Issue 21, May 30, 2017

CDC Science Clips: Volume 9, Issue 21, May 30, 2017

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

  1. Top Articles of the Week

    Selected weekly by a senior CDC scientist from the standard sections listed below.

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions RSS Word feed
      • A national effort to prevent type 2 diabetes: Participant-level evaluation of CDC’s National Diabetes Prevention ProgramExternal
        Ely EK, Gruss SM, Luman ET, Gregg EW, Ali MK, Nhim K, Rolka DB, Albright AL.
        Diabetes Care. 2017 May 12.

        OBJECTIVE: To assess participant-level results from the first 4 years of implementation of the National Diabetes Prevention Program (National DPP), a national effort to prevent type 2 diabetes in those at risk through structured lifestyle change programs. RESEARCH DESIGN AND METHODS: Descriptive analysis was performed on data from 14,747 adults enrolled in year-long type 2 diabetes prevention programs during the period February 2012 through January 2016. Data on attendance, weight, and physical activity minutes were summarized and predictors of weight loss were examined using a mixed linear model. All analyses were performed using SAS 9.3. RESULTS: Participants attended a median of 14 sessions over an average of 172 days in the program (median 134 days). Overall, 35.5% achieved the 5% weight loss goal (average weight loss 4.2%, median 3.1%). Participants reported a weekly average of 152 min of physical activity (median 128 min), with 41.8% meeting the physical activity goal of 150 min per week. For every additional session attended and every 30 min of activity reported, participants lost 0.3% of body weight (P < 0.0001). CONCLUSIONS: During the first 4 years, the National DPP has achieved widespread implementation of the lifestyle change program to prevent type 2 diabetes, with promising early results. Greater duration and intensity of session attendance resulted in a higher percent of body weight loss overall and for subgroups. Focusing on retention may reduce disparities and improve overall program results. Further program expansion and investigation is needed to continue lowering the burden of type 2 diabetes nationally.

    • Communicable Diseases RSS Word feed
      • Estimating the future burden of multidrug-resistant and extensively drug-resistant tuberculosis in India, the Philippines, Russia, and South Africa: a mathematical modelling studyExternal
        Sharma A, Hill A, Kurbatova E, van der Walt M, Kvasnovsky C, Tupasi TE, Caoili JC, Gler MT, Volchenkov GV, Kazennyy BY, Demikhova OV, Bayona J, Contreras C, Yagui M, Leimane V, Cho SN, Kim HJ, Kliiman K, Akksilp S, Jou R, Ershova J, Dalton T, Cegielski P.
        Lancet Infect Dis. 2017 May 09.

        BACKGROUND: Multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis are emerging worldwide. The Green Light Committee initiative supported programmatic management of drug-resistant tuberculosis in 90 countries. We used estimates from the Preserving Effective TB Treatment Study to predict MDR and XDR tuberculosis trends in four countries with a high burden of MDR tuberculosis: India, the Philippines, Russia, and South Africa. METHODS: We calibrated a compartmental model to data from drug resistance surveys and WHO tuberculosis reports to forecast estimates of incident MDR and XDR tuberculosis and the percentage of incident MDR and XDR tuberculosis caused by acquired drug resistance, assuming no fitness cost of resistance from 2000 to 2040 in India, the Philippines, Russia, and South Africa. FINDINGS: The model forecasted the percentage of MDR tuberculosis among incident cases of tuberculosis to increase, reaching 12.4% (95% prediction interval 9.4-16.2) in India, 8.9% (4.5-11.7) in the Philippines, 32.5% (27.0-35.8) in Russia, and 5.7% (3.0-7.6) in South Africa in 2040. It also predicted the percentage of XDR tuberculosis among incident MDR tuberculosis to increase, reaching 8.9% (95% prediction interval 5.1-12.9) in India, 9.0% (4.0-14.7) in the Philippines, 9.0% (4.8-14.2) in Russia, and 8.5% (2.5-14.7) in South Africa in 2040. Acquired drug resistance would cause less than 30% of incident MDR tuberculosis during 2000-40. Acquired drug resistance caused 80% of incident XDR tuberculosis in 2000, but this estimate would decrease to less than 50% by 2040. INTERPRETATION: MDR and XDR tuberculosis were forecast to increase in all four countries despite improvements in acquired drug resistance shown by the Green Light Committee-supported programmatic management of drug-resistant tuberculosis. Additional control efforts beyond improving acquired drug resistance rates are needed to stop the spread of MDR and XDR tuberculosis in countries with a high burden of MDR tuberculosis. FUNDING: US Agency for International Development and US Centers for Disease Control and Prevention, Division of Tuberculosis Elimination.

    • Disease Reservoirs and Vectors RSS Word feed
      • Transmission incompetence of Culex quinquefasciatus and Culex pipiens pipiens from North America for Zika virusExternal
        Kenney JL, Romo H, Duggal NK, Tzeng WP, Burkhalter KL, Brault AC, Savage HM.
        Am J Trop Med Hyg. 2017 May;96(5):1235-1240.

        AbstractIn late 2014, Zika virus (ZIKV; Flaviviridae, Flavivirus) emerged as a significant arboviral disease threat in the Western hemisphere. Aedes aegypti and Aedes albopictus have been considered the principal vectors of ZIKV in the New World due to viral isolation frequency and vector competence assessments. Limited reports of Culex transmission potential have highlighted the need for additional vector competence assessments of North American Culex species. Accordingly, North American Culex pipiens and Culex quinquefasciatus were orally exposed and intrathoracically inoculated with the African prototype ZIKV strain and currently circulating Asian lineage ZIKV strains to assess infection, dissemination, and transmission potential. Results indicated that these two North American Culex mosquito species were highly refractory to oral infection with no dissemination or transmission observed with any ZIKV strains assessed. Furthermore, both Culex mosquito species intrathoracically inoculated with either Asian or African lineage ZIKVs failed to expectorate virus in saliva. These in vivo results were further supported by the observation that multiple mosquito cell lines of Culex species origin demonstrated significant growth restriction of ZIKV strains compared with Aedes-derived cell lines. In summation, no evidence for the potential of Cx. pipiens or Cx. quinquefasciatus to serve as a competent vector for ZIKV transmission in North America was observed.

    • Food Safety RSS Word feed
      • Foodborne disease outbreaks in correctional institutions – United States, 1998-2014External
        Marlow MA, Luna-Gierke RE, Griffin PM, Vieira AR.
        Am J Public Health. 2017 May 18:e1-e7.

        OBJECTIVES: To present the first update on the epidemiology of US foodborne correctional institution outbreaks in 20 years. METHODS: We analyzed data from the Centers for Disease Control and Prevention’s Foodborne Disease Outbreak Surveillance System to describe correctional institution outbreaks from 1998 to 2014 and compare them with other foodborne outbreaks. RESULTS: Two hundred foodborne outbreaks in correctional institutions were reported, resulting in 20 625 illnesses, 204 hospitalizations, and 5 deaths. Median number of outbreak-associated illnesses per 100 000 population per year was 45 (range = 11-141) compared with 7 (range = 4-10) for other outbreaks. These outbreaks accounted for 6% (20 625 of 358 330) of outbreak-associated foodborne illnesses. Thirty-seven states reported at least 1 outbreak in a correctional institution. Clostridium perfringens (28%; 36 of 128) was the most frequently reported single etiology. The most frequently reported contributing factor was food remaining at room temperature (37%; 28 of 76). CONCLUSIONS: Incarcerated persons suffer a disproportionate number of outbreak-associated foodborne illnesses. Better food safety oversight and regulation in correctional food services could decrease outbreaks. Public Health Implications. Public health officials, correctional officials, and food suppliers can work together for food safety. Clearer jurisdiction over regulation of correctional food services is needed. (Am J Public Health. Published online ahead of print May 18, 2017: e1-e7. doi:10.2105/AJPH.2017.303816).

    • Genetics and Genomics RSS Word feed
      • Neisseria gonorrhoeae sequence typing for antimicrobial resistance, a novel antimicrobial resistance multilocus typing scheme for tracking global dissemination of N. gonorrhoeae strainsExternal
        Demczuk W, Sidhu S, Unemo M, Whiley DM, Allen VG, Dillon JR, Cole M, Seah C, Trembizki E, Trees DL, Kersh EN, Abrams AJ, de Vries HJ, van Dam AP, Medina I, Bharat A, Mulvey MR, Van Domselaar G, Martin I.
        J Clin Microbiol. 2017 May;55(5):1454-1468.

        A curated Web-based user-friendly sequence typing tool based on antimicrobial resistance determinants in Neisseria gonorrhoeae was developed and is publicly accessible ( The N. gonorrhoeae Sequence Typing for Antimicrobial Resistance (NG-STAR) molecular typing scheme uses the DNA sequences of 7 genes (penA, mtrR, porB, ponA, gyrA, parC, and 23S rRNA) associated with resistance to beta-lactam antimicrobials, macrolides, or fluoroquinolones. NG-STAR uses the entire penA sequence, combining the historical nomenclature for penA types I to XXXVIII with novel nucleotide sequence designations; the full mtrR sequence and a portion of its promoter region; portions of ponA, porB, gyrA, and parC; and 23S rRNA sequences. NG-STAR grouped 768 isolates into 139 sequence types (STs) (n = 660) consisting of 29 clonal complexes (CCs) having a maximum of a single-locus variation, and 76 NG-STAR STs (n = 109) were identified as unrelated singletons. NG-STAR had a high Simpson’s diversity index value of 96.5% (95% confidence interval [CI] = 0.959 to 0.969). The most common STs were NG-STAR ST-90 (n = 100; 13.0%), ST-42 and ST-91 (n = 45; 5.9%), ST-64 (n = 44; 5.72%), and ST-139 (n = 42; 5.5%). Decreased susceptibility to azithromycin was associated with NG-STAR ST-58, ST-61, ST-64, ST-79, ST-91, and ST-139 (n = 156; 92.3%); decreased susceptibility to cephalosporins was associated with NG-STAR ST-90, ST-91, and ST-97 (n = 162; 94.2%); and ciprofloxacin resistance was associated with NG-STAR ST-26, ST-90, ST-91, ST-97, ST-150, and ST-158 (n = 196; 98.0%). All isolates of NG-STAR ST-42, ST-43, ST-63, ST-81, and ST-160 (n = 106) were susceptible to all four antimicrobials. The standardization of nomenclature associated with antimicrobial resistance determinants through an internationally available database will facilitate the monitoring of the global dissemination of antimicrobial-resistant N. gonorrhoeae strains.

    • Immunity and Immunization RSS Word feed
      • Missed opportunities for measles, mumps, rubella vaccination among departing U.S. Adult travelers receiving pretravel health consultationsExternal
        Hyle EP, Rao SR, Jentes ES, Fiebelkorn AP, Hagmann SH, Walker AT, Walensky RP, Ryan ET, LaRocque RC.
        Ann Intern Med. 2017 May 16.

        Background: Measles outbreaks continue to occur in the United States and are mostly due to infections in returning travelers. Objective: To describe how providers assessed the measles immunity status of departing U.S. adult travelers seeking pretravel consultation and to assess reasons given for nonvaccination among those considered eligible to receive the measles, mumps, rubella (MMR) vaccine. Design: Observational study in U.S. pretravel clinics. Setting: 24 sites associated with Global TravEpiNet (GTEN), a Centers for Disease Control and Prevention-funded consortium. Patients: Adults (born in or after 1957) attending pretravel consultations at GTEN sites (2009 to 2014). Measurements: Structured questionnaire completed by traveler and provider during pretravel consultation. Results: 40 810 adult travelers were included; providers considered 6612 (16%) to be eligible for MMR vaccine at the time of pretravel consultation. Of the MMR-eligible, 3477 (53%) were not vaccinated at the visit; of these, 1689 (48%) were not vaccinated because of traveler refusal, 966 (28%) because of provider decision, and 822 (24%) because of health systems barriers. Most MMR-eligible travelers who were not vaccinated were evaluated in the South (2262 travelers [65%]) or at nonacademic centers (1777 travelers [51%]). Nonvaccination due to traveler refusal was most frequent in the South (1432 travelers [63%]) and in nonacademic centers (1178 travelers [66%]). Limitation: These estimates could underrepresent the opportunities for MMR vaccination because providers accepted verbal histories of disease and vaccination as evidence of immunity. Conclusion: Of U.S. adult travelers who presented for pretravel consultation at GTEN sites, 16% met criteria for MMR vaccination according to the provider’s assessment, but fewer than half of these travelers were vaccinated. An increase in MMR vaccination of eligible U.S. adult travelers could reduce the likelihood of importation and transmission of measles virus. Primary Funding Source: Centers for Disease Control and Prevention, National Institutes of Health, and the Steve and Deborah Gorlin MGH Research Scholars Award.

    • Injury and Violence RSS Word feed
      • Fatalities from firearm-related injuries in selected governorates of Iraq, 2010-2013External
        Nerlander MP, Leidman E, Hassan A, Sultan AS, Jaffar Hussain S, Browne LB, Bilukha OO.
        Prehosp Disaster Med. 2017 May 18:1-8.

        BACKGROUND: In Iraq, where Islamic State of Iraq and Syria (ISIS) and other groups have contributed to escalating violence in recent years, understanding the epidemiology of intentional firearm-related fatalities is essential for public health action. METHODS: The Iraqi Ministry of Health (MoH; Baghdad, Iraq) compiles surveillance of fatal injuries in eight of Iraq’s 18 governorates (Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya). Information is collected from coroner’s reports and interviews with family members. Analysis was performed on intentional firearm-related injuries, excluding injuries from intentional self-harm or negligent discharges, that occurred during 2010-2013, a subset of all fatal injuries, and compared to previously published explosive-related fatalities. RESULTS: Overall, the dataset included 7,985 firearm-related fatalities. Yearly fatalities were: 2010=1,706; 2011=1,642; 2012=1,662; and 2013=2,975. Among fatalities, 86.0% were men and 13.7% women; 83.4% were adults and 6.2% children <18 years of age. Where age and sex were both known, men aged 20-39 years accounted for 56.3% of fatalities. Three “high-burden” governorates had the highest fatality rate per 100,000 population-Baghdad (12.9), Ninevah (17.0), and Al-Anbar (14.6)-accounting for 85.9% of fatalities recorded in the eight governorates. Most fatalities occurred in the street (56.3%), followed by workplace (12.2%), home (11.3%), and farm/countryside (8.4%). Comparing the ratio of firearm-related fatalities to explosives-related fatalities revealed an overall ratio of 2.8:1. The ratio in Baghdad more than doubled from 2.9 in 2010 to 6.1 in 2013; the highest ratios were seen outside the high-burden governorates. CONCLUSIONS: Firearm-related fatalities remained relatively stable throughout 2010-2012, and almost doubled in 2013, correlating with increased ISIS activity. Three governorates contributed the majority of fatalities and experienced the highest fatality rates; these saw high levels of conflict. Firearm-related fatalities disproportionately affected younger men, who historically are over-represented as victims and perpetrators of violence. More than one-half of fatalities occurred in the street, indicating this as a common environment for conflict involving firearms. Firearms appear to account for more fatalities in Iraq than explosives and largely accounted for escalating violence in Baghdad during the study period. The high ratio observed outside the high-burden governorates is reflective of very low numbers of explosives-related fatalities; thus, violence in these governorates is likely non-conflict-related. These observations provide valuable public health information for targeted intervention to prevent violence. Nerlander MP , Leidman E , Hassan A , Sultan ASS , Hussain SJ , Browne LB , Bilukha OO . Fatalities from firearm-related injuries in selected governorates of Iraq, 2010-2013. Prehosp Disaster Med. 2017;32(5):1-8.

      • Trends in school-related victimization of lesbian, gay, and bisexual youths – Massachusetts, 1995-2015External
        O’Malley Olsen E, Vivolo-Kantor AM, Kann L, Milligan CN.
        Am J Public Health. 2017 May 18:e1-e3.

        OBJECTIVES: To compare changes over time in prevalence of school victimization among lesbian, gay, and bisexual (LGB) students compared with heterosexual students. METHODS: We analyzed data from 11 Youth Risk Behavior Surveys conducted among representative samples of students in grades 9 through 12 in Massachusetts during 1995 to 2015. We used multivariable logistic regression models to identify trends over time by sexual identity. RESULTS: During 1995 to 2015, the prevalence of missing school decreased overall (from 5.6% to 4.8%) and among heterosexual (from 4.3% to 3.8%) and LGB (from 25.0% to 13.4%) students. The prevalence of having been threatened decreased overall (from 7.8% to 4.1%) and among heterosexual (from 6.5% to 3.5%) and LGB (from 32.9% to 6.7%) students. CONCLUSIONS: We identified evidence of a significant decrease in victimization among all students regardless of sexual identity and a steep decline among LGB students. Additional actions to improve school climate may help eliminate the disparities and decrease victimization for all youths. (Am J Public Health. Published online ahead of print May 18, 2017: e1-e3. doi:10.2105/AJPH.2017.303761).

    • Laboratory Sciences RSS Word feed
      • In December 2016, a low pathogenic avian influenza (LPAI) A(H7N2) virus was identified as the causative source of an outbreak in a cat shelter in New York City, which subsequently spread to multiple shelters in New York and Pennsylvania. One person with occupational exposure to infected cats became infected with the virus, representing the first LPAI H7N2 human infection in North America since 2003. Considering the close contact that frequently occurs between companion animals and humans, it was critical to assess the relative risk of this novel virus to public health. Virus isolated from the human case, A/New York/108/2016 (NY/108), caused mild and transient illness in ferrets and mice, but did not transmit to naive co-housed ferrets following traditional or aerosol-based inoculation methods. Environmental persistence of NY/108 virus was generally comparable to other LPAI H7N2 viruses. However, NY/108 virus replicated with increased efficiency in human bronchial epithelial cells compared with previously isolated H7N2 viruses. Furthermore, the novel H7N2 virus was found to utilize a relatively lower pH for HA activation, similar to human influenza viruses. Our data suggest that the LPAI H7N2 virus requires further adaptation before representing a substantial threat to public health. However, the reemergence of a LPAI H7N2 virus in the Northeastern United States underscores the need for continuous surveillance of emerging zoonotic influenza viruses, inclusive of mammalian species such as domestic felines that are not commonly considered intermediate hosts for avian influenza viruses.IMPORTANCE Avian influenza viruses are capable of crossing the species barrier to infect mammals, an event of public health concern due to the potential acquisition of a pandemic phenotype. In December 2016, an H7N2 virus caused an outbreak in cats in multiple New York animal shelters, which was the first detection of this virus in the Northeastern U.S. in over a decade and the first documented infection of H7N2 virus in a felid. A veterinarian became infected following occupational exposure to H7N2 virus-infected cats, necessitating the evaluation of this virus for its capacity to cause mammalian disease. While the H7N2 virus was associated with mild illness in mice and ferrets, and did not spread well between ferrets, it nonetheless possessed several markers of mammalian virulence. These data highlight the promiscuity of influenza viruses and the need for diligent surveillance across multiple species to quickly identify an emerging strain with pandemic potential.

    • Occupational Safety and Health RSS Word feed
      • Job characteristics associated with self-rated fair or poor health among U.S. workersExternal
        Luckhaupt SE, Alterman T, Li J, Calvert GM.
        Am J Prev Med. 2017 May 08.

        INTRODUCTION: Approximately 60% of the U.S. adult population is employed. Many aspects of a person’s job may influence health, but it is unclear which job characteristics are most strongly associated with health at a population level. The purpose of this study was to identify important associations between job characteristics and workers’ self-rated health in a nationally representative survey of U.S. workers. METHODS: Data from the 2010 National Health Interview Survey were used to calculate weighted prevalence rates for self-reported fair/poor health for five categories of job characteristics: occupation; pay/benefits (economic); work organization; chemical/environmental hazards; and psychosocial factors. Backward elimination methods were used to build a regression model for self-reported health with the significant job characteristics, adjusting for sociodemographic variables and health behaviors. Data were collected in 2010 and analyzed in 2012-2016. RESULTS: After adjusting for covariates, workers were more likely to have fair/poor health if they were employed in business operations occupations (e.g., buyers, human resources workers, event planners, marketing specialists; adjusted prevalence ratio [APR]=1.85, 95% CI=1.19, 2.88); had no paid sick leave (APR=1.35, 95% CI=1.11, 1.63); worried about becoming unemployed (APR=1.43, 95% CI=1.22, 1.69); had difficulty combining work and family (APR=1.23, 95% CI=1.01, 1.49); or had been bullied/threatened on the job (APR=1.82, 95% CI=1.44, 2.29). CONCLUSIONS: Occupation, lack of paid sick leave, and multiple psychosocial factors were associated with fair/poor health among U.S. workers at the population level in 2010. Public health professionals and employers should consider these factors when developing interventions to improve worker health.

    • Physical Activity RSS Word feed
      • Increasing walking in the Hartsfield-Jackson Atlanta International Airport: The Walk to Fly StudyExternal
        Fulton JE, Frederick GM, Paul P, Omura JD, Carlson SA, Dorn JM.
        Am J Public Health. 2017 May 18:e1-e7.

        OBJECTIVES: To test the effectiveness of a point-of-decision intervention to prompt walking, versus motorized transport, in a large metropolitan airport. METHODS: We installed point-of-decision prompt signage at 4 locations in the airport transportation mall at Hartsfield-Jackson Atlanta International Airport (Atlanta, GA) at the connecting corridor between airport concourses. Six ceiling-mounted infrared sensors counted travelers entering and exiting the study location. We collected traveler counts from June 2013 to May 2016 when construction was present and absent (preintervention period: June 2013-September 2014; postintervention period: September 2014-May 2016). We used a model that incorporated weekly walking variation to estimate the intervention effect on walking. RESULTS: There was an 11.0% to 16.7% relative increase in walking in the absence of airport construction where 580 to 810 more travelers per day chose to walk. Through May 2016, travelers completed 390 000 additional walking trips. CONCLUSIONS: The Walk to Fly study demonstrated a significant and sustained increase in the number of airport travelers choosing to walk. Providing signage about options to walk in busy locations where reasonable walking options are available may improve population levels of physical activity and therefore improve public health. (Am J Public Health. Published online ahead of print May 18, 2017: e1-e7. doi:10.2105/AJPH.2017.303766).

    • Substance Use and Abuse RSS Word feed
      • Association between media doses of the tips from Former Smokers Campaign and cessation behaviors and intentions to quit among cigarette smokers, 2012-2015External
        Davis KC, Patel D, Shafer P, Duke J, Glover-Kudon R, Ridgeway W, Cox S.
        Health Educ Behav. 2017 May 01:1090198117709316.

        BACKGROUND: Since 2012, the Centers for Disease Control and Prevention (CDC) has implemented Tips From Former Smokers ( Tips), the first federally funded tobacco education campaign in the United States. To date, there are no evaluations of its long-term impact. AIMS: To assess the impact of varied doses of the Tips campaign from 2012 through 2015 on cessation-related behaviors and intentions among U.S. smokers. METHOD: We used a national probability-based online survey of cigarette smokers ( n = 22,189) and recent quitters ( n = 776) to examine associations between doses of Tips advertising, measured by gross rating points (GRPs), and intentions to quit smoking in the next 30 days and quit attempts within the past 3 months. A curvilinear (i.e., square root) functional form of GRPs was used to capture patterns of diminishing effects at higher GRP levels. RESULTS: An increase of 1,000 quarterly Tips GRPs at the media market level was associated with increased odds of making a quit attempt in the past 3 months (adjusted odds ratio = 1.23, p < .001) and increased odds of intending to quit in the next 30 days (adjusted odds ratio = 1.17, p = .030). DISCUSSION: Results suggest that CDC-recommended media buys of 800 to 1,000 GRPs per quarter are sufficient to generate statistically significant increases in the likelihood of quit attempts in the past quarter. CONCLUSIONS: The Tips campaign has had a substantial impact on cessation behaviors among U.S. adult smokers over time. These data support the continued use of graphic and/or emotional media campaigns that encourage smokers to quit to further reduce tobacco use in the United States.

  2. 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 RSS Word feed
      1. NIAID, NIEHS, NHLBI, MCAN Workshop Report: The Indoor Environment and Childhood Asthma: Implications for Home Environmental Intervention in Asthma Prevention and ManagementExternal
        Gold DR, Adamkiewicz G, Arshad SH, Celedon JC, Chapman MD, Chew GL, Cook DN, Custovic A, Gehring U, Gern JE, Johnson CC, Kennedy S, Koutrakis P, Leaderer B, Mitchell H, Litonjua AA, Mueller GA, O’Connor GT, Ownby D, Phipatanakul W, Persky V, Perzanowski MS, Ramsey CD, Salo PM, Schwaninger JM, Sordillo JE, Spira A, Suglia SF, Togias A, Zeldin DC, Matsui EC.
        J Allergy Clin Immunol. 2017 May 10.

        Environmental exposures have been recognized as critical in the initiation and exacerbation of asthma, one of the most common chronic childhood diseases. The National Institute of Allergy and Infectious Diseases (NIAID), National Institute of Environmental Health Sciences (NIEHS), National Heart, Lung, and Blood Institute (NHLBI), and Merck Childhood Asthma Network (MCAN) sponsored a joint workshop to discuss the current state of the science with respect to the indoor environment and its effects on the development and morbidity of childhood asthma. The workshop included U.S. and international experts with backgrounds in allergy/allergens, immunology, asthma, environmental health, environmental exposures and pollutants, epidemiology, public health, and bioinformatics. Workshop participants provided new insights into the biologic properties of indoor exposures, indoor exposure assessment and exposure reduction techniques. This informed a primary focus of the workshop– to critically review trials and research relevant to the prevention or control of asthma through environmental intervention. The participants identified important limitations and gaps in the scientific methodologies and knowledge, and proposed and prioritized areas for future research. The group reviewed socioeconomic and structural challenges to changing environmental exposure and offered recommendations for creative study design to overcome these challenges in trials to improve asthma management. The recommendations of this workshop can serve as guidance for future research in the study of the indoor environment and on environmental interventions as they pertain to the prevention and management of asthma and airway allergies.

      2. [No abstract]

      3. CDC’s public health surveillance of cancerExternal
        Ryerson AB, Massetti GM.
        Prev Chronic Dis. 2017 May 18;14:E39.

        Routine data collection efforts are a necessary, often underappreciated, component of nearly all cancer research and prevention efforts. Public health cancer surveillance data are crucial for identifying needs, planning interventions, directing public health resources, and evaluating the overall effectiveness of initiatives aimed at preventing or treating cancer and its negative health consequences. As the nation’s health protection agency, the Centers for Disease Control and Prevention (CDC) provides resources for disease surveillance systems to help protect our nation against expensive and dangerous health threats, including cancer. Therefore, public health surveillance is a core function of CDC. In this article we briefly describe CDC’s approach to cancer surveillance in our public health programs and other federal initiatives to monitor cancer-related outcomes. We also describe our premier cancer incidence surveillance system, the National Program of Cancer Registries, and discuss uses and applications of the program’s critical cancer data.

      4. Disparities in diabetes deaths among children and adolescents – United States, 2000-2014External
        Saydah S, Imperatore G, Cheng Y, Geiss LS, Albright A.
        MMWR Morb Mortal Wkly Rep. 2017 May 19;66(19):502-505.

        Diabetes is a common chronic disease of childhood affecting approximately 200,000 children and adolescents in the United States (1). Children and adolescents with diabetes are at increased risk for death from acute complications of diabetes, including hypoglycemia and diabetic ketoacidosis (2,3); in 2012, CDC reported that during 1968-2009, diabetes mortality among U.S. persons aged </=19 years declined by 61% (4). CDC observed disparities by race during 1979-2004, with black children and adolescents dying from diabetes at twice the rate of white children and adolescents (5). However, no previous study has examined Hispanic ethnicity. CDC analyzed data from the National Vital Statistics System for deaths among persons aged 1-19 years in the United States during 2000-2014, with diabetes listed as the underlying cause of death overall, and for Hispanic, non-Hispanic white (white), and non-Hispanic black (black) children and adolescents. During 2012-2014, black children and adolescents had the highest diabetes death rate (2.04 per 1 million population), followed by whites (0.92) and Hispanics (0.61). There were no statistically significant changes in diabetes death rates over the study period, but disparities persisted among racial/ethnic groups. Death from diabetes in children and adolescents is potentially preventable through increased awareness of diabetes symptoms (including symptoms of low blood sugar), earlier treatment and education related to diabetes, and management of diabetes ketoacidosis. Continued measures are needed to reduce diabetes mortality in children and understand the cause of racial and ethnic disparities.

      5. Questions about cervical and breast cancer screening knowledge, practice, and outcomes: A review of demographic and health surveysExternal
        Viens L, Perin D, Senkomago V, Neri A, Saraiya M.
        J Womens Health (Larchmt). 2017 May;26(5):403-412.

        United Nation’s Sustainable Development Goals and the World Health Organization’s Global Monitoring Framework support a strong global commitment to reducing the high burden of cervical and breast cancers among low- and middle-income countries. Strategies include vaccination, screening, and early diagnosis. Population-based surveys, such as those conducted by the Demographic and Health Surveys (DHS) Program, can collect the information needed to guide cancer control efforts in a standardized comparable manner. We identified and evaluated the breadth of breast and cervical cancer screening information that was collected by the DHS from 1984 through 2015. Then, we determined if these surveys currently provide the specific and measurable data about both the quantity and quality of cancer screening needed to guide national efforts to reduce the overall effects of cervical and breast cancers. We searched the DHS website to identify surveys conducted between the start of the DHS Program in 1984 and November 2015 that included questions about breast and cervical cancer screening. The relevant questions were extracted from the questionnaire, translated into English, and grouped by themes. Of the 90 countries where DHS surveys have been implemented, cervical cancer screening questions were included in 22 countries (24.4%) and breast cancer screening questions in 18 countries (20.0%). The common themes identified were disease knowledge, screening knowledge, screening practice, and screening outcomes. Most countries with survey questionnaires available for review addressed at least one aspect of screening practice (88.9% of cervical and 87.5% of breast), although few countries queried knowledge and outcomes. Questions that assess varied aspects of breast and cervical cancer screening have been incorporated into relatively few DHS surveys. The themes identified could guide the design of a standard set of questions for use in future population-based surveys and enable evaluation beyond the existence of screening, which would include assessment of the quality and impact of cervical and breast cancer screening.

      6. BACKGROUND: Major organizations recommend cytology screening (Pap test) every 3years for women aged 21-65; women aged 30 to 65 have the option of adding the HPV test (co-test) every 5years. We examined national percentages of cervical cancer screening, and we examined use of co-testing as an option for screening. METHODS: We used 2015 U.S. National Health Interview Survey (NHIS) data to examine recent cervical cancer screening (Pap test within 3years among women aged 21-65 without a hysterectomy; N=10,596) and co-testing (N=9125). We also conducted a multivariable analysis to determine odds of having had a Pap test or co-test by demographic variables. To evaluate changes in screening over time, we examined Pap testing during the years 2000, 2005, 2008, 2010, 2013 and 2015. Analysis completed in Atlanta, GA during 2016. RESULTS: Overall, 81.1% of eligible women reported having a Pap test within 3years; percentages declined over time among all age groups. An estimated 14 million women aged 21-65 had not been screened within the past 3years. Recent immigrants to the United States, women without insurance, and women without a usual source of healthcare had lower odds of being up to date with screening. About 1/3 of women up to date on Pap testing reported having a co-test with their most recent Pap. CONCLUSIONS: Declines in screening among women aged 21-65 are cause for concern. More research is needed on co-testing practices. Provider and patient education efforts may be needed to clarify recommended use of HPV tests.

    • Communicable Diseases RSS Word feed
      1. Relationship between body mass index and outcomes among hospitalized patients with community-acquired pneumoniaExternal
        Bramley AM, Reed C, Finelli L, Self WH, Ampofo K, Arnold SR, Williams DJ, Grijalva CG, Anderson EJ, Stockmann C, Trabue C, Fakhran S, Balk R, McCullers JA, Pavia AT, Edwards KM, Wunderink RG, Jain S.
        J Infect Dis. 2017 May 17.

        Background: The effect of body mass index (BMI) on community-acquired pneumonia (CAP) severity is unclear. Methods: We investigated the relationship between BMI and CAP outcomes [hospital length of stay (LOS), intensive care unit (ICU) admission, and invasive mechanical ventilation] in hospitalized CAP patients from the CDC Etiology of Pneumonia in the Community (EPIC) study, adjusting for age, demographics, underlying conditions, and smoking status (adults only). Results: Compared with normal weight children, odds of ICU admission were higher in children who were overweight (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.1-2.8) or obese (aOR 2.1, 1.4-3.2) and odds of mechanical ventilation were higher in children with obesity (aOR 2.7, 1.3-5.6). When stratified by asthma (presence/absence), these findings remained significant only in children with asthma. Compared with normal weight adults, odds of LOS >3 days were higher in adults who were underweight (aOR, 1.6, 1.1-2.4), and odds of mechanical ventilation were lowest in adults who were overweight (aOR, 0.5, 0.3-0.9). Conclusions: Children who were overweight or obese, particularly those with asthma, had higher odds of ICU admission or mechanical ventilation. In contrast, adults who were underweight had longer LOS. These results underscore the complex relationship between BMI and CAP outcomes.

      2. Delivery of isoniazid preventive therapy to reduce occupational TB among healthcare workers in SwazilandExternal
        Calnan M, Haumba S, Matsebula M, Shongwe N, Pasipamire M, Levy NK, Mirira M, Preko P, Smith-Arthur A, Ghazaryan V.
        S Afr J Infect Dis. 2017 ;32(1):39-42.

        Healthcare workers (HCWs) in Swaziland are at increased risk of acquiring tuberculosis (TB), but existing infection control and occupational health policies often fall short of mitigating the risk of acquiring TB in the workplace. Health service failure to systematically offer isoniazid preventive therapy (IPT) to HCWs, which is endorsed by the World Health Organisation (WHO), contributes signifcantly to the TB incidence among HCWs in high HIV prevalence settings. This paper describes a pilot introduction of IPT to HCWs, and expounds possible determinants for adherence and non-acceptance to IPT. Acceptance to the widespread use of IPT among HCWs can be improved through education on risk and counselling.

      3. Incident AIDS or death after initiation of human immunodeficiency virus treatment regimens including raltegravir or efavirenz among adults in the United StatesExternal
        Cole SR, Edwards JK, Hall HI, Brookhart MA, Mathews WC, Moore RD, Crane HM, Kitahata MM, Mugavero MJ, Saag MS, Eron JJ.
        Clin Infect Dis. 2017 Jun 01;64(11):1591-1596.

        Background.: The long-term effectiveness of human immunodeficiency virus (HIV) treatments containing integrase inhibitors is unknown. Methods.: We use observational data from the Centers for AIDS Research Network of Integrated Clinical Systems and the Centers for Disease Control and Prevention to estimate 4-year risk of AIDS and all-cause mortality among 415 patients starting a raltegravir regimen compared to 2646 starting an efavirenz regimen (both regimens include emtricitabine and tenofovir disoproxil fumarate). We account for confounding and selection bias as well as generalizability by standardization for measured variables, and present both observational intent-to-treat and per-protocol estimates. Results.: At treatment initiation, 12% of patients were female, 36% black, 13% Hispanic; median age was 37 years, CD4 count 321 cells/microL, and viral load 4.5 log10 copies/mL. Two hundred thirty-five patients incurred an AIDS-defining illness or died, and 741 patients left follow-up. After accounting for measured differences, the 4-year risk was similar among those starting both regimens (ie, intent-to treat hazard ratio [HR], 0.96 [95% confidence interval {CI}, .63-1.45]; risk difference, -0.9 [95% CI, -4.5 to 2.7]), as well as among those remaining on regimens (ie, per-protocol HR, 0.95 [95% CI, .59-1.54]; risk difference, -0.5 [95% CI, -3.8 to 2.9]). Conclusions.: Raltegravir and efavirenz-based initial antiretroviral therapy have similar 4-year clinical effects. Vigilance regarding longer-term comparative effectiveness of HIV regimens using observational data is needed because large-scale experimental data are not forthcoming.

      4. Increased risk of myocardial infarction in HIV-infected individuals in North America compared to the general populationExternal
        Drozd DR, Kitahata MM, Althoff KN, Zhang J, Gange SJ, Napravnik S, Burkholder GA, Mathews WC, Silverberg MJ, Sterling TR, Heckbert SR, Budoff MJ, Van Rompaey S, Delaney JA, Wong C, Tong W, Palella FJ, Elion RA, Martin JN, Brooks JT, Jacobson LP, Eron JJ, Justice AC, Freiberg MS, Klein DB, Post WS, Saag MS, Moore RD, Crane HM.
        J Acquir Immune Defic Syndr. 2017 May 17.

        BACKGROUND: Previous studies of cardiovascular disease (CVD) among HIV-infected individuals have been limited by the inability to validate and differentiate atherosclerotic type 1 myocardial infarctions (T1MIs) from other events. We sought to define the incidence of T1MIs and risk attributable to traditional and HIV-specific factors among participants in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), and compare adjusted incidence rates to the general population Atherosclerosis Risk in Communities (ARIC) cohort. METHODS: We ascertained and adjudicated incident MIs among individuals enrolled in seven NAACCORD cohorts between 1995-2014. We calculated incidence rates (IR), adjusted incidence rate ratios (aIRRs), and 95% confidence intervals ([,]) of risk factors for T1MI using Poisson regression. We compared aIRRs of T1MIs in NA-ACCORD with those from ARIC. RESULTS: Among 29,169 HIV-infected individuals, the IR for T1MIs was 2.57[2.30-2.86] per 1000 person-years, and the aIRR was significantly higher compared with participants in ARIC (1.30[1.09-1.56]). In multivariable analysis restricted to HIV-infected individuals and including traditional CVD risk factors, the rate of T1MI increased with decreasing CD4 count (>/=500 cells/iL: ref; 350-499 cells/iL: aIRR=1.32[0.98-1.77]; 200-349 cells/iL: aIRR=1.37[1.01-1.86]; 100-199 cells/iL: aIRR=1.60[1.09-2.34]; <100 cells/iL: aIRR=2.19[1.44-3.33]). Risk associated with detectable HIV RNA (<400 copies/mL: ref; >/=400 copies/mL: aIRR=1.36 [1.06-1.75]) was significantly increased only when CD4 was excluded. CONCLUSIONS: The higher incidence of T1MI in HIV-infected individuals and increased risk associated with lower CD4 count and detectable HIV RNA suggest that early suppressive antiretroviral treatment and aggressive management of traditional CVD risk factors are necessary to maximally reduce MI risk.

      5. Scale-up of early infant HIV diagnosis and improving access to pediatric HIV care in Global Plan countries: Past and future perspectivesExternal
        Essajee S, Bhairavabhotla R, Penazzato M, Kiragu K, Jani I, Carmona S, Rewari B, Kiyaga C, Nkengasong J, Peter T.
        J Acquir Immune Defic Syndr. 2017 May 01;75 Suppl 1:S51-s58.

        Investment to scale-up early infant diagnosis (EID) of HIV has increased substantially in the last decade. This investment includes physical infrastructure, equipment, human resources, and specimen transportation systems as well as specialized mechanisms to deliver laboratory results to clinics. The Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, as well as related international initiatives to prevent mother-to-child transmission of HIV and treat children living with HIV have been important drivers of this scale-up by mobilizing resources, creating advocacy, developing normative recommendations, and providing direct technical support to countries through the global community of international stakeholders. As a result, the number of early infant diagnosis tests performed annually has increased 10-fold between 2005 and 2015, and many thousands of infants are now receiving life-saving antiretroviral therapy because of this improved access. Despite these efforts and many success stories, timely infant diagnosis remains a challenge in many Global Plan countries. The most recent data (from the end of 2015) suggest a large variation in access. Some countries report that almost 90% of HIV-exposed infants are being tested; others report that the level of access has stagnated at 30%. Still, just over half of all exposed infants in Global Plan countries receive a test in the first 2 months of life. We discuss the key factors that are responsible for this scale-up of diagnostic capacity, highlight some of the challenges that have hampered progress, and describe priorities for the future that can help maintain momentum to achieve true universal access to HIV testing for children.

      6. Increased risk for meningococcal disease among men who have sex with men in the United States, 2012-2015External
        Folaranmi TA, Kretz CB, Kamiya H, MacNeil JR, Whaley MJ, Blain A, Antwi M, Dorsinville M, Pacilli M, Smith S, Civen R, Ngo V, Winter K, Harriman K, Wang X, Bowen VB, Patel M, Martin S, Misegades L, Meyer SA.
        Clin Infect Dis. 2017 May 13.

        Background: Several clusters of serogroup C meningococcal disease among men who have sex with men (MSM) have been reported in the United States in recent years. The epidemiology and risk of meningococcal disease among MSM is not well-described. Methods: All meningococcal disease cases among men aged 18-64 years reported to the National Notifiable Disease Surveillance System between January 2012 and June 2015 were reviewed. Characteristics of meningococcal disease cases among MSM and men not known to be MSM (non-MSM) were described. Annualized incidence rates among MSM and non-MSM were compared through calculation of the relative risk and 95% confidence intervals. Isolates from meningococcal disease cases among MSM were characterized using standard microbiological methods and whole genome sequencing. Results: Seventy-four cases of meningococcal disease were reported among MSM and 453 among non-MSM. Annualized incidence of meningococcal disease among MSM was 0.56 cases per 100,000 population, compared to 0.14 among non-MSM, for a relative risk of 4.0 (95% CI: 3.1-5.1). Among the 64 MSM with known status, 38 (59%) were HIV-infected. HIV-infected MSM had 10.1 times (95% CI: 6.1-16.6) the risk of HIV-uninfected MSM. All isolates from cluster-associated cases were serogroup C sequence type 11. Conclusions: MSM are at increased risk for meningococcal disease, although the incidence of disease remains low. HIV infection may be an important factor for this increased risk. Routine vaccination of HIV-infected persons with a quadrivalent meningococcal conjugate vaccine in accordance with Advisory Committee on Immunization Practices recommendations should be encouraged.

      7. Adult intestinal colonization botulism mimicking brain deathExternal
        Freund B, Hayes L, Rivera-Lara L, Sumner C, Chaudhry V, Chatham-Stephens K, Benedict K, Kalb S, Blythe D, Brooks R, Probasco JC.
        Muscle Nerve. 2017 May 13.

        [No abstract]

      8. HIV provider experiences engaging and retaining patients in HIV care and treatment: “A soft place to fall”External
        Gelaude DJ, Hart J, Carey JW, Denson D, Erickson C, Klein C, Mijares A, Pitts NL, Spitzer T.
        J Assoc Nurses AIDS Care. 2017 Mar 30.

        Engaging and retaining persons with HIV in care and treatment is key to reducing new HIV infections in the United States. Understanding the experiences, barriers, and facilitators to engaging and retaining persons in HIV care from the perspective of HIV care providers could help provide insight into how best to achieve this goal. We present qualitative data from 30 HIV care providers in three cities. We identified three facilitators to HIV care: providing a medical home, team-based care and strategies for engaging and retaining patients in HIV care, and focus on provider-patient relationships. We identified two main barriers to care: facility-level policies and patient-level challenges. Our findings suggest that providers embrace the medical home model for engaging patients but need support to identify aspects of the model that promote engagement in long-term HIV care, improve the quality of the provider-patient relationship, and address persistent logistical barriers, such as transportation.

      9. Rotavirus antigen, cytokine, and neutralising antibody profiles in sera of children with and without HIV infection in Blantyre, MalawiExternal
        Hull JJ, Cunliffe N, Jere KC, Sung-Moon S, Wang Y, Parashar U, Jiang B.
        Malawi Medical Journal. 2017 ;29(1):24-28.

        Background Rotavirus and HIV infection are major causes of death among children in sub-Saharan Africa. A previous study reported no association between concomitant HIV infection and rotavirus disease severity among hospitalised children in Malawi. This study examined rotavirus antigenaemia and broader immune responses among HIV-infected and uninfected children. Methods Stored (-80?C), paired sera from acute and convalescent phases of Malawian children less than 5 years old, hospitalised for acute gastroenteritis in the primary study, collected from July 1997 to June 1999, were utilised. Among children older than 15 months, HIV infection was defined as the presence of HIV antibody in the blood, when confirmed by at least 2 established methods. For those younger than 15 months, nested polymerase chain reaction (PCR) amplification of proviral DNA was used for verification. All were followed for up to 4 weeks after hospital discharge. Rotavirus antigen levels in sera were measured with Premier? Rotaclone? rotavirus enzyme immunoassay (EIA) kit. Acute-phase sera were examined for 17 cytokines, using Luminex fluorescent bead human cytokine immunoassay kit. Rotavirus-specific IgA and neutralising activity were determined by EIA and microneutralisation (MN) assay, respectively. Human strains and bovine-human reassortants were propagated in MA104 cells with serum-free Iscove?s Modified Dulbecco?s Medium (IMDM). Differences in results, from specimens with and without HIV infection, were analysed for statistical significance using the chi-square test. Results We detected rotavirus antigen in 30% of the HIV-infected and 21% HIV-uninfected, in the acute-phase sera. HIV-infected children developed slightly prolonged rotavirus antigenaemia compared to HIV-uninfected children. Conclusions Rotavirus-specific IgA seroconversion rates and neutralising titres were similar in HIV-infected and HIV-uninfected children, thus, HIV infection had no major effect on immune responses to rotavirus infection.

      10. Retention of South African adolescents in a 54-month longitudinal HIV risk reduction trialExternal
        Icard LD, Jemmott JB, Carty C, O’Leary A, Sidloyi L, Hsu J, Tyler J, Martinez O.
        Prev Sci. 2017 May 15.

        Retention of participants in clinical trials is a central concern of HIV/STI behavioral researchers and research sponsors. This article describes the strategies used for addressing the challenges in retaining South African adolescents for a 54-month longitudinal study. The objective of the South African adolescent health promotion long-term follow-up trial was to test the sustainability of the effects of an HIV/STI risk reduction intervention, “Let Us Protect Our Future,” on young adolescents as they aged into middle and late adolescence. Inaccurate contact information, invalid mobile telephone numbers, lack of transportation, transitory family addresses, and family relocation were among the challenges to retaining participants. Despite a significant gap in time of 36 months between the main trial and the long-term follow-up study, 99.2% of 1057 participants were retained. Solutions used for retaining the adolescents are discussed with suggestions offered for retaining adolescents in longitudinal HIV/STI prevention clinical trials in low resource countries.

      11. Incidence of gonorrhea and chlamydia following HIV preexposure prophylaxis among men who have sex with men: A modeling studyExternal
        Jenness SM, Weiss KM, Goodreau SM, Gift T, Chesson H, Hoover KW, Smith DK, Liu AY, Sullivan PS, Rosenberg ES.
        Clin Infect Dis. 2017 May 13.

        Background: Preexposure prophylaxis (PrEP) is highly effective for preventing HIV, but risk compensation (RC) in men who have sex with men (MSM) raises concerns about increased sexually transmitted infections (STIs). CDC’s PrEP guidelines recommend biannual STI screening, which may reduce incidence by treating STIs that would otherwise remain undiagnosed. We investigated the impact of these two potentially counteracting phenomena. Methods: With a stochastic network-based mathematical model of HIV and rectal/urogenital Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) transmission dynamics among MSM in the United States, we simulated PrEP uptake following the prescription indications and HIV/STI screening recommendations in the CDC guidelines. Model scenarios varied PrEP coverage (the proportion of MSM indicated for PrEP who received it), RC (as a reduction in the per-act probability of condom use), and the STI screening interval. Results: In our reference scenario (40% coverage, 40% RC), 42% of NG and 40% of CT infections would be averted over the next decade. A doubling of RC would still result in net STI prevention relative to no PrEP. STIs declined because PrEP-related STI screening resulted in a 17% and 16% absolute increase in the treatment of asymptomatic and rectal STIs, respectively. Screening and timely treatment at quarterly vs biannual intervals would reduce STI incidence a further 50%. Conclusions: Implementation of the CDC PrEP guidelines while scaling up PrEP coverage could result in a significant decline in STI incidence among MSM. Our study highlights the design of PrEP not only as antiretroviral medication, but as combination HIV/STI prevention incorporating STI screening.

      12. Clinical and bacteriological characteristics associated with clustering of multidrug-resistant tuberculosisExternal
        Feng JY, Jarlsberg LG, Salcedo K, Rose J, Janes M, Lin SG, Osmond DH, Jost KC, Soehnlen MK, Flood J, Graviss EA, Desmond E, Moonan PK, Nahid P, Hopewell PC, Kato-Maeda M.
        Int J Tuberc Lung Dis. 2017 May 16.

        SETTING: The impact of the genetic characteristics of Mycobacterium tuberculosis on the clustering of multidrug-resistant tuberculosis (MDR-TB) has not been analyzed together with clinical and demographic characteristics. OBJECTIVE: To determine factors associated with genotypic clustering of MDR-TB in a community-based study. DESIGN: We measured the proportion of clustered cases among MDR-TB patients and determined the impact of clinical and demographic characteristics and that of three M. tuberculosis genetic characteristics: lineage, drug resistance-associated mutations, and rpoA and rpoC compensatory mutations. RESULTS: Of 174 patients from California and Texas included in the study, the number infected by East-Asian, Euro-American, Indo-Oceanic and East-African-Indian M. tuberculosis lineages were respectively 70 (40.2%), 69 (39.7%), 33 (19.0%) and 2 (1.1%). The most common mutations associated with isoniazid and rifampin resistance were respectively katG S315T and rpoB S531L. Potential compensatory mutations in rpoA and rpoC were found in 35 isolates (20.1%). Hispanic ethnicity (OR 26.50, 95%CI 3.73?386.80), infection with an East-Asian M. tuberculosis lineage (OR 30.00, 95%CI 4.20?462.40) and rpoB mutation S531L (OR 4.03, 95%CI 1.05?23.10) were independent factors associated with genotypic clustering. CONCLUSION: Among the bacterial factors studied, East-Asian lineage and rpoB S531L mutation were independently associated with genotypic clustering, suggesting that bacterial factors have an impact on the ability of M. tuberculosis to cause secondary cases.

      13. Lessons learned from Option B+ in the evolution toward “Test and Start” from Malawi, Cameroon, and the United Republic of TanzaniaExternal
        Kalua T, Tippett Barr BA, van Oosterhout JJ, Mbori-Ngacha D, Schouten EJ, Gupta S, Sande A, Zomba G, Tweya H, Lungu E, Kajoka D, Tih P, Jahn A.
        J Acquir Immune Defic Syndr. 2017 May 01;75 Suppl 1:S43-s50.

        The acceleration of prevention of mother-to-child transmission (PMTCT) activities, coupled with the rollout of 2010 World Health Organization (WHO) guidelines, led to important discussions and innovations at global and country levels. One paradigm-shifting innovation was Option B+ in Malawi. It was later included in WHO guidelines and eventually adopted by all 22 Global Plan priority countries. This article presents Malawi’s experience with designing and implementing Option B+ and provides complementary narratives from Cameroon and Tanzania. Malawi’s HIV program started in 2002, but by 2009, the PMTCT program was lagging far behind the antiretroviral therapy (ART) program because of numerous health system challenges. When WHO recommended Option A and Option B for PMTCT in 2010, it was clear that Malawi’s HIV program would not be able to successfully implement either option without increasing existing barriers to PMTCT services and potentially decreasing women’s access to care. Subsequent stakeholder discussions led to the development of Option B+. Operationalizing Option B+ required several critical considerations, including the complete integration of ART and PMTCT programs, systematic reduction of barriers to facilitate doubling the number of ART sites in less than a year, building consensus with stakeholders, and securing additional resources for the new program. During the planning and implementation process, several lessons were learned which are considerations for countries transitioning to “treat-all”: Comprehensive change requires effective government leadership and coordination; national clinical guidelines must accommodate health system limitations; ART services and commodities should be decentralized within facilities; the general public should be well informed about major changes in the national HIV program; and patients should be educated on clinic processes to improve program monitoring.

      14. Evaluation of the Families Matter! Program in Tanzania: An intervention to promote effective parent-child communication about sex, sexuality, and sexual risk reductionExternal
        Kamala BA, Rosecrans KD, Shoo TA, Al-Alawy HZ, Berrier F, Bwogi DF, Miller KS.
        AIDS Educ Prev. 2017 Apr;29(2):105-120.

        The Families Matter! Program (FMP) is a curriculum-based intervention designed to give parents and other primary caregivers the knowledge, skills, comfort, and confidence to deliver messages to their 9-12-year-old children about sexuality and practice positive parenting skills. A pre- and post-intervention evaluation study on FMP outcomes was conducted with 658 parent participants and their preadolescent children in two administrative wards in Tanzania in 2014. There was an increase in the proportion of study participants (parent-preadolescent pairs) that had positive attitudes toward sex education. On parent-child communication, the majority of participants (59-87%) reported having had more sexuality discussions. On communication responsiveness about sexual issues, scores improved in the period between surveys, with parents showing more improvements than preadolescents. Our results corroborate evidence from previous FMP evaluations, lending support to the conclusion that FMP is successful in promoting attitude and behavior change among parents and preadolescents in different cultural contexts.

      15. Keeping an eye on chlamydia and gonorrhea conjunctivitis in infants in the United States, 2010-2015External
        Kreisel K, Weston E, Braxton J, Llata E, Torrone E.
        Sex Transm Dis. 2017 Jun;44(6):356-358.

        Perinatal transmission of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) can result in conjunctivitis in infants. We examined national rates of reported CT/GC conjunctivitis among infants. Surveillance of these infections is heavily affected by the completeness of reported data on specimen source and age. Alternative data sources should be evaluated.

      16. Evaluation of student handwashing practices during a school-based hygiene program in rural western Kenya, 2007External
        La Con G, Schilling K, Harris J, Person B, Owuor M, Ogange L, Faith S, Quick R.
        Int Q Community Health Educ. 2017 Jan;37(2):121-128.

        Unsafe drinking water and inadequate handwashing facilities in primary schools increase the risk of absenteeism due to diarrhea and respiratory infections. To mitigate these risks, we provided 28 schools in rural Western Kenya with handwashing and drinking water stations (containers with lids and taps on metal stands), bleach for water treatment, soap for handwashing, and educational materials. We observed the use of the water stations and assessed teachers’ attitudes toward the intervention. Of 151 total handwashing stations, 69 (59%) were observed to have soap and water and treated drinking water 4 months after implementation; observations of pupils showed an increase in handwashing behavior in water stations located < 10 m, as compared with those >10 m, from latrines ( p < .02). In focus groups, teachers reported improved cleanliness and decreased illness in pupils. Teacher training and installation of water stations resulted in observed improvements in pupils’ hygiene, particularly when water stations were located <10 m from latrines.

      17. Using respondent driven sampling, we conducted a cross-sectional bio-behavioral survey among men who have sex with men (MSM) in Bamako, Mali. Eligibility criteria included age >/=18 years and having had sex with another man in the last 6 months. We enrolled 552 MSM, 99.6% were tested for HIV. MSM in Bamako were young (69.6% </=24 years) and educated (63.7% >/=secondary). HIV prevalence among MSM in Bamako was 13.7; 90.1% of HIV-infected men were unaware of their HIV status. Almost one-third had never been tested for HIV. Factors associated with higher odds of HIV included younger age, being receptive with last partner, condom breaking during anal sex in last 6 months, talking to peer educator about HIV, and having sexually transmitted infection symptoms in past year. The results suggest the need for enhanced HIV prevention and treatment services targeted at MSM in Bamako, with emphasis on repeated HIV testing.

      18. Since 1989, the USA has been pursuing the goal of tuberculosis elimination. After substantial progress during the past two decades, the rate of tuberculosis cases in the USA each year has now levelled off and remains well above the elimination threshold. Both epidemiological data and modelling underline the necessity of addressing latent tuberculosis infection if further progress is to be made in eliminating the disease. In this Personal View we explore next steps towards elimination. Given the estimated prevalence of latent tuberculosis infection, compared with the limited testing and treatment that currently occur, a major new effort is required. This effort should consist of a surveillance system or registry to monitor progress, scale-up of targeted testing for latent tuberculosis infection in at-risk populations, scale-up of short-course treatment regimens, engagement of affected communities and medical providers who serve those communities, and increased public health staffing for implementation and oversight. Such an effort would benefit greatly from the development of new tools, such as tests that better indicate reactivation risk, and even shorter latent tuberculosis infection treatment regimens than currently exist.

      19. Translating technical support into country action: The role of the Interagency Task Team on the Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and Children in the Global Plan eraExternal
        Luo C, Hirnschall G, Rodrigues J, Romano S, Essajee S, Rogers B, McCarthy E, Mwango A, Sangrujee N, Adler MR, Houston JC, Langa JO, Urso M, Bolu O, Tene G, Elat Nfetam JB, Kembou E, Phelps BR.
        J Acquir Immune Defic Syndr. 2017 May 01;75 Suppl 1:S7-s16.

        While the Interagency Task Team on the Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and Children (IATT) partnership existed before the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan), its reconfiguration was critical to coordinating provision of technical assistance that positively influenced country decision-making and program performance. This article describes how the Global Plan anchored the work of the IATT and, in turn, how the IATT’s technical assistance helped to accelerate achievement of the Global Plan targets and milestones. The technical assistance that will be discussed addressed a broad range of priority actions and milestones described in the Global Plan: (1) planning for and implementing Option B+; (2) strengthening monitoring and evaluation systems; (3) translating evidence into action and advocacy; and (4) promoting community engagement. This article also reviews the ongoing challenges and opportunities of providing technical assistance in a rapidly evolving environment that calls for ever more flexible and contextualized responses. The effectiveness of technical assistance facilitated by the IATT was defined by its timeliness, evidence base, and unique global perspective that built on the competencies of its partners and promoted synergies across program areas. Reaching the final goal of eliminating vertical transmission of HIV infection and achieving an AIDS-free generation in countries with the highest HIV burden requires that the IATT partnership and technical assistance remain responsive to country-specific needs while aligning with the current programmatic reality and new global goals such as the Sustainable Development Goals and 90-90-90 targets.

      20. BACKGROUND: Antibiotics have profound and lasting effects on the lower intestinal (gut) microbiome that can both promote resistance and increase susceptibility to colonization and infection; knowledge of these changes is important to the prevention and treatment of traveler’s diarrhea. METHODS: Recent data from epidemiologic and modern metagenomics studies were reviewed in regard to how such findings could inform the prevention and treatment of traveler’s diarrhea. RESULTS: Although it is well recognized that antibiotics increase the risk for Clostridium difficile infection, it is less recognized how they predispose patients to typically foodborne pathogens such as Salmonella or Camplyobacter spp. While these pathogens account for only a fraction of traveler’s diarrhea, such predisposition reflects how antibiotic exposure that precedes or occurs during travel may increase the risk for infection with other more common pathogens, even possibly enterotoxigenic Eschericia coli, especially in the setting of acquired resistance. Even short antibiotic exposures disrupt the gut microbiome up to a year or more and repeated exposures appear to attenuate recovery from ever occurring. One bacterial phylum that commonly increases in the gut following antibiotics are the proteobacteria including Enterobacteriacea; these are pro-inflammatory and often carry antibiotic resistance genes, the number and diversity of these genes (i.e. the resistome) commonly expands following antibiotics. The gut resistome among healthy community-dwelling adults reflects geographic variability in antibiotic use practices in both humans and food-producing animals as well as possibly the transmission of antibiotic resistance genes through the food supply. CONCLUSIONS: Because antibiotic use among travelers will influence the resistome and thereby promote geographic spread of resistance, it is important that antibiotic use recommendations for travelers be guided by resistance surveillance data as well as a careful assessment of the risks and benefits to both the individual and society.

      21. PURPOSE: We examined factors associated with antiretroviral therapy (ART) adherence among transgender women living with HIV (TWLWH). METHODS: We used combined data from the 2009 to 2013 cycles of Medical Monitoring Project, an HIV surveillance system designed to produce nationally representative estimates of the characteristics of HIV-infected adults receiving HIV medical care in the United States. Rao-Scott chi-square tests and multivariable logistic regression were used to identify factors associated with dose adherence (defined as taking 100% of prescribed ART doses in the past 3 days). RESULTS: Among TWLWH who reported current ART use, an estimated 80.5% self-reported dose adherence. Multivariable factors independently associated with lower (<100%) dose adherence were younger age (30-39 vs. 40 and over), not having health insurance coverage, depression, lower self-efficacy to take medication as prescribed, and having greater than one daily ART dose. CONCLUSION: Our findings suggest several ways to potentially improve ART adherence of TWLWH including tailoring efforts to address the needs of TWLWH under age 40, increasing access to health insurance coverage, addressing mental health morbidities, building skills to improve medication adherence self-efficacy, and simplifying ART regimens when possible.

      22. Two imported cases of congenital rubella syndrome and infection-control challenges in New York State, 2013-2015External
        Robyn M, Dufort E, Rosen JB, Southwick K, Bryant PW, Greenko J, Adams E, Kurpiel P, Alvarez KJ, Burstein G, Sen K, Vasquez D, Rausch-Phung E, Schulte C, Lutterloh E, Blog D.
        J Pediatric Infect Dis Soc. 2017 May 16.

        Rubella was declared eliminated in the United States in 2004. During 2013-2015, 2 infants with congenital rubella syndrome (CRS) were born in New York State. Both mothers were foreign born and traveled to Yemen during their pregnancy. Delayed consideration of CRS led to preventable exposures and a substantial public health response.

      23. Group B streptococcus among pregnant women and newborns in Mirzapur, Bangladesh: Colonization, vertical transmission and serotype distributionExternal
        Saha SK, Ahmed ZB, Modak JK, Naziat H, Saha S, Uddin MA, Islam M, Baqui AH, Darmstadt GL, Schrag SJ.
        J Clin Microbiol. 2017 May 17.

        Group B Streptococcus (GBS) infection is a leading cause of death in newborns in developed countries. Data on burden of GBS in Asian countries is lacking. This study aimed to understand i) rate of maternal recto-vaginal GBS carriage, ii) vertical transmission of GBS as determined by culturing ear, umbilicus and nasal swabs, and iii) distribution of GBS serotypes. This prospective observational study was conducted from September 2012 to November 2013 at Kumudini Hospital, a secondary level hospital, at Mirzapur, Bangladesh. The study enrolled pregnant women who visited the out-patient clinic for antenatal care (ANC) and/or delivered a child at the in-patient department of Kumudini Hospital, and babies born to these mothers. Among 1151 enrolled pregnant women, 172 (15%; 95% CI: 13%-17%) carried GBS and 26 (38%; 95% CI: 27%-51%) babies born to the mothers (n=68) with carriage had GBS on their body surface, indicating vertical transmission. Typing of the isolates (n=172) identified all 10 GBS serotypes, most commonly Ia (40%; 69/172), V (23%; 40/172), II (14%; 24/172), and III (12%; 20/172). This study shows that Bangladesh has all the ingredients for invasive GBS diseases, including colonization of mothers by invasive serotypes and vertical transmission to babies.

      24. Concordance between anal and oral human papillomavirus (HPV) infections among young men who have sex with menExternal
        Steinau M, Gorbach P, Gratzer B, Braxton J, Kerndt PR, Crosby RA, Unger ER, Markowitz LE, Meites E.
        J Infect Dis. 2017 May 15.

        Prevalence of human papillomavirus (HPV) infections was assessed among 1033 young men who have sex with men (MSM) aged 18-26 years. HPV (any type) was detected in 742 (71.8%) anal specimens and 101 (9.8%) oral specimens. Although HPV was detected in specimens from both anatomical sites in 83 (8.0%) participants, type-specific concordance for at least one HPV type was found in only 35 (3.4%) participants. HIV and smoking were associated with higher prevalence at both sites and frequency of concordant types. Coinfections of identical HPV types were rare, suggesting independent infection events and/or different modes of clearance.

      25. Anthrax cases associated with animal-hair shaving brushesExternal
        Szablewski CM, Hendricks K, Bower WA, Shadomy SV, Hupert N.
        Emerg Infect Dis. 2017 May;23(5):806-808.

        During the First World War, anthrax cases in the United States and England increased greatly and seemed to be associated with use of new shaving brushes. Further investigation revealed that the source material and origin of shaving brushes had changed during the war. Cheap brushes of imported horsehair were being made to look like the preferred badger-hair brushes. Unfortunately, some of these brushes were not effectively disinfected and brought with them a nasty stowaway: Bacillus anthracis. A review of outbreak summaries, surveillance data, and case reports indicated that these cases originated from the use of ineffectively disinfected animal-hair shaving brushes. This historical information is relevant to current public health practice because renewed interest in vintage and animal-hair shaving brushes has been seen in popular culture. This information should help healthcare providers and public health officials answer questions on this topic.

    • Environmental Health RSS Word feed
      1. Polyfluoroalkyl substance exposure in the Mid-Ohio River Valley, 1991-2012External
        Herrick RL, Buckholz J, Biro FM, Calafat AM, Ye X, Xie C, Pinney SM.
        Environ Pollut. 2017 May 12;228:50-60.

        BACKGROUND: Industrial discharges of perfluorooctanoic acid (PFOA) to the Ohio River, contaminating water systems near Parkersburg, WV, were previously associated with nearby residents’ serum PFOA concentrations above US general population medians. Ohio River PFOA concentrations downstream are elevated, suggesting Mid-Ohio River Valley residents are exposed through drinking water. OBJECTIVES: Quantify PFOA and 10 other per- and polyfluoroalkyl substances (PFAS) in Mid-Ohio River Valley resident sera collected between 1991 and 2013 and determine whether the Ohio River and Ohio River Aquifer are exposure sources. METHODS: We measured eleven PFAS in 1608 sera from 931 participants. Serum PFOA concentration and water source associations were assessed using linear mixed-effects models. We estimated between-sample serum PFOA using one-compartment pharmacokinetics for participants with multiple samples. RESULTS: In serum samples collected as early as 1991, PFOA (median = 7.6 ng/mL) was detected in 99.9% of sera; 47% had concentrations greater than US population 95th percentiles. Five other PFAS were detected in greater than 82% of samples; median other PFAS concentrations were similar to the US general population. Serum PFOA was significantly associated with water source, sampling year, age at sampling, tap water consumption, pregnancy, gravidity and breastfeeding. Serum PFOA was 40-60% lower with granular activated carbon (GAC) use. Repeated measurements and pharmacokinetics suggest serum PFOA peaked 2000-2006 for participants using water without GAC treatment; where GAC was used, serum PFOA concentrations decreased from 1991 to 2012. CONCLUSIONS: Mid-Ohio River Valley residents appear to have PFOA, but not other PFAS, serum concentrations above US population levels. Drinking water from the Ohio River and Ohio River Aquifer, primarily contaminated by industrial discharges 209-666 km upstream, is likely the primary exposure source. GAC treatment of drinking water mitigates, but does not eliminate, PFOA exposure.

      2. BACKGROUND: Prenatal exposure to organophosphate insecticides may be associated with autism spectrum disorders and related behaviors. This association may be modified by single nucleotide polymorphisms in the paraoxonase (PON1) enzyme. OBJECTIVE: We examined the relationship of prenatal organophosphate insecticide biomarkers with reciprocal social, repetitive, and stereotypic behaviors in 8-year old children, and modification of this relationship by child PON1 polymorphisms. METHODS: Among 224 pregnant women, we quantified concentrations of six nonspecific dialkyl phosphate (DAP) metabolites of organophosphate insecticides in two urine samples collected at ~16 and ~26 weeks gestation. When children were eight years old, we administered the Social Responsiveness Scale (SRS), a continuous measure of various dimensions of interpersonal behavior, communication, and repetitive/stereotypic behaviors. We estimated the association between a 10-fold increase in the sum of six DAP concentrations (SigmaDAP) and SRS scores. We examined whether child PON1192 and PON1-108 genotypes modified this association. RESULTS: After covariate adjustment, SigmaDAP concentrations were not associated with SRS scores [beta=-1.2; 95% confidence interval (CI): -4.0, 1.6]. Among children with the PON1-108TT genotype, SigmaDAP concentrations were associated with 2.5-point higher (95% CI: -4.9, 9.8) SRS scores; however, the association was not different from the 1.8-point decrease (95% CI: -5.8, 2.2) among children with PON1-108CT/CC genotypes (SigmaDAP x PON1-108 p-value =0.54). The association between SigmaDAP concentrations and SRS scores was not modified by PON1192 (SigmaDAP x PON1192 p-value =0.89). CONCLUSIONS: In this cohort, prenatal urinary DAP concentrations were not associated with children’s social behaviors; these associations were not modified by child PON1 genotype.

      3. Inhalational chlorine injuries at public aquatic venues – California, 2008-2015External
        Wilken JA, DiMaggio M, Kaufmann M, O’Connor K, Smorodinsky S, Armatas C, Barreau T, Kreutzer R, Ancheta L.
        MMWR Morb Mortal Wkly Rep. 2017 May 19;66(19):498-501.

        In June 2015, personnel from California’s Contra Costa Health Services Environmental Health and Hazardous Materials (hazmat) divisions were alerted to a possible chemical release at a swimming pool in an outdoor municipal water park. Approximately 50 bathers were in the pool when symptoms began; 34 (68%) experienced vomiting, coughing, or eye irritation. Among these persons, 17 (50%) were treated at the scene by Contra Costa’s Emergency Medical Services (EMS) and released, and 17 (50%) were transported to local emergency departments; five patients also were evaluated later at an emergency department or by a primary medical provider. Environmental staff members determined that a chemical controller malfunction had allowed sodium hypochlorite and muriatic acid (hydrochloric acid) solutions to be injected into the main pool recirculation line while the recirculation pump was off; when the main recirculation pump was restarted, toxic chlorine gas (generated by the reaction of concentrated sodium hypochlorite and muriatic acid) was released into the pool. A review of 2008-2015 California pesticide exposure records identified eight additional such instances of toxic chlorine gas releases at public aquatic venues caused by equipment failure or human error that sickened 156 persons. Chemical exposures at public aquatic venues can be prevented by proper handling, storage, and monitoring of pool chemicals; appropriate equipment operation and maintenance; training of pool operators and staff members on pool chemical safety; and reporting of chemical exposures.

    • Epidemiology and Surveillance RSS Word feed
      1. [No abstract]

    • Genetics and Genomics RSS Word feed
      1. Metazoan Ribosome Inactivating Protein encoding genes acquired by Horizontal Gene TransferExternal
        Lapadula WJ, Marcet PL, Mascotti ML, Sanchez-Puerta MV, Juri Ayub M.
        Sci Rep. 2017 May 12;7(1):1863.

        Ribosome inactivating proteins (RIPs) are RNA N-glycosidases that depurinate a specific adenine residue in the conserved sarcin/ricin loop of 28S rRNA. These enzymes are widely distributed among plants and their presence has also been confirmed in several bacterial species. Recently, we reported for the first time in silico evidence of RIP encoding genes in metazoans, in two closely related species of insects: Aedes aegypti and Culex quinquefasciatus. Here, we have experimentally confirmed the presence of these genes in mosquitoes and attempted to unveil their evolutionary history. A detailed study was conducted, including evaluation of taxonomic distribution, phylogenetic inferences and microsynteny analyses, indicating that mosquito RIP genes derived from a single Horizontal Gene Transfer (HGT) event, probably from a cyanobacterial donor species. Moreover, evolutionary analyses show that, after the HGT event, these genes evolved under purifying selection, strongly suggesting they play functional roles in these organisms.

    • Healthcare Associated Infections RSS Word feed
      1. Pseudomonas aeruginosa outbreak in a neonatal intensive care unit attributed to hospital tap waterExternal
        Bicking Kinsey C, Koirala S, Solomon B, Rosenberg J, Robinson BF, Neri A, Laufer Halpin A, Arduino MJ, Moulton-Meissner H, Noble-Wang J, Chea N, Gould CV.
        Infect Control Hosp Epidemiol. 2017 May 18:1-8.

        OBJECTIVE To investigate an outbreak of Pseudomonas aeruginosa infections and colonization in a neonatal intensive care unit. DESIGN Infection control assessment, environmental evaluation, and case-control study. SETTING Newly built community-based hospital, 28-bed neonatal intensive care unit. PATIENTS Neonatal intensive care unit patients receiving care between June 1, 2013, and September 30, 2014. METHODS Case finding was performed through microbiology record review. Infection control observations, interviews, and environmental assessment were performed. A matched case-control study was conducted to identify risk factors for P. aeruginosa infection. Patient and environmental isolates were collected for pulsed-field gel electrophoresis to determine strain relatedness. RESULTS In total, 31 cases were identified. Case clusters were temporally associated with absence of point-of-use filters on faucets in patient rooms. After adjusting for gestational age, case patients were more likely to have been in a room without a point-of-use filter (odds ratio [OR], 37.55; 95% confidence interval [CI], 7.16-infinity). Case patients had higher odds of exposure to peripherally inserted central catheters (OR, 7.20; 95% CI, 1.75-37.30) and invasive ventilation (OR, 5.79; 95% CI, 1.39-30.62). Of 42 environmental samples, 28 (67%) grew P. aeruginosa. Isolates from the 2 most recent case patients were indistinguishable by pulsed-field gel electrophoresis from water-related samples obtained from these case-patient rooms. CONCLUSIONS This outbreak was attributed to contaminated water. Interruption of the outbreak with point-of-use filters provided a short-term solution; however, eradication of P. aeruginosa in water and fixtures was necessary to protect patients. This outbreak highlights the importance of understanding the risks of stagnant water in healthcare facilities. Infect Control Hosp Epidemiol 2017;1-8.

      2. Modern healthcare versus nontuberculous mycobacteria: Who will have the upper hand?External
        Crist MB, Perz JF.
        Clin Infect Dis. 2017 Apr 01;64(7):912-913.

        [No abstract]

      3. Invasive nontuberculous mycobacterial infections among cardiothoracic surgical patients exposed to heater-cooler devicesExternal
        Lyman MM, Grigg C, Kinsey CB, Keckler MS, Moulton-Meissner H, Cooper E, Soe MM, Noble-Wang J, Longenberger A, Walker SR, Miller JR, Perz JF, Perkins KM.
        Emerg Infect Dis. 2017 May;23(5):796-805.

        Invasive nontuberculous mycobacteria (NTM) infections may result from a previously unrecognized source of transmission, heater-cooler devices (HCDs) used during cardiac surgery. In July 2015, the Pennsylvania Department of Health notified the Centers for Disease Control and Prevention (CDC) about a cluster of NTM infections among cardiothoracic surgical patients at 1 hospital. We conducted a case-control study to identify exposures causing infection, examining 11 case-patients and 48 control-patients. Eight (73%) case-patients had a clinical specimen identified as Mycobacterium avium complex (MAC). HCD exposure was associated with increased odds of invasive NTM infection; laboratory testing identified patient isolates and HCD samples as closely related strains of M. chimaera, a MAC species. This investigation confirmed a large US outbreak of invasive MAC infections in a previously unaffected patient population and suggested transmission occurred by aerosolization from HCDs. Recommendations have been issued for enhanced surveillance to identify potential infections associated with HCDs and measures to mitigate transmission risk.

      4. Notes from the field: Ongoing transmission of Candida auris in health care facilities – United States, June 2016-May 2017External
        Tsay S, Welsh RM, Adams EH, Chow NA, Gade L, Berkow EL, Poirot E, Lutterloh E, Quinn M, Chaturvedi S, Kerins J, Black SR, Kemble SK, Barrett PM, Barton K, Shannon DJ, Bradley K, Lockhart SR, Litvintseva AP, Moulton-Meissner H, Shugart A, Kallen A, Vallabhaneni S, Chiller TM, Jackson BR.
        MMWR Morb Mortal Wkly Rep. 2017 May 19;66(19):514-515.

        [No abstract]

    • Immunity and Immunization RSS Word feed
      1. Correlates of protection for enteric vaccinesExternal
        Holmgren J, Parashar UD, Plotkin S, Louis J, Ng SP, Desauziers E, Picot V, Saadatian-Elahi M.
        Vaccine. 2017 May 11.

        An immunological Correlate of Protection (CoP) is an immune response that is statistically interrelated with protection. Identification of CoPs for enteric vaccines would help design studies to improve vaccine performance of licensed vaccines in low income settings, and would facilitate the testing of future vaccines in development that might be more affordable. CoPs are lacking today for most existing and investigational enteric vaccines. In order to share the latest information on CoPs for enteric vaccines and to discuss novel approaches to correlate mucosal immune responses in humans with protection, the Foundation Merieux organized an international conference of experts where potential CoPs for vaccines were examined using case-studies for both bacterial and viral enteric pathogens. Experts on the panel concluded that to date, all established enteric vaccine CoPs, such as those for hepatitis A, Vi typhoid and poliovirus vaccines, are based on serological immune responses even though these may poorly reflect the relevant gut immune responses or predict protective efficacy. Known CoPs for cholera, norovirus and rotavirus could be considered as acceptable for comparisons of similarly composed vaccines while more work is still needed to establish CoPs for the remaining enteric pathogens and their candidate vaccines. Novel approaches to correlate human mucosal immune responses with protection include the investigation of gut-originating antibody-secreting cells (ASCs), B memory cells and follicular helper T cells from samples of peripheral blood during their recirculation.

      2. Impact of provider recommendation on Tdap vaccination of adolescents aged 13-17 yearsExternal
        Lu PJ, Yankey D, Jeyarajah J, O’Halloran A, Meyer SA, Elam-Evans LD, Reagan-Steiner S.
        Am J Prev Med. 2017 May 08.

        INTRODUCTION: Tetanus, diphtheria, and acellular pertussis (Tdap) vaccination has been recommended for adolescents in the U.S. since 2006. Information on Tdap vaccination by provider recommendation is limited. The purpose of this study is to assess recent Tdap vaccination by provider recommendation status among adolescents aged 13-17 years. METHODS: The 2013 National Immunization Survey-Teen data (N=18,948) were analyzed in 2016 to assess national and state-specific Tdap vaccination coverage disparities among adolescents by provider recommendation status, and other demographic and access to care variables. Multivariable logistic regression analysis and predictive marginal modeling evaluated associations between Tdap vaccination and provider recommendation status and other factors among adolescents aged 13-17 years. RESULTS: Overall, only 56.9% of adolescents aged 13-17 years received a provider recommendation for Tdap. Coverage was significantly higher among adolescents with a provider recommendation (88.6%) compared with those without a provider recommendation (80.5%) (p<0.05). Multivariable logistic regression showed that characteristics independently associated with a higher likelihood of Tdap vaccination included receiving a provider recommendation, Hispanic ethnicity, having two to three physician contacts in the past 12 months, having one or two vaccination providers, and receiving vaccinations from more than one type of facility (p<0.05). CONCLUSIONS: Provider recommendations were significantly associated with Tdap vaccination among adolescents aged 13-17 years. However, 43% of parents of adolescents did not receive a provider recommendation. Evidence-based strategies such as standing orders and provider reminders alone or health systems interventions in combination should be taken to improve provider recommendation and Tdap vaccination coverage.

      3. Updated recommendations for use of MenB-FHbp serogroup B meningococcal vaccine – Advisory Committee on Immunization Practices, 2016External
        Patton ME, Stephens D, Moore K, MacNeil JR.
        MMWR Morb Mortal Wkly Rep. 2017 May 19;66(19):509-513.

        Two serogroup B meningococcal (MenB) vaccines are currently licensed for use in persons aged 10-25 years in the United States. The two vaccines are MenB-FHbp (Trumenba, Pfizer, Inc.) (1) and MenB-4C (Bexsero, GlaxoSmithKline Biologicals, Inc.) (2). In February 2015, the Advisory Committee on Immunization Practices (ACIP) recommended use of MenB vaccines among certain groups of persons aged >/=10 years who are at increased risk for serogroup B meningococcal disease* (Category A) (3), and in June 2015, ACIP recommended that adolescents and young adults aged 16-23 years may be vaccinated with MenB vaccines to provide short-term protection against most strains of serogroup B meningococcal disease (Category Bdagger) (4). Consistent with the original Food and Drug Administration (FDA) licensure for the two available MenB vaccines, ACIP recommended either a 3-dose series of MenB-FHbp or a 2-dose series of MenB-4C. Either MenB vaccine can be used when indicated; ACIP does not state a product preference. The two MenB vaccines are not interchangeable; the same vaccine product must be used for all doses in a series. In April 2016, changes to the dosage and administration of MenB-FHbp were approved by FDA to allow for both a 2-dose series (administered at 0 and 6 months) and a 3-dose series (administered at 0, 1-2, and 6 months) (5,6). In addition, the package insert now states that the choice of dosing schedule depends on the patient’s risk for exposure and susceptibility to serogroup B meningococcal disease. These recommendations are regarding use of the 2- and 3-dose schedules of MenB-FHbp vaccine (Trumenba) and replace previous ACIP recommendations for use of MenB-FHbp vaccine published in 2015 (3,4). Recommendations regarding use of MenB-4C (Bexsero) are unchanged (3,4).

      4. Serogroup B meningococcal disease vaccine recommendations at a university, New Jersey, USA, 2016External
        Soeters HM, Dinitz-Sklar J, Kulkarni PA, MacNeil JR, McNamara LA, Zaremski E, Chang HY, Lujan E, Granoff D, Lasky M, Montana B.
        Emerg Infect Dis. 2017 May;23(5):867-869.

        In response to a university-based serogroup B meningococcal disease outbreak, the serogroup B meningococcal vaccine Trumenba was recommended for students, a rare instance in which a specific vaccine brand was recommended. This outbreak highlights the challenges of using molecular and immunologic data to inform real-time response.

      5. Feasibility of text message influenza vaccine safety monitoring during pregnancyExternal
        Stockwell MS, Cano M, Jakob K, Broder KR, Gyamfi-Bannerman C, Castano PM, Lewis P, Barrett A, Museru OI, Castellanos O, LaRussa PS.
        Am J Prev Med. 2017 May 02.

        INTRODUCTION: The feasibility and accuracy of text messaging to monitor events after influenza vaccination throughout pregnancy and the neonatal period has not been studied, but may be important for seasonal and pandemic influenza vaccines and future maternal vaccines. METHODS: This prospective observational study was conducted during 2013-2014 and analyzed in 2015-2016. Enrolled pregnant women receiving inactivated influenza vaccination at a gestational age <20 weeks were sent text messages intermittently through participant-reported pregnancy end to request fever, health events, and neonatal outcomes. Text message response rates, Day 0-2 fever (>/=100.4 degrees F), health events, and birth/neonatal outcomes were assessed. RESULTS: Most (80.2%, n=166) eligible women enrolled. Median gestational age was 8.9 (SD=3.9) weeks at vaccination. Response rates remained high (80.0%-95.2%). Only one Day 0-2 fever was reported. Women reported via text both pregnancy- and non-pregnancy-specific health events, not all associated with medical visits. Most pregnancy-specific events in the electronic medical record (EMR) were reported via text message. Of all enrollees, 84.9% completed the study (131 reported live birth, ten reported pregnancy loss). Two losses reported via text were not medically attended; there was one additional EMR-identified loss. Gestational age and weight at birth were similar between text message-reported and EMR-abstracted data and 95% CIs were overlapping for proportions of prematurity, low birth weight, small for gestational age, and major birth defects, as identified by text message-reported versus EMR-abstracted plus text message-reported versus EMR-abstracted data only. CONCLUSIONS: This study demonstrated the feasibility of text messaging for influenza vaccine safety surveillance sustained throughout pregnancy. In these women receiving inactivated influenza vaccination during pregnancy, post-vaccination fever was infrequent and a typical pattern of maternal and neonatal health outcomes was observed.

    • Injury and Violence RSS Word feed
      1. Economic insecurity and intimate partner and sexual violence victimizationExternal
        Breiding MJ, Basile KC, Klevens J, Smith SG.
        Am J Prev Med. 2017 May 10.

        INTRODUCTION: Previous research has consistently found that low SES is associated with higher levels of both intimate partner violence (IPV) and sexual violence (SV) victimization. Though associated with poverty, two indicators of economic insecurity, food and housing insecurity, have been identified as conceptually distinct social determinants of health. This study examined the relationship between food and housing insecurity experienced in the preceding 12 months and IPV and SV victimization experienced in the preceding 12 months, after controlling for SES and other demographic variables. METHODS: Data were from the 2010 National Intimate Partner and Sexual Violence Survey, a nationally representative telephone survey of U.S. adults. In 2016, multivariate logistic regression modeling was used to examine the association between food and housing insecurity and multiple forms of IPV and SV victimization. RESULTS: Robust associations were found between food and housing insecurity experienced in the preceding 12 months and IPV and SV experienced in the preceding 12 months, for women and men, even after controlling for age, family income, race/ethnicity, education, and marital status. CONCLUSIONS: Food and housing insecurity may be important considerations for the prevention of SV and IPV or the reductions of their consequences, although future research is needed to disentangle the direction of the association. Strategies aimed at buffering economic insecurity may reduce vulnerability to IPV and SV victimization.

      2. Older adult falls: Effective approaches to preventionExternal
        Dellinger A.
        Curr Trauma Rep. 2017 28 Apr:1-6.

        Purpose: The issue of older adult falls combines a problem with high incidence and high injury susceptibility with an increasing population at risk. A firm understanding of both fall risk factors and effective strategies is required to reduce risk and prevent these injuries. Recent Findings: Each year, 28.7% of older adults aged >65 sustain a fall. At the national level, this represents 29 million falls resulting in 27,000 deaths and 7 million injuries requiring medical treatment or restricted activity for at least 1 day. There are several strategies that have been shown to effectively reduce the risk or the incidence of falls. Summary: More than 90% of older adults see a medical provider at least once a year providing an opportunity to identify and address fall risk factors. Comprehensive fall prevention in the primary care setting is both feasible and practical.

      3. Methods and findings from the National Violent Death Reporting System for identifying gang-like homicides, 2005-2008External
        Frazier L, Ortega L, Patel N, Barnes J, Crosby AE, Hempstead K.
        J Natl Med Assoc. 2017 ;09.

        Background: The National Violent Death Reporting System (NVDRS) captures homicides that law enforcement or coroner/medical examiners deem as gang-related but the criteria used may vary across locations. Also, the existing gang-related variable likely underestimates the number of homicides that are associated with gang activity. This study utilizes NVDRS data to identify “gang-like” homicides which are not currently captured as “gang-related.”. Methods: A set of criteria recommended by a panel of experts in gang violence, was applied to homicides collected in the NVDRS. These criteria, termed “gang-like” characteristics, were developed in order to better identify homicides consistent with gang activity. The narratives of the identified cases were then reviewed to refine the operational standard. After the reviews were complete, the typology was modified to finalize the operationalization of “gang-like” homicides. Results: A total of 481 gang-like homicides were identified using the “gang-like” criteria. This represents an increase of almost 69% over the 696 gang-related homicides captured in NVDRS dataset.Gang-like and gang-related homicides combined represented 6.6% of homicides that occurred from 2005 to 2008. Among the 16 states included in this analysis, Colorado (15.5%) and Oklahoma (14%) had the highest percentage of homicides that were either gang-related or gang-like.Maryland had the greatest relative increase (227.3%) between gang related and gang-like homicides. Conclusion: The new “gang-like” variable complements the existing “gang-related” variable by providing an automated, standardized way to identify homicides that have circumstances consistent with gang activity. This new variable might be useful to states and localities seeking an efficient way to monitor homicides potentially resulting from gang activity. Additional efforts are needed to standardize the reporting of homicides associated with gang activity.

      4. In the present study, we assess the effects of the Expect Respect Support Groups (ERSG) on frequency of teen dating violence (TDV) and general youth violence. ERSG is a school-based violence prevention program for youth who have been exposed to violence in their home, school, or community. Boys and girls (N=1,678, Mage=14.3, S.D.=1.7, Range=11-17) from 36 schools in Texas participated in this accelerated longitudinal (7-year trajectory) study beginning in 2011. Latent growth curve analyses were conducted using three waves of data from three cross-sectional cohorts of adolescents. Among boys, the number of ERSG sessions attended related to incremental declines in psychological TDV perpetration and victimization, physical TDV victimization, sexual TDV perpetration and victimization, reactive aggression, and proactive aggression. Girls attending ERSG demonstrated reductions in reactive and proactive aggression. The present findings suggest ERSG may be an effective cross-cutting strategy to reduce TDV and other forms of violence among high-risk boys and possibly girls. This information provides valuable understanding of TDV and youth violence in high-risk populations and may be useful in tailoring future prevention efforts to different groups of teens.

    • Laboratory Sciences RSS Word feed
      1. Nasal delivery of Protollin-adjuvanted H5N1 vaccine induces enhanced systemic as well as mucosal immunity in miceExternal
        Cao W, Kim JH, Reber AJ, Hoelscher M, Belser JA, Lu X, Katz JM, Gangappa S, Plante M, Burt DS, Sambhara S.
        Vaccine. 2017 May 09.

        Sporadic, yet frequent human infections with avian H5N1 influenza A viruses continue to pose a potential pandemic threat. Poor immunogenicity of unadjuvanted H5N1 vaccines warrants developing novel adjuvants and formulations as well as alternate delivery systems to improve their immunogenicity and efficacy. Here, we show that Protollin, a nasal adjuvant composed of Neisseria meningitides outer membrane proteins non-covalently linked to Shigella flexneri 2a lipopolysaccharide, is a potent nasal adjuvant for an inactivated split virion H5N1 clade 1 A/Viet Nam1203/2004 (A/VN/1203/04) vaccine in a mouse model. Protollin-adjuvanted vaccines elicited enhanced serum protective hemagglutination inhibition titers, mucosal IgA responses, and H5N1-specific cell-mediated immunity that resulted in complete protection against a lethal challenge with a homologous virus as well as a heterologous clade 2 virus A/Indonesia/05/2005 (A/IN/05/05). Detailed analysis of adaptive immunity revealed that Protollin increased the frequency of lymphoid- as well as local tissue-resident antibody-secreting cells, local germinal center reaction of B cells, broad-spectrum of CD4 T cell response. Our findings suggest that nasal delivery of H5N1 vaccine with Protollin adjuvant can overcome the poor immunogenicity of H5N1 vaccines, induce both cellular and humoral immune responses, enhance protection against challenge with clade 1 and clade 2 H5N1 viruses and achieve significant antigen dose-sparing.

      2. Evaluation of personal inhalable aerosol samplers with different filters for use during anthrax responsesExternal
        Grinshpun SA, Weber AM, Yermakov M, Indugula R, Elmashae Y, Reponen T, Rose L.
        J Occup Environ Hyg. 2017 May 16:0.

        Risk of inhalation exposure to viable Bacillus anthracis (B. anthracis) spores has primarily been assessed using short-term, stationary sampling methods which may not accurately characterize the concentration of inhalable-sized spores reaching a person’s breathing zone. While a variety of aerosol sampling methods have been utilized during previous anthrax responses, no consensus has yet been established for personal air sampling. The goal of this study was to determine the best sampler-filter combination(s) for the collection and extraction of B. anthracis spores. The study was designed to 1) evaluate the performance of four filter types [one mixed cellulose ester, MCE (pore size = 3 microm), two polytetrafluoroethylene, PTFE (1 and 3 microm), and one polycarbonate, PC (3 microm)], and 2) evaluate the best performing filters in two commercially-available inhalable aerosol samplers (IOM and Button). Bacillus thuringiensis kurstaki [Bt(k)], a simulant for B. anthracis, served as the aerosol challenge. The filters were assessed based on criteria such as ability to maintain low pressure drop over an extended sampling period, filter integrity under various environmental conditions, spore collection and extraction efficiencies, ease of loading and unloading the filters into the samplers, cost, and availability. Three of four tested collection filters – except MCE – were found suitable for efficient collection and recovery of Bt(k) spores sampled from dry and humid as well as dusty and clean air environments for up to 8 h. The PC (3 microm) filter was identified as the best performing filter in this study. The PTFE (3 microm) demonstrated a comparable performance, but it is more costly. Slightly higher concentrations were measured with the IOM inhalable sampler which is the preferred sampler’s performance criterion when detecting a highly pathogenic agent with no established “safe” inhalation exposure level. Additional studies are needed to address the effects of environmental conditions and spore concentration. The data obtained in this investigation are crucial for future efforts on the development and optimization of a method for assessing inhalation exposure to B. anthracis.

      3. Monitoring influenza virus susceptibility to oseltamivir using a new rapid assay, iARTExternal
        Gubareva LV, Fallows E, Mishin VP, Hodges E, Brooks A, Barnes J, Fry AM, Kramp W, Shively R, Wentworth DE, Weidemaier K, Jacobson R.
        Euro Surveill. 2017 May 04;22(18).

        A new rapid assay for detecting oseltamivir resistance in influenza virus, iART, was used to test 149 clinical specimens. Results were obtained for 132, with iART indicating 41 as ‘resistant’. For these, sequence analysis found known and suspected markers of oseltamivir resistance, while no such markers were detected for the remaining 91 samples. Viruses isolated from the 41 specimens showed reduced or highly reduced inhibition by neuraminidase inhibition assay. iART may facilitate broader antiviral resistance testing.

      4. [No abstract]

      5. Gulf War Illness (GWI) is a chronic multi-symptom disorder affecting veterans of the 1991 Gulf War. Among the symptoms of GWI are those associated with sickness behavior, observations suggestive of underlying neuroinflammation. We have shown that exposure of mice to the stress hormone, corticosterone (CORT), and to diisopropyl fluorophosphate (DFP), as a nerve agent mimic, results in marked neuroinflammation, findings consistent with a stress/neuroimmune basis of GWI. Here, we examined the contribution of irreversible and reversible acetylcholinesterase (AChE) inhibitors to neuroinflammation in our mouse model of GWI. Male C57BL/6J mice received four days of CORT (400 mg/L) in the drinking water followed by a single dose of chlorpyrifos (CPO; 8 mg/kg, i.p.), DFP (4 mg/kg, i.p.), pyridostigmine (PB; 3 mg/kg, i.p.), or physostigmine (PHY; 0.5 mg/kg, i.p.). CPO and DFP alone caused cortical and hippocampal neuroinflammation assessed by qPCR of TNF-alpha, IL-6, C-C chemokine ligand 2 (CCL2), IL-1beta, leukemia inhibitory factor (LIF) and oncostatin M (OSM); CORT pretreatment markedly augmented these effects. Additionally, CORT exposure prior to DFP or CPO enhanced activation of the neuroinflammation signal transducer, STAT3. In contrast, PHY or PB alone or with CORT pretreatment did not produce neuroinflammation or STAT3 activation. While all of the CNS-acting AChE inhibitors (DFP, CPO, and PHY) decreased brain AChE activity, CORT pretreatment abrogated these effects for the irreversible inhibitors. Taken together, these findings suggest that irreversible AChE inhibitor-induced neuroinflammation and particularly its exacerbation by CORT, result from non-cholinergic effects of these compounds, pointing potentially to organophosphorylation of other neuroimmune targets. This article is protected by copyright. All rights reserved.

      6. Breakpoints are used to predict whether an antifungal agent will be clinically effective against a particular fungal isolate. They are based on a combination of MIC values, pharmacokinetic/pharmacodynamic values, and clinical outcome data. For many fungus-antifungal combinations, these data might never be available. For these combinations, epidemiological cutoff values (ECVs) provide a methodology for categorizing isolates as either wild type (WT) or non-WT. In this review, we define ECVs, explain how they are generated using the CLSI methodology in standard M57, and describe how they can be used in clinical practice.

      7. Effect of surface functionalizations of multi-walled carbon nanotubes on neoplastic transformation potential in primary human lung epithelial cellsExternal
        Stueckle TA, Davidson DC, Derk R, Wang P, Friend S, Schwegler-Berry D, Zheng P, Wu N, Castranova V, Rojanasakul Y, Wang L.
        Nanotoxicology. 2017 May 17:1-37.

        Functionalized multi-walled carbon nanotube (fMWCNT) development has intensified to improve their surface activity for numerous applications, and potentially reduce toxic effects. Although MWCNT exposures are associated with lung tumorigenesis in vivo, adverse responses associated with exposure to different fMWCNTs in human lung epithelium are presently unknown. This study hypothesized that different plasma coating functional groups determine MWCNT neoplastic transformation potential. Using our established model, human primary small airway epithelial cells (pSAECs) were continuously exposed for 8 and 12 weeks at 0.06 microg/cm2 to three month aged as prepared-(pMWCNT), carboxylated-(MW-COOH), and aminated-MWCNTs (MW-NHx). Ultrafine carbon black (UFCB) and crocidolite asbestos (ASB) served as particle controls. fMWCNTs were characterized during storage, and exposed cells were assessed for several established cancer cell hallmarks. Characterization analyses conducted at 0 and 2 months of aging detected a loss of surface functional groups over time due to atmospheric oxidation, with MW-NHx possessing less oxygen and greater lung surfactant binding affinity. Following 8 weeks of exposure, all fMWCNT-exposed cells exhibited significant increased proliferation compared to controls at 7 d post-treatment, while UFCB- and ASB-exposed cells did not differ significantly from controls. UFCB, pMWCNT, and MW-COOH exposure stimulated significant transient invasion behavior. Conversely, aged MW-NHx exposed cells displayed moderate increases in soft agar colony formation and morphological transformation potential, while UFCB cells showed a minimal effect compared to all other treatments. In summary, surface properties of aged fMWCNTs can impact cell transformation events in vitro following continuous, occupationally relevant exposures.

      8. Mozambique’s journey toward accreditation of the National Tuberculosis Reference LaboratoryExternal
        Viegas SO, Azam K, Madeira C, Aguiar C, Dolores C, Mandlaze AP, Chongo P, Masamha J, Cirillo DM, Jani IV, Gudo ES.
        Afr J Lab Med. 2017 31 Mar;6 (2) (a491).

        Background:Internationally-accredited laboratories are recognised for their superior test reliability, operational performance, quality management and competence. In a bid to meet international quality standards, the Mozambique National Institute of Health enrolled the National Tuberculosis Reference Laboratory (NTRL) in a continuous quality improvement process towards ISO 15189 accreditation. Here, we describe the road map taken by the NTRL to achieve international accreditation. Methods:The NTRL adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme as a strategy to implement a quality management system. After SLMTA, the Mozambique National Institute of Health committed to accelerate the NTRL’s process toward accreditation. An action plan was designed to streamline the process. Quality indicators were defined to benchmark progress. Staff were trained to improve performance. Mentorship from an experienced assessor was provided. Fulfilment of accreditation standards was assessed by the Portuguese Accreditation Board. Results:Of the eight laboratories participating in SLMTA, the NTRL was the best-performing laboratory, achieving a 53.6%improvement over the SLMTA baseline conducted in February 2011 to the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) assessment in June 2013. During the accreditation assessment in September 2014, 25 minor nonconformities were identified and addressed. In March 2015, the NTRL received Portuguese Accreditation Board recognition of technical competency for fluorescence smear microscopy, and solid and liquid culture. The NTRL is the first laboratory in Mozambique to achieve ISO 15189 accreditation. Conclusions:From our experience, accreditation was made possible by institutional commitment, strong laboratory leadership, staff motivation, adequate infrastructure and a comprehensive action plan.

      9. Quantification of saxitoxin in human blood by ELISAExternal
        Wharton RE, Feyereisen MC, Gonzalez AL, Abbott NL, Hamelin EI, Johnson RC.
        Toxicon. 2017 May 07.

        Saxitoxin (STX) is a potent marine toxin that causes paralytic shellfish poisoning (PSP) which can result in significant morbidity and mortality in humans. Low lethal doses, rapid onset of PSP symptoms, and brief STX half-life in vivo require sensitive and rapid diagnostic techniques to monitor human exposures. Our laboratory has validated an enzyme-linked immunosorbent assay (ELISA) for quantitative detection of STX from 0.020 to 0.80 ng/mL in human whole blood and from 0.06 to 2.0 ng/mL in dried human blood which is simple, sensitive, rapid, and cost-effective. To our knowledge, this is the first validated method for the quantitation of saxitoxin in whole blood. Microsampling devices were used in sample collection which allows for standardized collection of blood, stable storage, and cost-efficient shipping. Quality control precision and accuracy were evaluated over the course of validation and were within 20% of theoretical concentrations. No detectable background concentrations of STX were found among fifty whole blood and dried blood convenience samples. Additionally, ten spiked individual whole blood and dried blood samples were tested for accuracy and precision and were within 20% of theoretical concentrations. Gonyautoxins 2&3 (GTX2&3) cross-reacted with this ELISA by 21%, but all other structurally related PSP toxins tested cross-reacted less than two percent. While clinical diagnosis or treatment of PSP would be unaffected by GTX2&3 cross-reactivity by ELISA, to accurately quantify individual PSP toxins, these results should be coupled with high performance liquid chromatography mass spectrometry measurements.

      10. Modeling of the interaction between grip force and vibration transmissibility of a fingerExternal
        Wu JZ, Welcome DE, McDowell TW, Xu XS, Dong RG.
        Med Eng Phys. 2017 May 09.

        It is known that the vibration characteristics of the fingers and hand and the level of grip action interacts when operating a power tool. In the current study, we developed a hybrid finger model to simulate the vibrations of the hand-finger system when gripping a vibrating handle covered with soft materials. The hybrid finger model combines the characteristics of conventional finite element (FE) models, multi-body musculoskeletal models, and lumped mass models. The distal, middle, and proximal finger segments were constructed using FE models, the finger segments were connected via three flexible joint linkages (i.e., distal interphalangeal joint (DIP), proximal interphalangeal joint (PIP), and metacarpophalangeal (MCP) joint), and the MCP joint was connected to the ground and handle via lumped parameter elements. The effects of the active muscle forces were accounted for via the joint moments. The bone, nail, and hard connective tissues were assumed to be linearly elastic whereas the soft tissues, which include the skin and subcutaneous tissues, were considered as hyperelastic and viscoelastic. The general trends of the model predictions agree well with the previous experimental measurements in that the resonant frequency increased from proximal to the middle and to the distal finger segments for the same grip force, that the resonant frequency tends to increase with increasing grip force for the same finger segment, especially for the distal segment, and that the magnitude of vibration transmissibility tends to increase with increasing grip force, especially for the proximal segment. The advantage of the proposed model over the traditional vibration models is that it can predict the local vibration behavior of the finger to a tissue level, while taking into account the effects of the active musculoskeletal force, the effects of the contact conditions on vibrations, the global vibration characteristics.

      11. ToF-SIMS quantification of bromine based insecticide in mosquito nettingExternal
        Zhou C, Stevie FA, Smith SC.
        J Vac Sci Technol B Nanotechnol Microelectron. 2017 ;35(3).

        Insecticides are used to combat diseases such as malaria by incorporation in or topical application on mosquito netting. Determination of the insecticide available on the surface of the treated material has been difficult to achieve. A recent study of the chlorine based insecticide permethrin in mosquito netting has shown that time-of-flight secondary ion mass spectrometry (ToF-SIMS) was able to detect and, with the development of ion implanted standards, to quantify permethrin on the fiber surface and subsurface. The ion implantation method has been used extensively for SIMS quantification. A similar approach to analysis and quantification has now been achieved for the brominated insecticide deltamethrin, which is used at significantly lower concentrations than permethrin. ToF-SIMS analysis of deltamethrin indicated a dominant bromine ion in the negative ion mass spectrum. 79Br was implanted into high density polyethylene (HDPE), which is the netting material, into acetone washed netting fibers, and into silicon to verify implant dose. ToF-SIMS depth profiles of the implanted HDPE showed a detection limit of 5.2 x 1017 atoms/cm3, which corresponds to a detection limit of 0.046% by weight for deltamethrin. The implanted fiber showed an implant profile superimposed on the bromine contributed from the deltamethrin. The insecticide concentration below the fiber surface at two different locations was measured at 0.17 and 0.23 wt. %, which is in excellent agreement with the insecticide specification of 0.18 wt. % +/-25%. Analysis of unimplanted netting fibers showed localized high concentrations of insecticide. The results obtained provide quantitative analysis of the insecticide on the surface and bulk of the netting and are significant to evaluate net performance.

    • Maternal and Child Health RSS Word feed
      1. Hepatitis B surface antigen screening among pregnant women and care of infants of hepatitis B surface antigen-positive mothers – Guam, 2014External
        Abara WE, Cha S, Malik T, DeSimone MS, Schumann B, Mallada E, Klemme M, Aguon V, Santos AM, Collier M, Kamb M.
        MMWR Morb Mortal Wkly Rep. 2017 May 19;66(19):506-508.

        Hepatitis B virus (HBV) infection is endemic among adults in the U.S. territory of Guam. Perinatal HBV transmission, which occurs at birth from an infected mother to her newborn infant, is a major mode of HBV transmission and maintains HBV endemicity. Approximately 90% of HBV-infected infants will develop chronic HBV infection, and approximately 25% of those will die prematurely from liver failure or hepatocellular carcinoma. Since 1988, the Advisory Committee on Immunization Practices has recommended that all pregnant women be screened for hepatitis B surface antigen (HBsAg), an indicator of HBV infection, and that infants of women who screen positive (HBsAg-positive women) receive postexposure prophylaxis (PEP) (hepatitis B vaccine and hepatitis B immunoglobulin [HBIG]). When received within 12 hours of birth, PEP is 85%-95% effective in preventing perinatal HBV transmission. Hepatitis B vaccine provides long-term active immunity to HBV infection and HBIG provides short-term passive immunity to HBV infection until the infant responds to the vaccine. Hepatitis B vaccine was introduced into the routine universal infant vaccination schedule in Guam in 1988.

      2. Validation study of maternal recall on breastfeeding duration 6 years after childbirthExternal
        Amissah EA, Kancherla V, Ko YA, Li R.
        J Hum Lact. 2017 May;33(2):390-400.

        BACKGROUND: Breastfeeding duration is an important indicator commonly measured in maternal and child health and nutrition research. Maternal short-term recall for both initiation and duration of breastfeeding has been shown to be valid; however, validity of long-term recall is not well understood. Research aim: This study aims to assess the validity of maternal recall of breastfeeding duration 6 years after childbirth and its association with sociodemographic factors. METHODS: Among 635 mother-child pairs, breastfeeding duration data collected monthly throughout the 1st year after childbirth in the Infant Feeding Practices Study II (IFPS II) were compared to recall data obtained 6 years later during the Year 6 Follow-Up. The intraclass correlation coefficient (ICC) and Bland-Altman plots were examined to study the agreement between the two data sets. Sociodemographic factors associated with accurate recall to within 1 month of the IFPS II breastfeeding duration were assessed using multivariable logistic regression modeling. RESULTS: Maternal recall of breastfeeding duration was found to be valid 6 years after childbirth with a small median overall bias (1 week) toward overestimation. The overall concordance was high (ICC = 0.84), except for high school graduates (ICC = 0.63) and smokers (ICC = 0.61). Smokers (adjusted odds ratio = 0.52; 95% confidence interval [0.4, 0.8]) and multiparous women (adjusted odds ratio = 0.57; 95% confidence interval [0.4, 0.9]) were also less likely to give an accurate recall of their breastfeeding duration to within 1 month. CONCLUSION: Our study found that maternal recall of breastfeeding duration varies by sociodemographic factors but is accurate 6 years after childbirth.

      3. Use of Rapid Ascertainment Process for Institutional Deaths (RAPID) to identify pregnancy-related deaths in tertiary-care obstetric hospitals in three departments in HaitiExternal
        Boyd AT, Hulland EN, Grand’Pierre R, Nesi F, Honore P, Jean-Louis R, Handzel E.
        BMC Pregnancy Childbirth. 2017 May 16;17(1):145.

        BACKGROUND: Accurate assessment of maternal deaths is difficult in countries lacking standardized data sources for their review. As a first step to investigate suspected maternal deaths, WHO suggests surveillance of “pregnancy-related deaths”, defined as deaths of women while pregnant or within 42 days of termination of pregnancy, irrespective of cause. Rapid Ascertainment Process for Institutional Deaths (RAPID), a surveillance tool, retrospectively identifies pregnancy-related deaths occurring in health facilities that may be missed by routine surveillance to assess gaps in reporting these deaths. METHODS: We used RAPID to review pregnancy-related deaths in six tertiary obstetric care facilities in three departments in Haiti. We reviewed registers and medical dossiers of deaths among women of reproductive age occurring in 2014 and 2015 from all wards, along with any additional available dossiers of deaths not appearing in registers, to capture pregnancy status, suspected cause of death, and timing of death in relation to the pregnancy. We used capture-recapture analyses to estimate the true number of in-hospital pregnancy-related deaths in these facilities. RESULTS: Among 373 deaths of women of reproductive age, we found 111 pregnancy-related deaths, 25.2% more than were reported through routine surveillance, and 22.5% of which were misclassified as non-pregnancy-related. Hemorrhage (27.0%) and hypertensive disorders (18.0%) were the most common categories of suspected causes of death, and deaths after termination of pregnancy were statistically significantly more common than deaths during pregnancy or delivery. Data were missing at multiple levels: 210 deaths had an undetermined pregnancy status, 48.7% of pregnancy-related deaths lacked specific information about timing of death in relation to the pregnancy, and capture-recapture analyses in three hospitals suggested that approximately one-quarter of pregnancy-related deaths were not captured by RAPID or routine surveillance. CONCLUSIONS: Across six tertiary obstetric care facilities in Haiti, RAPID identified unreported pregnancy-related deaths, and showed that missing data was a widespread problem. RAPID is a useful tool to more completely identify facility-based pregnancy-related deaths, but its repeated use would require a concomitant effort to systematically improve documentation of clinical findings in medical records. Limitations of RAPID demonstrate the need to use it alongside other tools to more accurately measure and address maternal mortality.

      4. Maternal race-ethnicity, immigrant status, country of birth, and the odds of a child with autismExternal
        Fairthorne J, de Klerk N, Leonard HM, Schieve LA, Yeargin-Allsopp M.
        Child Neurol Open. 2017 Jan-Dec;4:2329048×16688125.

        The risk of autism spectrum disorder varies by maternal race-ethnicity, immigration status, and birth region. In this retrospective cohort study, Western Australian state registries and a study population of 134 204 mothers enabled us to examine the odds of autism spectrum disorder with intellectual disability in children born from 1994 to 2005 by the aforementioned characteristics. We adjusted for maternal age, parity, socioeconomic status, and birth year. Indigenous women were 50% less likely to have a child with autism spectrum disorder with intellectual disability than Caucasian, nonimmigrant women. Overall, immigrant women were 40% less likely to have a child with autism spectrum disorder with intellectual disability than nonimmigrant women. However, Black women from East Africa had more than 3.5 times the odds of autism spectrum disorder with intellectual disability in their children than Caucasian nonimmigrant women. Research is implicated on risk and protective factors for autism spectrum disorder with intellectual disability in the children of immigrant women.

      5. Quality of case management for pneumonia and diarrhea among children seen at health facilities in southern MalawiExternal
        Kobayashi M, Mwandama D, Nsona H, Namuyinga RJ, Shah MP, Bauleni A, Eng JV, Rowe AK, Mathanga DP, Steinhardt LC.
        Am J Trop Med Hyg. 2017 May;96(5):1107-1116.

        Pneumonia and diarrhea are leading causes of child deaths in Malawi. Guidelines to manage childhood illnesses in resource-poor settings exist, but studies have reported low health-care worker (HCW) adherence to guidelines. We conducted a health facility survey from January to March 2015 to assess HCW management of pneumonia and diarrhea in children < 5 years of age in southern Malawi, and to determine factors associated with case management quality. Descriptive statistics and multivariable logistic regression models examined patient, HCW, and health facility factors associated with recommended pneumonia and diarrhea management, using Malawi’s national guidelines as the gold standard. Of 694 surveyed children 2-59 months of age at 95 health facilities, 132 (19.0%) met survey criteria for pneumonia; HCWs gave recommended antibiotic treatment to 90 (68.2%). Of 723 children < 5 years of age, 222 (30.7%) had uncomplicated diarrhea; HCWs provided recommended treatment to 94 (42.3%). In multivariable analyses, caregivers’ spontaneous report of children’s symptoms was associated with recommended treatment of both pneumonia (odds ratio [OR]: 2.8, 95% confidence interval [CI]: 1.2-6.8, P = 0.023) and diarrhea (OR: 24.2, 95% CI: 6.0-97.0, P < 0001). Malaria diagnosis was negatively associated with recommended treatment (OR for pneumonia: 0.5, 95% CI: 0.2-1.0, P = 0.046; OR for diarrhea: 0.3, 95% CI: 0.1-0.6, P = 0.003). To improve quality of care, children should be assessed systematically, even when malaria is suspected. Renewed efforts to invigorate such a systematic approach, including HCW training, regular follow-up supervision, and monitoring HCW performance, are needed in Malawi.

    • Nutritional Sciences RSS Word feed
      1. Re: “Iodine Content in milk alternatives” by Ma et al. (Thyroid 2016;26:1308-1310)External
        Vance K, Makhmudov A, Jones RL, Caldwell KL.
        Thyroid. 2017 May;27(5):748-749.

        [No abstract]

    • Occupational Safety and Health RSS Word feed
      1. Physical and organizational job stressors in pregnancy and associations with primary cesarean deliveriesExternal
        Guendelman S, Gemmill A, Hosang N, MacDonald LA.
        J Occup Environ Med. 2017 May 11.

        OBJECTIVE: The aim of this study was to assess the relationship between exposure to physical and organizational job stressors during pregnancy and cesarean delivery. METHODS: We sampled 580 employed women in California who participated in a nested population-based case-control study of birth outcomes. Adjusted multivariate regression analyses estimated associations between heavy lifting, frequent bending, high noise, extreme temperature, prolonged standing and organizational stressors (shift work, inflexible schedules, effort-reward ratio), and primary cesarean (vs vaginal) delivery, controlling for covariates. RESULTS: Women occupationally exposed had higher odds of cesarean. Those exposed to daily manual lifting more than 15 pounds [adjusted odds ratio = 2.54; 95% confidence interval (95% CI) 1.21 to 5.32] and at least four physical job stressors (adjusted odds ratio = 3.49; 95% CI 1.21 to 10.09) had significantly elevated odds of cesarean delivery. Exposed morbid women experienced greater risk; risk was lower among those with schedule flexibility. CONCLUSION: Associations were found between modifiable exposure to physical job stressors during pregnancy and cesarean delivery.

      2. Allergic sinusitis and severe asthma caused by occupational exposure to locust bean gum: Case reportExternal
        Hawley B, Cummings KJ, Mohammed M, Dimmock AE, Bascom R.
        Am J Ind Med. 2017 May 12.

        We present a case that highlights the difficulties with diagnosis and the dangers of occupational allergic sinusitis and asthma left unrecognized. We describe the case history of a man who experienced work-related symptoms 1 year after beginning work as a cheesemaker at a creamery, and whose respiratory symptoms progressively worsened over 16 years before an occupational cause of his asthma was identified. His initial discrete episodes of sinusitis and acute bronchitis evolved into persistent asthma of increasing severity with exacerbations requiring repeated emergency room treatment. The case described in our report emphasizes the importance of clinician diagnosis of OA, and subsequent removal from exposure, such that asthma severity does not progress to near-fatal or fatal asthma in the sensitized worker. As demonstrated by this case report, identification of an occupational cause of asthma relies on a high degree of suspicion and excellent detective work by the clinician.

      3. In 1974, the National Institute for Occupational Safety and Health recommended a ban on the use of abrasives containing >1% silica, giving rise to abrasive substitutes like copper slag. We present results from a National Institute for Occupational Safety and Health industrial hygiene survey at a copper slag processing facility that consisted of the collection of bulk samples for metals and silica; and full-shift area and personal air samples for dust, metals, and respirable silica. Carcinogens, suspect carcinogens, and other toxic elements were detected in all bulk samples, and area and personal air samples. Area air samples identified several areas with elevated levels of inhalable and respirable dust, and respirable silica: quality control check area (236 mg/m3 inhalable; 10.3 mg/m3 respirable; 0.430 mg/m3 silica), inside the screen house (109 mg/m3 inhalable; 13.8 mg/m3 respirable; 0.686 mg/m3 silica), under the conveyor belt leading to the screen house (19.8 mg/m3 inhalable), and inside a conveyor access shack (11.4 mg/m3 inhalable; 1.74 mg/m3 respirable; 0.067 mg/m3 silica). Overall, personal dust samples were lower than area dust samples and did not exceed published occupational exposure limits. Silica samples collected from a plant hand and a laborer exceeded the American Conference of Governmental Industrial Hygienist Threshold Limit Value of 0.025 microg/m3. All workers involved in copper slag processing (n = 5) approached or exceeded the Occupational Safety and Health Administration permissible exposure limit of 10 microg/m3 for arsenic (range: 9.12-18.0 microg/m3). Personal total dust levels were moderately correlated with personal arsenic levels (Rs = 0.70) and personal respirable dust levels were strongly correlated with respirable silica levels (Rs = 0.89). We identified multiple areas with elevated levels of dust, respirable silica, and metals that may have implications for personal exposure at other facilities if preventive measures are not taken. To our knowledge, this is the first attempt to characterize exposures associated with copper slag processing. More in-depth air monitoring and health surveillance is needed to understand occupational exposures and health outcomes in this industry.

      4. An approach to assess the burden of work-related injury, disease, and distressExternal
        Schulte PA, Pana-Cryan R, Schnorr T, Schill AL, Guerin R, Felknor S, Wagner GR.
        Am J Public Health. 2017 May 18:e1-e7.

        The true burden (morbidity, mortality, disability, cost, pain, distress) of occupational and work-related diseases and injuries is unknown, and what is reported as burden is significantly underestimated. This underestimation affects the way decision-makers view investments in research and worker protection, which in turn has a substantial impact on national welfare and public health. To better describe the societal and individual burdens of occupational and work-related diseases and injuries, we propose an approach to gauge what is known about burden and where new assessments may be made. This approach consists of 4 elements to consider in burden assessments: (1) utilizing multiple domains, including the individual worker, the worker’s family, the community in which the workplace is located, the employer, and society as a whole; (2) taking a broader view of the work-relatedness of disease and injury; (3) assessing the impact of the entire working-life continuum; and (4) applying the comprehensive concept of “well-being” as an indicator in addressing contemporary changes in the nature of work, the workplace, and the workforce. Further research on burden and enhanced surveillance is needed to develop these elements. (Am J Public Health. Published online ahead of print May 18, 2017: e1-e7. doi:10.2105/AJPH.2017.303765).

    • Occupational Safety and Health – Mining RSS Word feed
      1. Respiratory morbidity among U.S. coal miners in states outside of central AppalachiaExternal
        Reynolds LE, Blackley DJ, Laney AS, Halldin CN.
        Am J Ind Med. 2017 Jun;60(6):513-517.

        BACKGROUND: Recent NIOSH publications have focused on the respiratory health of coal miners in central Appalachia, yet 57% of U.S. coal miners work in other regions. We characterized respiratory morbidity in coal miners from these regions. METHODS: Active coal miners working outside of central Appalachia who received chest radiographs and/or spirometry during 2005-2015 were included. Chest radiographs were classified according to International Labour Office standards and spirometry was interpreted using the American Thoracic Society guidelines. Prevalence of coal workers’ pneumoconiosis (CWP) and abnormal spirometry were compared by region. RESULTS: A total of 103 (2.1%) miners had CWP. The eastern region had the highest prevalence (3.4%), followed by the western (1.7%), and interior (0.8%) regions. A total of 524 (9.3%) miners had abnormal spirometry. CONCLUSIONS: CWP occurs in all U.S. coal mining regions. Prevalence of CWP was higher in the eastern region, but lower than levels reported in central Appalachia.

    • Parasitic Diseases RSS Word feed
      1. Comparison of artemether-lumefantrine and chloroquine with and without primaquine for the treatment of Plasmodium vivax infection in Ethiopia: A randomized controlled trialExternal
        Abreha T, Hwang J, Thriemer K, Tadesse Y, Girma S, Melaku Z, Assef A, Kassa M, Chatfield MD, Landman KZ, Chenet SM, Lucchi NW, Udhayakumar V, Zhou Z, Shi YP, Kachur SP, Jima D, Kebede A, Solomon H, Mekasha A, Alemayehu BH, Malone JL, Dissanayake G, Teka H, Auburn S, von Seidlein L, Price RN.
        PLoS Med. 2017 May;14(5):e1002299.

        BACKGROUND: Recent efforts in malaria control have resulted in great gains in reducing the burden of Plasmodium falciparum, but P. vivax has been more refractory. Its ability to form dormant liver stages confounds control and elimination efforts. To compare the efficacy and safety of primaquine regimens for radical cure, we undertook a randomized controlled trial in Ethiopia. METHODS AND FINDINGS: Patients with normal glucose-6-phosphate dehydrogenase status with symptomatic P. vivax mono-infection were enrolled and randomly assigned to receive either chloroquine (CQ) or artemether-lumefantrine (AL), alone or in combination with 14 d of semi-supervised primaquine (PQ) (3.5 mg/kg total). A total of 398 patients (n = 104 in the CQ arm, n = 100 in the AL arm, n = 102 in the CQ+PQ arm, and n = 92 in the AL+PQ arm) were followed for 1 y, and recurrent episodes were treated with the same treatment allocated at enrolment. The primary endpoints were the risk of P. vivax recurrence at day 28 and at day 42. The risk of recurrent P. vivax infection at day 28 was 4.0% (95% CI 1.5%-10.4%) after CQ treatment and 0% (95% CI 0%-4.0%) after CQ+PQ. The corresponding risks were 12.0% (95% CI 6.8%-20.6%) following AL alone and 2.3% (95% CI 0.6%-9.0%) following AL+PQ. On day 42, the risk was 18.7% (95% CI 12.2%-28.0%) after CQ, 1.2% (95% CI 0.2%-8.0%) after CQ+PQ, 29.9% (95% CI 21.6%-40.5%) after AL, and 5.9% (95% CI 2.4%-13.5%) after AL+PQ (overall p < 0.001). In those not prescribed PQ, the risk of recurrence by day 42 appeared greater following AL treatment than CQ treatment (HR = 1.8 [95% CI 1.0-3.2]; p = 0.059). At the end of follow-up, the incidence rate of P. vivax was 2.2 episodes/person-year for patients treated with CQ compared to 0.4 for patients treated with CQ+PQ (rate ratio: 5.1 [95% CI 2.9-9.1]; p < 0.001) and 2.3 episodes/person-year for AL compared to 0.5 for AL+PQ (rate ratio: 6.4 [95% CI 3.6-11.3]; p < 0.001). There was no difference in the occurrence of adverse events between treatment arms. The main limitations of the study were the early termination of the trial and the omission of haemoglobin measurement after day 42, resulting in an inability to estimate the cumulative risk of anaemia. CONCLUSIONS: Despite evidence of CQ-resistant P. vivax, the risk of recurrence in this study was greater following treatment with AL unless it was combined with a supervised course of PQ. PQ combined with either CQ or AL was well tolerated and reduced recurrence of vivax malaria by 5-fold at 1 y. TRIAL REGISTRATION: NCT01680406.

      2. BACKGROUND: Currently, the reference standard assay for the serodiagnosis of neurocysticercosis (NCC) is the lentil lectin-bound glycoproteins/enzyme-linked immunoelectrotransfer blot (LLGP-EITB). The main disadvantage of this technique is the complexity of obtaining and purifying the LLGP extract. This could be solved by replacement with highly specific recombinant antigens from Taenia solium. Based on previous studies, we selected and produced the recombinant Ts8B2 and T24H proteins and applied them to three diagnostic techniques: western blot (WB), enzyme-linked immunosorbent assay (ELISA) and the multiplex bead-based assay (MBA). METHODS: The Ts8B2 and T24H cDNA sequences were expressed in a prokaryotic system and the corresponding expression products purified; three recombinant proteins were further characterized: T24H-his, GST-T24H and GST-Ts8B2. The proteins on WB, ELISA and MBA were tested against 149 sera from patients with NCC confirmed by brain imaging, 40 sera from patients with other parasitic diseases, and 131 sera from US. individuals without evidence of neurocysticercosis (clinical/serological/brain imaging). The sensitivity and specificity of each antigen by WB were calculated by counting the number of true positive, false positive, true negative and false negative results. Using the receiver operating characteristic (ROC) curves, the cut-off values for the ELISA and MBA were established as well as the sensitivity and specificity of each assay. RESULTS: All three antigens showed a high sensitivity on WB in active NCC cases with two or more viable cysts and low sensitivity for cases with single viable cyst or calcified lesions and inactive NCC. WB showed the highest specificity and sensitivity out of the three diagnostic techniques. The recombinant T24H-his was the best diagnostic reagent in WB (100% sensitivity, 99.4% specificity), exhibiting similar results to the LLGP-EITB, against the same panel of NCC sera. The GST-T24H antigen worked better than the others in ELISA and MBA protocols (88.3 and 96.1% sensitivity, respectively and 96.5% specificity). CONCLUSIONS: The sensitivity and specificity that we obtained were similar to results from a previous study using a similar recombinant antigen (rT24H), suggesting that recombinant antigens may be good alternatives to crude extracts in a variety of diagnostic techniques. Furthermore, these antigens can be applied in the development of point-of-care tests which would be useful in NCC field studies.

      3. Using molecular characterization to support investigations of aquatic facility-associated outbreaks of cryptosporidiosis – Alabama, Arizona, and Ohio, 2016External
        Hlavsa MC, Roellig DM, Seabolt MH, Kahler AM, Murphy JL, McKitt TK, Geeter EF, Dawsey R, Davidson SL, Kim TN, Tucker TH, Iverson SA, Garrett B, Fowle N, Collins J, Epperson G, Zusy S, Weiss JR, Komatsu K, Rodriguez E, Patterson JG, Sunenshine R, Taylor B, Cibulskas K, Denny L, Omura K, Tsorin B, Fullerton KE, Xiao L.
        MMWR Morb Mortal Wkly Rep. 2017 May 19;66(19):493-497.

        Cryptosporidiosis is a nationally notifiable gastrointestinal illness caused by parasitic protozoa of the genus Cryptosporidium, which can cause profuse, watery diarrhea that can last up to 2-3 weeks in immunocompetent patients and can lead to life-threatening wasting and malabsorption in immunocompromised patients. Fecal-oral transmission of Cryptosporidium oocysts, the parasite’s infectious life stage, occurs via ingestion of contaminated recreational water, drinking water, or food, or following contact with infected persons or animals, particularly preweaned bovine calves (1). The typical incubation period is 2-10 days. Since 2004, the annual incidence of nationally notified cryptosporidiosis has risen approximately threefold in the United States (1). Cryptosporidium also has emerged as the leading etiology of nationally notified recreational water-associated outbreaks, particularly those associated with aquatic facilities (i.e., physical places that contain one or more aquatic venues [e.g., pools] and support infrastructure) (2). As of February 24, 2017, a total of 13 (54%) of 24 states reporting provisional data detected at least 32 aquatic facility-associated cryptosporidiosis outbreaks in 2016. In comparison, 20 such outbreaks were voluntarily reported to CDC via the National Outbreak Reporting System for 2011, 16 for 2012, 13 for 2013, and 16 for 2014. This report highlights cryptosporidiosis outbreaks associated with aquatic facilities in three states (Alabama, Arizona, and Ohio) in 2016. This report also illustrates the use of CryptoNet, the first U.S. molecularly based surveillance system for a parasitic disease, to further elucidate Cryptosporidium chains of transmission and cryptosporidiosis epidemiology. CryptoNet data can be used to optimize evidence-based prevention strategies. Not swimming when ill with diarrhea is key to preventing and controlling aquatic facility-associated cryptosporidiosis outbreaks (

      4. Evaluating malaria case management at public health facilities in two provinces in AngolaExternal
        Plucinski MM, Ferreira M, Ferreira CM, Burns J, Gaparayi P, Joao L, da Costa O, Gill P, Samutondo C, Quivinja J, Mbounga E, de Leon GP, Halsey ES, Dimbu PR, Fortes F.
        Malar J. 2017 May 03;16(1):186.

        BACKGROUND: Malaria accounts for the largest portion of healthcare demand in Angola. A pillar of malaria control in Angola is the appropriate management of malaria illness, including testing of suspect cases with rapid diagnostic tests (RDTs) and treatment of confirmed cases with artemisinin-based combination therapy (ACT). Periodic systematic evaluations of malaria case management are recommended to measure health facility readiness and adherence to national case management guidelines. METHODS: Cross-sectional health facility surveys were performed in low-transmission Huambo and high-transmission Uige Provinces in early 2016. In each province, 45 health facilities were randomly selected from among all public health facilities stratified by level of care. Survey teams performed inventories of malaria commodities and conducted exit interviews and re-examinations, including RDT testing, of a random selection of all patients completing outpatient consultations. Key health facility readiness and case management indicators were calculated adjusting for the cluster sampling design and utilization. RESULTS: Availability of RDTs or microscopy on the day of the survey was 71% (54-83) in Huambo and 85% (67-94) in Uige. At least one unit dose pack of one formulation of an ACT (usually artemether-lumefantrine) was available in 83% (66-92) of health facilities in Huambo and 79% (61-90) of health facilities in Uige. Testing rates of suspect malaria cases in Huambo were 30% (23-38) versus 69% (53-81) in Uige. Overall, 28% (13-49) of patients with uncomplicated malaria, as determined during the re-examination, were appropriately treated with an ACT with the correct dose in Huambo, compared to 60% (42-75) in Uige. Incorrect case management of suspect malaria cases was associated with lack of healthcare worker training in Huambo and ACT stock-outs in Uige. CONCLUSIONS: The results reveal important differences between provinces. Despite similar availability of testing and ACT, testing and treatment rates were lower in Huambo compared to Uige. A majority of true malaria cases seeking care in health facilities in Huambo were not appropriately treated with anti-malarials, highlighting the importance of continued training and supervision of healthcare workers in malaria case management, particularly in areas with decreased malaria transmission.

    • Public Health Leadership and Management RSS Word feed
      1. Scientific document review at the Centers for Disease Control and Prevention: The CLEAR approachExternal
        Iskander JK, Calugar A, Peavy RD, Sowell A.
        Am J Public Health. 2017 Jun;107(6):858-859.

        [No abstract]

    • Social and Behavioral Sciences RSS Word feed
      1. Two experiments tested whether age and racial stereotypes influence communication. Specifically, both studies sought to understand if older African American targets would experience a communicative double jeopardy. In the first experiment, participants assessed targets? language performance and beliefs about their own speech style (i.e., patronizing speech style). Age (participant and target) interacted with stereotype to influence ratings of language competence, and an interaction of target race, stereotype, and participant age influenced the elicitation of patronizing speech. In the second experiment, participants assessed communication competence and patronizing speech. Age groups of the targets and the participants, rather than racial groups, significantly influenced perceptions of both ratings of communication competence and the adoption of a patronizing speech style. Implications for the Age Stereotype in Interaction Model of intergenerational communication and future research on intersectionality are discussed.

      2. Factors associated with psychological distress among young women in Kisumu, KenyaExternal
        Gust DA, Gvetadze R, Furtado M, Makanga M, Akelo V, Ondenge K, Nyagol B, McLellan-Lemal E.
        Int J Womens Health. 2017 ;9:255-264.

        BACKGROUND: Attention to mental health issues is growing globally. In many countries, including Kenya, however, assessment of psychological distress, especially in rural areas, is limited. METHODS: We analyzed data from young women screened for a longitudinal contraceptive ring study in Kisumu, Kenya. Multivariable regression analysis was used to assess factors associated with recent moderate and high psychological distress, as measured by the Kessler (K-6) psychological distress scale. RESULTS: Among the 461 women screened, most (58.4%) were categorized as having moderate psychological distress, 20.8% were categorized as having low or no psychological distress, and 20.8% were categorized as having high psychological distress. Moderate psychological distress (vs low/no) was significantly more likely among women who reported a history of forced sex and were concerned about recent food insecurity. High (vs low/no) psychological distress was significantly more likely among women who reported a history of forced sex, who were concerned about recent food insecurity, and who self-reported a sexually transmitted infection. CONCLUSION: To reduce psychological distress, a focus on prevention as well as care methods is needed. Girls need a path toward a healthy and productive adulthood with a focus on education, which would help them gain skills to avoid forced sex. Women would benefit from easy access to social services and supports that would help them with basic needs like food security among other things. A holistic or ecological approach to services that would address mental, educational, social, health, and economic issues may have the highest chance of having a long-term positive impact on public health.

    • Substance Use and Abuse RSS Word feed
      1. Point-of-sale cigarette purchase patterns among U.S. adult smokers – National Adult Tobacco Survey, 2012-2014External
        Kruger J, Jama A, Lee JG, Kennedy S, Banks A, Sharapova S, Agaku I.
        Prev Med. 2017 May 11.

        Tobacco products are ubiquitous in most U.S. retail environments. Given that data on preferred point-of-sale purchase locations among U.S. adult tobacco users are limited, an enhanced understanding of tobacco purchase locations can help inform tobacco control policy, planning, and practice. We investigated prevalence and sociodemographic characteristics associated with cigarette purchase location among U.S. adult smokers. Pooled data came from the 2012-2013 (N=60,192) and 2013-2014 (N=75,233) National Adult Tobacco Surveys. Current cigarette smokers (n=18,005) aged >/=18 were asked if they purchased cigarettes within the previous 30 days (n=15,182) and, if so, where they last purchased cigarettes. In 2016, logistic regression adjusted for sex, age, race/ethnicity, education level and annual household income was used to assess characteristics associated with purchase location. Among current smokers, 90.2% reported purchasing cigarettes in the past 30days. The most common purchase locations were convenience stores/gas stations (69.1%), tobacco discount stores (9.9%), drug stores (5.0%), supermarkets (4.9%), and liquor stores (3.6%). The odds of purchasing cigarettes at convenience stores/gas stations were higher among men (adjusted odds ratio (AOR)=1.4; 95% confidence interval (CI)=1.2-1.5) than women; and among adults aged 18-24 (AOR=3.1; 95% CI=2.4-3.9), 25-44 (AOR=3.1; 95% CI=2.7-3.7), and 45-64years (AOR=1.8 95% CI=1.6-2.1) than adults aged >/=65 years. Over two-thirds of U.S. smokers last purchased cigarettes from convenience stores/gas stations. Understanding the relationship between purchase location and smoker characteristics may inform tobacco control strategies in the retail environment.

    • Zoonotic and Vectorborne Diseases RSS Word feed
      1. Rabies surveillance in the United States during 2015External
        Birhane MG, Cleaton JM, Monroe BP, Wadhwa A, Orciari LA, Yager P, Blanton J, Velasco-Villa A, Petersen BW, Wallace RM.
        J Am Vet Med Assoc. 2017 May 15;250(10):1117-1130.

        OBJECTIVE To describe rabies and rabies-related events occurring during 2015 in the United States. DESIGN Observational study based on passive surveillance data. ANIMALS All animals submitted for rabies testing in the United States during 2015. PROCEDURES State and territorial public health programs provided data on animals submitted for rabies testing in 2015. Data were analyzed temporally and geographically to assess trends in domestic and sylvatic animal rabies cases. RESULTS During 2015, 50 states and Puerto Rico reported 5,508 rabid animals to the CDC, representing an 8.7% decrease from the 6,033 rabid animals reported in 2014. Of the 5,508 cases of animal rabies, 5,088 (92.4%) involved wildlife. Relative contributions by the major animal groups were as follows: 1,704 (30.9%) bats, 1,619 (29.4%) raccoons, 1,365 (24.8%) skunks, 325 (5.9%) foxes, 244 (4.4%) cats, 85 (1.5%) cattle, and 67 (1.2%) dogs. There was a 4.1% decrease in the number of samples submitted for testing in 2015, compared with the number submitted in 2014. Three human rabies deaths were reported in 2015, compared with only 1 in 2014. A 65-year-old man in Massachusetts was bitten by a rabid dog while abroad. A 77-year-old woman in Wyoming had contact with a bat. A 54-year-old man in Puerto Rico was bitten by a mongoose. The only connection among these 3 cases was that none received postexposure prophylaxis. CONCLUSIONS AND CLINICAL RELEVANCE Laboratory testing of animals suspected to be rabid remains a critical public health function and continues to be a cost-effective method to directly influence human rabies postexposure prophylaxis recommendations. (J Am Vet Med Assoc 2017;250:1117-1130).

      2. Transmission of Borrelia miyamotoi sensu lato relapsing fever group spirochetes in relation to duration of attachment by Ixodes scapularis nymphsExternal
        Breuner NE, Dolan MC, Replogle AJ, Sexton C, Hojgaard A, Boegler KA, Clark RJ, Eisen L.
        Ticks Tick Borne Dis. 2017 Apr 05.

        Borrelia miyamotoi sensu lato relapsing fever group spirochetes are emerging as causative agents of human illness (Borrelia miyamotoi disease) in the United States. Host-seeking Ixodes scapularis ticks are naturally infected with these spirochetes in the eastern United States and experimentally capable of transmitting B. miyamotoi. However, the duration of time required from tick attachment to spirochete transmission has yet to be determined. We therefore conducted a study to assess spirochete transmission by single transovarially infected I. scapularis nymphs to outbred white mice at three time points post-attachment (24, 48, and 72h) and for a complete feed (>72-96h). Based on detection of B. miyamotoi DNA from the blood of mice fed on by an infected nymph, the probability of spirochete transmission increased from 10% by 24h of attachment (evidence of infection in 3/30 mice) to 31% by 48h (11/35 mice), 63% by 72h (22/35 mice), and 73% for a complete feed (22/30 mice). We conclude that (i) single I. scapularis nymphs effectively transmit B. miyamotoi relapsing fever group spirochetes while feeding, (ii) transmission can occur within the first 24h of nymphal attachment, and (iii) the probability of transmission increases with the duration of nymphal attachment.

      3. Diagnosis and management of Borrelia turicatae infection in febrile soldier, Texas, USAExternal
        Christensen AM, Pietralczyk E, Lopez JE, Brooks C, Schriefer ME, Wozniak E, Stermole B.
        Emerg Infect Dis. 2017 May;23(5):883-884.

        In August 2015, a soldier returned from field exercises in Texas, USA, with nonspecific febrile illness. Culture and sequencing of spirochetes from peripheral blood diagnosed Borrelia turicatae infection. The patient recovered after receiving doxycycline. No illness occurred in asymptomatic soldiers potentially exposed to the vector tick and prophylactically given treatment.

      4. Fatal flea-borne typhus in Texas: A retrospective case series, 1985-2015External
        Pieracci EG, Evert N, Drexler NA, Mayes B, Vilcins I, Huang P, Campbell J, Behravesh CB, Paddock CD.
        Am J Trop Med Hyg. 2017 May;96(5):1088-1093.

        AbstractFlea-borne (murine) typhus is a global rickettsiosis caused by Rickettsia typhi. Although flea-borne typhus is no longer nationally notifiable, cases are reported for surveillance purposes in a few U.S. states. The infection is typically self-limiting, but may be severe or life-threatening in some patients. We performed a retrospective review of confirmed or probable cases of fatal flea-borne typhus reported to the Texas Department of State Health Services during 1985-2015. When available, medical charts were also examined. Eleven cases of fatal flea-borne typhus were identified. The median patient age was 62 years (range, 36-84 years) and 8 (73%) were male. Patients presented most commonly with fever (100%), nausea and vomiting (55%), and rash (55%). Respiratory (55%) and neurologic (45%) manifestations were also identified frequently. Laboratory abnormalities included thrombocytopenia (82%) and elevated hepatic transaminases (63%). Flea or animal contact before illness onset was frequently reported (55%). The median time from hospitalization to administration of a tetracycline-class drug was 4 days (range, 0-5 days). The median time from symptom onset to death was 14 days (range, 1-34 days). Flea-borne typhus can be a life-threatening disease if not treated in a timely manner with appropriate tetracycline-class antibiotics. Flea-borne typhus should be considered in febrile patients with animal or flea exposure and respiratory or neurologic symptoms of unknown etiology.

      5. African tick bite fever treated successfully with rifampin in a patient with doxycycline intoleranceExternal
        Strand A, Paddock CD, Rinehart AR, Condit ME, Marus JR, Gilliani S, Chung IH, Fowler VG.
        Clin Infect Dis. 2017 May 13.

        African tick bite fever is the most commonly encountered travel-associated rickettsiosis, occurring in as many as 5% of travelers returning from rural sub-equatorial Africa. This case report illustrates that rifampin represents an effective alternative to doxycycline for treatment of ATBF in some selective situations.

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

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