reefhuis, J.

      3. Prenatal syphilis screening among pregnant Medicaid enrollees by sexually transmitted infection history and race/ethnicity
        Hammerslag LR, Campbell-Baier RE, Otter CA, Lopez-DeFede A, Smith JP, Whittington LA, Humble LJ, Myers ER, Kennedy SR, Talbert JC, Pearson WS.
        Am J Obstet Gynecol MFM. 2023 :100937.
        BACKGROUND: Congenital syphilis can cause severe morbidity, including miscarriage and stillbirth, and rates are increasing rapidly within the US. However, congenital syphilis can be prevented with early detection and treatment of syphilis during pregnancy. Current screening recommendations hold that all women should be screened early in pregnancy, while women at elevated risk of congenital syphilis should be screened again later in pregnancy. The rapid increase in congenital syphilis rates suggests that there are still gaps in prenatal syphilis screening. OBJECTIVES: To examine associations between the odds of prenatal syphilis screening and sexually transmitted infection (STI) history or other patient characteristics, in three states with elevated rates of congenital syphilis. STUDY DESIGN: We used Medicaid claims data from Kentucky, Louisiana, and South Carolina from women with deliveries between 2017 and 2021. Within each state, we examined the log-odds of prenatal syphilis screening as a function of the mother's patient health history, demographic factors, and Medicaid enrollment history. Patient history was established using a 4-year lookback of Medicaid claims data; in State A, STI surveillance data was used to improve STI history. RESULTS: Prenatal syphilis screening rates varied by state, ranging from 62.8-85.1% for deliveries by women without a recent history of STI and from 78.1-91.1% for deliveries by women with prior STI. For the main outcome, syphilis screening at any time in pregnancy, deliveries associated with prior STI had 1.09-1.37 times higher adjusted odds ratios (aOR). Deliveries by women with continuous Medicaid throughout the first trimester also had higher odds of syphilis screening at any time (a = 2.45-3.15). Among deliveries by women with a prior STI, only 53.6-63.6% received first trimester screening and this rate was still just 55.0-69.5% when considering only deliveries by women with a prior STI and full first trimester Medicaid coverage. Fewer delivering women received third trimester screening (20.3-55.8% of women with prior STI). Compared to deliveries by White women, deliveries by Black women had lower odds of first trimester screening (aOR = 0.85 in all states) but higher odds of third trimester screening (aOR = 1.23-2.03), potentially impacting maternal and birth outcomes. For State A, linkage to surveillance data doubled the rate of prior STI detection, as 53.0% of deliveries by women with a prior STI would not have had STI history detected using Medicaid claims alone. CONCLUSIONS: Prior STI and continuous pre-conception Medicaid enrollment were associated with higher rates of syphilis screening, but Medicaid claims alone do not fully capture patient STI history. Overall screening rates were lower than would be expected, given that all women should undergo prenatal screening, but rates in the third trimester were particularly low. Notably, there are gaps in early screening for non-Hispanic Black women, who had lower odds of first trimester screening compared to non-Hispanic White women despite being at elevated risk of syphilis.

        Pearson, W. S.

      4. National collaborative on childhood obesity research efforts to advance childhood obesity research: Progress and next steps
        Sharfman AS, Berrigan D, Galuska DA, Khan LK, Stowe EW, Reedy J.
        Am J Prev Med. 2023 .

      5. Maternal dietary caffeine consumption and risk of birth defects in the National Birth Defects Prevention Study, 1997-2011
        Williford EM, Howley MM, Fisher SC, Conway KM, Romitti PA, Reeder MR, Olshan AF, Reefhuis J, Browne ML.
        Birth Defects Res. 2023 .
        BACKGROUND: Caffeine consumption is common during pregnancy, but published associations with birth defects are mixed. We updated estimates of associations between prepregnancy caffeine consumption and 48 specific birth defects from the National Birth Defects Prevention Study (NBDPS) for deliveries from 1997 to 2011. METHODS: NBDPS was a large population-based case-control study conducted in 10 U.S. states. We categorized self-reported total dietary caffeine consumption (mg/day) from coffee, tea, soda, and chocolate as: <10, 10 to <100, 100 to <200, 200 to <300, and ≥ 300. We used logistic regression to estimate adjusted odds ratios (aORs [95% confidence intervals]). Analyses for defects with ≥5 exposed case children were adjusted for maternal race/ethnicity, age at delivery, body mass index, early pregnancy cigarette smoking and alcohol use, and study site. RESULTS: Our analysis included 30,285 case and 11,502 control children, with mothers of 52% and 54%, respectively, reporting consuming <100 mg caffeine, and 11% of mothers of both cases and controls reported consuming ≥300 mg per day. Low (10 to <100 mg/day) levels of prepregnancy caffeine consumption were associated with statistically significant increases in aORs (1.2-1.7) for 10 defects. Associations with high (≥300 mg/day) levels of caffeine were generally weaker, except for craniosynostosis and aortic stenosis (aORs = 1.3 [1.1-1.6], 1.6 [1.1-2.3]). CONCLUSIONS: Given the large number of estimates generated, some of the statistically significant results may be due to chance and thus the weakly increased aORs should be interpreted cautiously. This study supports previous observations suggesting lack of evidence for meaningful associations between caffeine consumption and the studied birth defects.

        Reefhuis, J.

      6. PURPOSE: Cyclobenzaprine is a muscle relaxant indicated for acute pain. Little is known about cyclobenzaprine's safety during pregnancy. We explored the association between maternal cyclobenzaprine exposure and risk of birth defects among offspring. METHODS: We combined data from two large, multi-site, population-based case-control studies in the US. Cases were identified from birth defects registries across 10 states; controls were liveborn infants without birth defects randomly selected from the same catchment areas. Participants reported cyclobenzaprine use during the month before conception through the third month of pregnancy ("periconception") via computer-assisted telephone interview. We used logistic regression to assess associations between periconceptional cyclobenzaprine exposure and selected structural birth defects. We calculated crude odds ratios (OR) with corresponding 95% confidence intervals (CI). RESULTS: Our study included 33,615 cases and 13,110 controls. Overall, 51 case (0.15%) and 9 control (0.07%) participants reported periconceptional cyclobenzaprine use. We observed increased risk for all seven defects with >3 exposed cases: cleft palate (OR=4.79, 95% CI 1.71-13.44), cleft lip (OR=2.50, 95% CI 0.89-7.02), anorectal atresia/stenosis (OR=6.91, 95% CI 1.67, 28.65), d-transposition of the great arteries (OR=6.97, 95% CI 2.17-22.36), coarctation of the aorta (OR=5.58, 95% CI 1.88-16.58), pulmonary valve stenosis (OR=4.55, 95% CI 1.10-18.87), and secundum atrial septal defect (OR=3.08, 95% CI 0.83-11.45). CONCLUSIONS: Even in our large sample, cyclobenzaprine use was rare. Our estimates are unadjusted and imprecise so should be interpreted cautiously. These hypothesis-generating results warrant confirmation and further research to explore possible mechanisms.

        Tran, E. L. Ailes, E. C.

    • Military Medicine and Health
      1. We estimated the prevalence of short sleep duration (<8 h/average school night) among high school students (grades 9-12) during the COVID-19 pandemic by using data from the Adolescent Behaviors and Experiences Survey (January-June 2021; N = 7,705). An adjusted logistic regression model predicted prevalence ratios for more difficulty doing schoolwork during the pandemic compared with before the pandemic. Most (76.5%) students experienced short sleep duration, and two-thirds perceived more difficulty doing schoolwork. Students who slept less than 7 hours per school night or experienced poor mental health were more likely to report increased difficulty doing schoolwork. Addressing students' sleep duration could complement efforts to bolster their mental health and learning.

        Sliwa, S. A. Wheaton, A. G. Li, J. Michael, S. L.

    • Occupational Safety and Health
      1. BACKGROUND: Fluid leakage through the glove-protective clothing interface is an area of concern for many healthcare personnel, including emergency medical service providers, who may wear coveralls to protect themselves from multiple types of hazards. There is currently no established standard test method to specifically evaluate the barrier performance of the glove-protective clothing interface region for any personal protective equipment ensemble. OBJECTIVE: This study quantifies the fluid leakage at the coverall and glove interface using single and double gloving. METHODS: A robotic arm, which can simulate upper extremity movements of healthcare personnel, was used to test five coverall models and an extended examination glove model in single and double glove conditions. RESULTS: The results show that there was a significant difference in fluid leakage amounts between some of the coverall models and the number of glove layers studied. Findings also highlight that there is a high correlation between basis weight and stiffness of the coverall fabrics and the fluid leakage amounts. CONCLUSIONS: These results underline that coverall constructed from thin and less stiff fabrics can result in lower fluid leakage levels. Also, there was no significant difference in fluid leakage amounts between single and double gloves when tested with each of the coverall models, with the exception of the coveralls with the highest basis weight and stiffness.

        Kahveci, Z. Kilinc-Balci, F. S. Yorio, P. L.

      2. Objective: Paid sick leave (PSL) laws mandate employers give workers paid time off when they are sick or injured. This current study aims to examine whether access to PSL is associated with healthcare utilization and health outcomes and to summarize the types of utilization and outcomes which have been reported to be associated with PSL. Methods: We conducted a rapid evidence review. Our search of seven databases, including Medline, Embase, PsycINFO, Cochrane Library, CINAHL, Scopus, and JSTOR, on September 21, 2020, identified 757 studies, 30 of which were retained. Results: Previous evidence is mostly provided by cross-sectional studies with survey data. In this study, evidence suggests that PSL is significantly associated with some types of healthcare utilization and health outcomes. In terms of healthcare utilization, findings indicate PSL is associated with an increase in the use of some preventive services and a decrease in the use of emergency care; while findings are mixed regarding associations of PSL with health provider visits and the use of mammograms and pap smears. As for health outcomes, findings suggest PSL is associated with improved mental and self-rated health, decreased incidence of influenza-like illness, and lower occupational injuries and mortality rates. Conclusion: PSL may be an effective tool in improving some healthcare utilization and health outcomes. Future research could help identify mechanisms through which PSL access works and identify what policy components lead to better outcomes. © 2023

        Song, S. Calhoun, B. H. Kucik, J. E. Hilson, R.

      3. All causes of death among veterinarians in the United States during 1979 through 2015
        Tomasi SE, Fechter-Leggett ED, Edwards NT, Reddish AD, Nett RJ.
        J Am Vet Med Assoc. 2022 ;260(9):1-10.
        OBJECTIVE: To assess proportionate mortality from all causes for male and female US veterinarians during 1979 through 2015. SAMPLE: Death records for 11,620 veterinarians. PROCEDURES: For this proportionate mortality ratio (PMR) study, information for veterinarians who died during 1979 through 2015 was obtained from AVMA obituary and life insurance databases and submitted to a centralized database of US death records to obtain underlying causes of death. Decedent data that met records-matching criteria were imported into a software program for calculation of PMRs for all causes stratified by sex and indirectly standardized for age, race, and 5-year calendar period with 95% CIs. RESULTS: 11,620 decedents consisted of 11,049 (95%) males and 571 (5%) females with a median age at death of 77 years. Proportionate mortality for all veterinarian decedents was higher than expected for melanoma (PMRs, 2.1 and 2.2 for males and females, respectively), suicide (PMRs, 2.1 and 3.5 for males and females, respectively), and transportation injuries (PMRs, 1.7 and 1.6 for males and females, respectively). Proportionate mortality for all decedents was lower than expected for respiratory cancers (PMRs, 0.6 and 0.5 for males and females, respectively), diabetes mellitus (PMRs, 0.7 and 0.4 for males and females, respectively), heart disease (PMRs, 0.9 and 0.6 for males and females, respectively), and respiratory disorders (PMRs, 0.7 and 0.6 for males and females, respectively). CLINICAL RELEVANCE: Results indicated proportionate mortality from malignant melanoma, transportation injuries, and suicide for male and female veterinarians was higher than the general population. These data may help stakeholders improve veterinarian workplace safety and health guidelines.

        Tomasi, S. E. Fechter-Leggett, E. D. Edwards, N. T. Nett, R. J.

      4. The role of emergency incident type in identifying first responders' health exposure risks
        Haas EJ, Yoon KN, Furek A, Casey M, Moore SM.
        J Saf Sci Resilience. ;4(2):167-173.
        Fire-based emergency management service (EMS) personnel are dispatched to various incidents daily, many of which have unique occupational risks. To fully understand the variability of incident types and how to best prepare and respond, an exploration of the U.S. coding system of incident types is necessary. This study uses potential exposure to SARS-CoV-2 as a case example to understand if and how coding categories for incident call types may be updated to improve data standardization and emergency response decision making. Researchers received emergency response incident data generated by three fire department computer-aided dispatch (CAD) systems between March and September 2020. Each incident was labeled EMS, Fire, or Other. Of the 162,766 incidents, approximately 8.1% (n = 13,144) noted potential SARS-CoV-2 exposure within their narrative descriptions of which 86.3% were coded as EMS, 9.9% as Fire, and 3.9% as Other. To assess coding variability across incident types, researchers used the original 3-incident type variable and a new 5-incident type variable reassigned by researchers into EMS, Fire, Other, Hazmat, and Motor Vehicle. Logit regressions compared differences in potential exposure using the 3- and 5-incident type variables. When evaluating the 3-incident type variable, those responding to a Fire versus an EMS incident were 84% less likely to be associated with potential exposure to SARS-CoV-2. For the 5-incident type variable, those responding to Fire incidents were 77% less likely to be associated with a potential exposure than those responding to EMS incidents. Changes in potential exposure between the 3- and 5-incident type models show the need to understand how incident types are assigned. This demonstrates the need for data standardization to accurately categorize incident types to improve emergency preparedness and response. Results have implications for incident type coding at fire department municipality and national levels.

        Haas, E. J. Yoon, K. N. Furek, A. Casey, M. Moore, S. M.

      5. Factors associated with receipt of COVID-19 vaccination and SARS-CoV-2 seropositivity among healthcare workers in Albania (February 2021–June 2022): secondary analysis of a prospective cohort study
        Jorgensen P, Schmid A, Sulo J, Preza I, Hasibra I, Kissling E, Fico A, Sridhar S, Rubin-Smith JE, Kota M, Vasili A, Daja R, Nika M, Pebody R, Lafond KE, Katz MA, Bino S.
        Lancet Reg Health Eur. 2023 .
        Background: Healthcare workers (HCWs) have been disproportionally affected by COVID-19. We investigated factors associated with two- and three-dose COVID-19 vaccine uptake and SARS-CoV-2 seropositivity among 1504 HCWs enrolled (19 February-7 May 2021) in a prospective COVID-19 vaccine effectiveness cohort in Albania through a secondary analysis. Methods: We collected sociodemographic, occupational, health, prior SARS-CoV-2 infection, and COVID-19 vaccination data from all HCWs at enrollment. Vaccination status was assessed weekly through June 2022. A serum sample was collected from all participants at enrollment and tested for anti-spike SARS-CoV-2 antibodies. We analyzed HCWs characteristics and outcomes using multivariable logistic regression. Findings: By 11 June 2022, 1337 (88.9%) HCWs had received two COVID-19 vaccine doses, of whom 255 (19.1%) received a booster. Factors significantly associated with receiving three doses (adjusted odds ratio (aOR), 95% CIs) were being ≥35 years (35–44 years: 1.76 (1.05–2.97); 45–54 years: 3.11 (1.92–5.05); ≥55 years: 3.38 (2.04–5.59)) and vaccinated against influenza (1.78; 1.20–2.64). Booster dose receipt was lower among females (0.58; 0.41–0.81), previously infected (0.67; 0.48–0.93), nurses and midwives (0.31; 0.22–0.45), and support staff (0.19; 0.11–0.32). Overall 1076 (72%) were SARS-CoV-2 seropositive at enrollment. Nurses and midwifes (1.45; 1.05–2.02), support staff (1.57; 1.03–2.41), and HCWs performing aerosol-generating procedures (AGPs) (1.40; 1.01–1.94) had higher odds of being seropositive, while smokers had reduced odds (0.55; 0.40–0.75). Interpretation: In a large cohort of Albanian HCWs, COVID-19 vaccine booster dose uptake was very low, particularly among younger, female, and non-physician HCWs, despite evidence demonstrating the added benefit of boosters in preventing infection and severe disease. Reasons behind these disparities should be explored to develop targeted strategies in order to promote uptake in this critical population. SARS-CoV-2 seroprevalence was higher among non-physicians and HCWs performing APGs. A better understanding of the factors contributing to these differences is needed to inform interventions that could reduce infections in the future. Funding: This study was funded by the Task Force for Global Health (US Centers for Disease Control (CDC) cooperative agreement # NU51IP000873) and the World Health Organization, Regional Office for Europe. © 2023 World Health Organization

        Lafond, K. E.

    • Parasitic Diseases
      1. Using antenatal care as a platform for malaria surveillance data collection: study protocol
        Gutman JR, Mwesigwa JN, Arnett K, Kangale C, Aaron S, Babarinde D, Buekens J, Candrinho B, Debe S, Digre P, Drake M, Gansané A, Gogue C, Griffith KS, Hicks J, Kinda R, Koenker H, Lemwayi R, Munsey A, Obi E, Ogouyèmi-Hounto A, Okoko OO, Onikpo F, Onoja A, Porter T, Savaio B, Tynuv K, Uhomoibhi P, Wagman J, Wolf K, Zulliger R, Walker P, Miller JM, Robertson M.
        Malar J. 2023 ;22(1):99.
        BACKGROUND: While many malaria-endemic countries have health management information systems that can measure and report malaria trends in a timely manner, these routine systems have limitations. Periodic community cross-sectional household surveys are used to estimate malaria prevalence and intervention coverage but lack geographic granularity and are resource intensive. Incorporating malaria testing for all women at their first antenatal care (ANC) visit (i.e., ANC1) could provide a more timely and granular source of data for monitoring trends in malaria burden and intervention coverage. This article describes a protocol designed to assess if ANC-based surveillance could be a pragmatic tool to monitor malaria. METHODS: This is an observational, cross-sectional study conducted in Benin, Burkina Faso, Mozambique, Nigeria, Tanzania, and Zambia. Pregnant women attending ANC1 in selected health facilities will be tested for malaria infection by rapid diagnostic test and administered a brief questionnaire to capture key indicators of malaria control intervention coverage and care-seeking behaviour. In each location, contemporaneous cross-sectional household surveys will be leveraged to assess correlations between estimates obtained using each method, and the use of ANC data as a tool to track trends in malaria burden and intervention coverage will be validated. RESULTS: This study will assess malaria prevalence at ANC1 aggregated at health facility and district levels, and by gravidity relative to current pregnancy (i.e., gravida 1, gravida 2, and gravida 3 +). ANC1 malaria prevalence will be presented as monthly trends. Additionally, correlation between ANC1 and household survey-derived estimates of malaria prevalence, bed net ownership and use, and care-seeking will be assessed. CONCLUSION: ANC1-based surveillance has the potential to provide a cost-effective, localized measure of malaria prevalence that is representative of the general population and useful for tracking monthly changes in parasite prevalence, as well as providing population-representative estimates of intervention coverage and care-seeking behavior. This study will evaluate the representativeness of these measures and collect information on operational feasibility, usefulness for programmatic decision-making, and potential for scale-up of malaria ANC1 surveillance.

        Gutman, J. R. Munsey, A.

    • Public Health Leadership and Management
      1. Building national health security through a rapid self-assessment and annual operational plan in Uganda, May to September 2021
        Nabatanzi M, Bakiika H, Nabukenya I, Lamorde M, Bukirwa J, Achan MI, Babigumira PA, Nakiire L, Lubanga T, Mbabazi E, Taremwa RB, Mayinja H, Nakinsige A, Makanga DK, Muruta A, Okware S, Komakech I, Makumbi I, Wetaka MM, Kayiwa J, Ocom F, Ario AR, Nabatanzi S, Ojwang J, Boore A, Yemanaberhan R, Lee CT, Obuku E, Stowell D.
        Health Secur. 2023 .
        Uganda established a National Action Plan for Health Security in 2019, following a Joint External Evaluation (JEE) of International Health Regulations (2005) capacities in 2017. The action plan enhanced national health security awareness, but implementation efforts were affected by limited funding, excess of activities, and challenges related to monitoring and evaluation. To improve implementation, Uganda conducted a multisectoral health security self-assessment in 2021 using the second edition of the JEE tool and developed a 1-year operational plan. From 2017 to 2021, Uganda's composite ReadyScore improved by 20%, with improvement in 13 of the 19 technical areas. Indicator scores showing limited capacity declined from 30% to 20%, and indicators with no capacity declined from 10% to 2%. More indicators had developed (47% vs 40%), demonstrated (29% vs 20%), and sustained (2% vs 0%) capacities in 2021 compared with 2017. Using the self-assessment JEE scores, 72 specific activities from the International Health Regulations (2005) benchmarks tool were selected for inclusion in a 1-year operational plan (2021-2022). In contrast to the 264 broad activities in the 5-year national action plan, the operational plan prioritized a small number of activities to enable sectors to focus limited resources on implementation. While certain capacities improved before and during implementation of the action plan, countries may benefit from using short-term operational planning to develop realistic and actionable health security plans to improve health security capacities.

        Nabatanzi, S. Ojwang, J. Boore, A. Stowell, D.

    • Substance Use and Abuse
      1. BACKGROUND: Delta-8 tetrahydrocannabinol (THC) is a psychoactive cannabinoid from the cannabis plant that can be synthetically converted from cannabidiol (CBD). Most states permit the full or restricted sale of hemp and hemp-derived CBD products, and therefore, delta-8 THC products are on the rise. Delta-8 THC consumption can cause intoxication. Products are often sold in edible form and occasionally in packaging that appears similar to candy. Clinical presentations for delta-8 THC ingestions are understudied and may differ from those described for delta-9 THC ingestions. CASE PRESENTATION: This case report describes unintentional ingestions of putative delta-8 THC by two pediatric patients that results in admission to the pediatric intensive care unit. The ingestions were of putative delta-8 THC infused product that resembled popular candies. Both patients developed periods of bradypnea with continued intermittent periods of agitation. Medical intervention included observation, noninvasive positive pressure ventilation via high flow nasal cannula, and intubation-but was not needed for both patients. Although family noted ongoing irritability for the patients, both were discharged approximately 45 h after ingestion. Delta-8 THC ingestion is reliant on self-report. CONCLUSIONS: As the availability of delta-8 THC increases, along with associated pediatric exposures, it is imperative for health care providers to quickly recognize and provide adequate treatment. While there is no specific antidote for THC intoxication beyond supportive care, providers can play an important role in prevention by educating parents and guardians on safe cannabis storage and by documenting cases for adverse event monitoring.

        Hoots, B. E. Roehler, D. R.

      2. Trends in nicotine strength in electronic cigarettes sold in the United States by flavor, product type, and manufacturer, 2017-2022
        Wang X, Ghimire R, Shrestha SS, Borowiecki M, Emery S, Trivers KF.
        Nicotine Tob Res. 2023 .
        INTRODUCTION: Most e-cigarettes contain highly addictive nicotine. This study assessed trends in nicotine strength in e-cigarettes sold in the United States during January 2017-March 2022. AIMS AND METHODS: We obtained January 2017-March 2022 national retail e-cigarette sales data from NielsenIQ. We assessed monthly average nicotine strength overall, by e-cigarette product and flavor type, and manufacturer. A Joinpoint regression model assessed the magnitude and significance of changes in nicotine strength. RESULTS: During January 2017-March 2022, monthly average nicotine strength of e-cigarette products increased from 2.5% to 4.4%, an average of 0.8% per month (p < .001). Monthly average nicotine strength of disposable e-cigarettes increased the most (average monthly percentage change [AMPC] = 1.26%, p < .001) as compared to prefilled pods (AMPC = 0.6%, p < .001) and e-liquids (AMPC = 0.5%, p = .218). Monthly average nicotine strength for all flavors of e-cigarette products increased except for mint-flavored products. Increases were greatest for beverage-flavored products (AMPC = 2.1%, p < .001), followed by menthol-flavored products (AMPC = 1.2%, p < .001). Among the top 10 e-cigarette manufacturers assessed, monthly average nicotine strength decreased for Juul Labs products from 5% to 4.7% (AMPC = -0.1%, p < .001) but increased significantly for five manufacturers' products and remained unchanged at 5%-6% for four manufacturers' products. CONCLUSIONS: Monthly average nicotine strength of e-cigarette products increased overall, for most product and flavor types, and for some manufacturers in the United States during the study period. Imposing maximum limits on nicotine strength of e-cigarettes together with other evidence-based tobacco control strategies can help reduce the use of e-cigarettes among youth and increase tobacco product cessation among adults. IMPLICATIONS: From January 2017 to March 2022, the monthly average nicotine strength of disposable e-cigarettes increased substantially and exceeded prefilled pods since May 2020. E-cigarettes with menthol flavor and youth-appealing flavors, like fruit, also had sharp increases in monthly average nicotine strength. Among the top 10 e-cigarette manufacturers, monthly average nicotine strength increased or remained unchanged at a high nicotine level for all manufacturers' products, except Juul Lab's products. Comprehensive strategies including restricting sales of all flavored e-cigarettes, restricting youth tobacco product access, and imposing maximum limits on nicotine strength may help reduce youth e-cigarette use and increase tobacco cessation.

        Wang, X. Trivers, K. F.

    • Telehealth and Telemedicine
      1. Care trajectories for patients utilizing electronic visits for COVID-like symptoms in a large healthcare delivery system: May 2020-December 2021
        Groom HC, Crawford P, Azziz-Baumgartner E, Henninger ML, Smith N, Salas B, Donald J, Naleway AL.
        J Telemed Telecare. 2023 :1357633x231162874.
        BACKGROUND: There is limited information about how on-line screening tools developed by integrated systems facilitated management of COVID-like illness patients. METHODS: Using the Kaiser Permanente Northwest (KPNW) Electronic Health Record, we identified adult plan members who accessed online COVID-19 screening e-visits and enumerated their subsequent medical encounters, tests for SARS-CoV-2, and test outcomes. RESULTS: Between May 2020 and December 2021, members completed 55,139 e-visits, with disproportionate representation among females (65% vs. 53% in the overall membership) and members aged <45 years (61% vs. 39%). Thirty percent of patients (16,953) were managed entirely through e-visits and 70% received subsequent in-person care. The percent of SARS-CoV-2 positive individuals was highest among the 1055 individuals triaged to inpatient care (17.9%), compared to 9.5% among those escalated to additional ambulatory care. CONCLUSIONS: The e-visit on-line screening tool helped KPNW assist thousands of patients with COVID-19 symptoms, avoid unnecessary in-person patient encounters, and preserved KPNW infection control and pandemic surge capacity.

        Azziz-Baumgartner, E.

    • Zoonotic and Vectorborne Diseases
      1. Raccoon rabies control and elimination in the northeastern U.S. and southern Québec, Canada
        Davis AJ, Gagnier M, Massé A, Nelson KM, Kirby JD, Wallace R, Ma X, Fehlner-Gardiner C, Chipman RB, Gilbert AT.
        Epidemiol Infect. 2023 :1-32.

      2. Notes From the Field: First evidence of locally acquired dengue virus infection - Maricopa County, Arizona, November 2022
        Kretschmer M, Collins J, Dale AP, Garrett B, Koski L, Zabel K, Staab RN, Turnbow K, Nativio J, Andrews K, Smith WE, Townsend J, Busser N, Will J, Burr K, Jones FK, Santiago GA, Fitzpatrick KA, Ruberto I, Fitzpatrick K, White JR, Adams L, Sunenshine RH.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(11):290-291.

      3. Notes from the field: Prevalence of previous dengue virus infection among children and adolescents - U.S. Virgin Islands, 2022
        Mac VV, Wong JM, Volkman HR, Perez-Padilla J, Wakeman B, Delorey M, Biggerstaff BJ, Fagre A, Gumbs A, Drummond A, Zimmerman B, Lettsome B, Medina FA, Paz-Bailey G, Lawrence M, Ellis B, Rosenblum HG, Carroll J, Roth J, Rossington J, Meeker JR, Joseph J, Janssen J, Ekpo LL, Carrillo M, Hernandez N, Charles P, Tosado R, Soto R, Battle S, Bart SM, Wanga V, Valentin W, Powell W, Battiste Z, Ellis EM, Adams LE.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(11):288-289.

      4. Trends in reported babesiosis cases - United States, 2011-2019
        Swanson M, Pickrel A, Williamson J, Montgomery S.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(11):273-277.
        Babesiosis is a tickborne disease caused by intraerythrocytic Babesia parasites. In the United States, most babesiosis cases are caused by Babesia microti, transmitted from bites of blacklegged ticks, Ixodes scapularis, in northeastern and midwestern states. Transmission can also occur through blood transfusions, transplantation of organs from infected donors, or congenital (mother-to-child) transmission (1). Babesia infection can be asymptomatic or cause mild to severe illness that can be fatal. Overall, U.S. tickborne disease cases have increased 25%, from 40,795 reported in 2011 to 50,856 in 2019 (2). Babesiosis trends were assessed in 10 states* where babesiosis was reportable during 2011-2019. Incidence increased significantly in Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, and Vermont (p<0.001), with the largest increases reported in Vermont (1,602%, from two to 34 cases), Maine (1,422%, from nine to 138), New Hampshire (372%, from 13 to 78), and Connecticut (338%, from 74 to 328). Unlike the other seven states, Maine, New Hampshire, and Vermont, were not included as states with endemic disease in previous CDC babesiosis surveillance summaries. These three states should now be considered to have endemic transmission comparable to that in other high-incidence states; they have consistently identified newly acquired cases every year during 2011-2019 and documented presence of Babesia microti in the associated tick vector (3). Because incidence in Northeastern states, including Maine, New Hampshire, and Vermont, is increasing, tick prevention messaging, provider education, and awareness of infection risk among travelers to these states should be emphasized.

        Swanson, M. Williamson, J. Montgomery, S.


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