Issue 28, June 18, 2017

CDC Science Clips: Volume 9, Issue 28, July 18, 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. CDC Public Health Grand Rounds
    • Substance Use and Abuse – E-Cigarettes RSS Word feed
      1. Current tobacco smoking and desire to quit smoking among students aged 13-15 years – Global Youth Tobacco Survey, 61 countries, 2012-2015External
        Arrazola RA, Ahluwalia IB, Pun E, Garcia de Quevedo I, Babb S, Armour BS.
        MMWR Morb Mortal Wkly Rep. 2017 May 26;66(20):533-537.

        Tobacco use is the world’s leading cause of preventable morbidity and mortality, resulting in nearly 6 million deaths each year (1). Smoked tobacco products, such as cigarettes and cigars, are the most common form of tobacco consumed worldwide (2), and most tobacco smokers begin smoking during adolescence (3). The health benefits of quitting are greater for persons who stop smoking at earlier ages; however, quitting smoking at any age has health benefits (4). CDC used the Global Youth Tobacco Survey (GYTS) data from 61 countries across the six World Health Organization (WHO) regions from 2012 to 2015 to examine the prevalence of current tobacco smoking and desire to quit smoking among students aged 13-15 years. Across all 61 countries, the median current tobacco smoking prevalence among students aged 13-15 years was 10.7% (range = 1.7%, Sri Lanka to 35.0%, Timor-Leste). By sex, the median current tobacco smoking prevalence was 14.6% among males (range = 2.9%, Tajikistan to 61.4%, Timor-Leste) and 7.5% among females (range = 1.6%, Tajikistan to 29.0%, Bulgaria). In the majority of countries assessed, the proportion of current tobacco smokers who desired to quit smoking exceeded 50%. These findings could be used by country level tobacco control programs to inform strategies to prevent and reduce youth tobacco use (1,4).

      2. Flavored tobacco product use among middle and high school students – United States, 2014External
        Corey CG, Ambrose BK, Apelberg BJ, King BA.
        MMWR Morb Mortal Wkly Rep. 2015 ;64(38):1066-70.

        [No abstract]

      3. Exposure to electronic cigarette television advertisements among youth and young adultsExternal
        Duke JC, Lee YO, Kim AE, Watson KA, Arnold KY, Nonnemaker JM, Porter L.
        Pediatrics. 2014 Jul;134(1):e29-36.

        BACKGROUND AND OBJECTIVE: Currently, the US Food and Drug Administration does not regulate electronic cigarette (e-cigarette) marketing unless it is advertised as a smoking cessation aid. To date, the extent to which youth and young adults are exposed to e-cigarette television advertisements is unknown. The objective of this study was to analyze trends in youth and young adult exposure to e-cigarette television advertisements in the United States. METHODS: Nielsen data on television household audiences’ exposure to e-cigarette advertising across US markets were examined by calendar quarter, year, and sponsor. RESULTS: Youth exposure to television e-cigarette advertisements, measured by target rating points, increased 256% from 2011 to 2013. Young adult exposure increased 321% over the same period. More than 76% of all youth e-cigarette advertising exposure occurred on cable networks and was driven primarily by an advertising campaign for 1 e-cigarette brand. CONCLUSIONS: E-cigarette companies currently advertise their products to a broad audience that includes 24 million youth. The dramatic increase in youth and young adult television exposure between 2011 and 2013 was driven primarily by a large advertising campaign on national cable networks. In the absence of evidence-based public health messaging, the current e-cigarette television advertising may be promoting beliefs and behaviors that pose harm to the public health. If current trends in e-cigarette television advertising continue, awareness and use of e-cigarettes are likely to increase among youth and young adults.

      4. Tobacco use among middle and high school students – United States, 2011-2016External
        Jamal A, Gentzke A, Hu SS, Cullen KA, Apelberg BJ, Homa DM, King BA.
        MMWR Morb Mortal Wkly Rep. 2017 Jun 16;66(23):597-603.

        Tobacco use is the leading cause of preventable disease and death in the United States; nearly all tobacco use begins during youth and young adulthood (1,2). Among youths, use of tobacco products in any form is unsafe (1,3). CDC and the Food and Drug Administration (FDA) analyzed data from the 2011-2016 National Youth Tobacco Surveys (NYTS) to determine recent patterns of current (past 30-day) use of seven tobacco product types among U.S. middle (grades 6-8) and high (grades 9-12) school students. In 2016, 20.2% of surveyed high school students and 7.2% of middle school students reported current tobacco product use. In 2016, among current tobacco product users, 47.2% of high school students and 42.4% of middle school students used >/=2 tobacco products, and electronic cigarettes (e-cigarettes) were the most commonly used tobacco product among high (11.3%) and middle (4.3%) school students. Current use of any tobacco product did not change significantly during 2011-2016 among high or middle school students, although combustible tobacco product use declined. However, during 2015-2016, among high school students, decreases were observed in current use of any tobacco product, any combustible product, >/=2 tobacco products, e-cigarettes, and hookahs. Among middle school students, current use of e-cigarettes decreased. Comprehensive and sustained strategies can help prevent and reduce the use of all forms of tobacco products among U.S. youths (1-3).

      5. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescenceExternal
        Leventhal AM, Strong DR, Kirkpatrick MG, Unger JB, Sussman S, Riggs NR, Stone MD.
        JAMA. 2015 Aug 18;314(7):700-7.

        IMPORTANCE: Exposure to nicotine in electronic cigarettes (e-cigarettes) is becoming increasingly common among adolescents who report never having smoked combustible tobacco. OBJECTIVE: To evaluate whether e-cigarette use among 14-year-old adolescents who have never tried combustible tobacco is associated with risk of initiating use of 3 combustible tobacco products (ie, cigarettes, cigars, and hookah). DESIGN, SETTING, AND PARTICIPANTS: Longitudinal repeated assessment of a school-based cohort at baseline (fall 2013, 9th grade, mean age = 14.1 years) and at a 6-month follow-up (spring 2014, 9th grade) and a 12-month follow-up (fall 2014, 10th grade). Ten public high schools in Los Angeles, California, were recruited through convenience sampling. Participants were students who reported never using combustible tobacco at baseline and completed follow-up assessments at 6 or 12 months (N = 2530). At each time point, students completed self-report surveys during in-classroom data collections. EXPOSURE: Student self-report of whether he or she ever used e-cigarettes (yes or no) at baseline. MAIN OUTCOMES AND MEASURES: Six- and 12-month follow-up reports on use of any of the following tobacco products within the prior 6 months: (1) any combustible tobacco product (yes or no); (2) combustible cigarettes (yes or no), (3) cigars (yes or no); (4) hookah (yes or no); and (5) number of combustible tobacco products (range: 0-3). RESULTS: Past 6-month use of any combustible tobacco product was more frequent in baseline e-cigarette ever users (n = 222) than never users (n = 2308) at the 6-month follow-up (30.7% vs 8.1%, respectively; difference between groups in prevalence rates, 22.7% [95% CI, 16.4%-28.9%]) and at the 12-month follow-up (25.2% vs 9.3%, respectively; difference between groups, 15.9% [95% CI, 10.0%-21.8%]). Baseline e-cigarette use was associated with greater likelihood of use of any combustible tobacco product averaged across the 2 follow-up periods in the unadjusted analyses (odds ratio [OR], 4.27 [95% CI, 3.19-5.71]) and in the analyses adjusted for sociodemographic, environmental, and intrapersonal risk factors for smoking (OR, 2.73 [95% CI, 2.00-3.73]). Product-specific analyses showed that baseline e-cigarette use was positively associated with combustible cigarette (OR, 2.65 [95% CI, 1.73-4.05]), cigar (OR, 4.85 [95% CI, 3.38-6.96]), and hookah (OR, 3.25 [95% CI, 2.29-4.62]) use and with the number of different combustible products used (OR, 4.26 [95% CI, 3.16-5.74]) averaged across the 2 follow-up periods. CONCLUSIONS AND RELEVANCE: Among high school students in Los Angeles, those who had ever used e-cigarettes at baseline compared with nonusers were more likely to report initiation of combustible tobacco use over the next year. Further research is needed to understand whether this association may be causal.

      6. National and state-specific sales and prices for electronic cigarettes-U.S., 2012-2013External
        Loomis BR, Rogers T, King BA, Dench DL, Gammon DG, Fulmer EB, Agaku IT.
        Am J Prev Med. 2015 Jun 29.

        INTRODUCTION: The growing market for electronic cigarettes (e-cigarettes) has been widely reported in the media, but very little objective data exist in the scientific literature, and no data have been published on state-specific trends in prices or sales. Our objective is to assess state-specific annual sales and average prices for e-cigarettes in the U.S. METHODS: Commercial retail scanner data were used to assess total dollar sales and average price per unit for disposable e-cigarettes, starter kits, and cartridge refills for selected states and the total U.S. during 2012-2013. Data were analyzed in 2014. Data were available for convenience stores (29 states) and food, drug, and mass merchandisers (44 states). RESULTS: In convenience stores, dollar sales increased markedly during 2012-2013: 320.8% for disposable e-cigarettes, 72.4% for starter kits, and 82% for cartridges. In food, drug, and mass merchandisers, dollar sales increased 49.5% for disposable e-cigarettes, 89.4% for starter kits, and 126.2% for cartridges. Average prices across all product categories increased in convenience stores and decreased in food, drug, and mass merchandisers. Sales and prices varied substantially across states included in the analyses. CONCLUSIONS: Sales of all e-cigarette device types grew considerably in convenience stores and food, drug, and mass merchandisers during 2012-2013. The market for e-cigarettes is growing rapidly, resulting in dynamic sales and price changes that vary across the U.S. Continued state-specific surveillance of the e-cigarette market is warranted.

      7. State laws prohibiting sales to minors and indoor use of electronic nicotine delivery systems–United States, November 2014External
        Marynak K, Holmes CB, King BA, Promoff G, Bunnell R, McAfee T.
        MMWR Morb Mortal Wkly Rep. 2014 Dec 12;63(49):1145-50.

        Electronic nicotine delivery systems (ENDS), including electronic cigarettes (e-cigarettes) and other devices such as electronic hookahs, electronic cigars, and vape pens, are battery-powered devices capable of delivering aerosolized nicotine and additives to the user. Experimentation with and current use of e-cigarettes has risen sharply among youths and adults in the United States. Youth access to and use of ENDS is of particular concern given the potential adverse effects of nicotine on adolescent brain development. Additionally, ENDS use in public indoor areas might passively expose bystanders (e.g., children, pregnant women, and other nontobacco users) to nicotine and other potentially harmful constituents. ENDS use could have the potential to renormalize tobacco use and complicate enforcement of smoke-free policies. State governments can regulate the sales of ENDS and their use in indoor areas where nonusers might be involuntarily exposed to secondhand aerosol. To learn the current status of state laws regulating the sales and use of ENDS, CDC assessed state laws that prohibit ENDS sales to minors and laws that include ENDS use in conventional smoking prohibitions in indoor areas of private worksites, restaurants, and bars. Findings indicate that as of November 30, 2014, 40 states prohibited ENDS sales to minors, but only three states prohibited ENDS use in private worksites, restaurants, and bars. Of the 40 states that prohibited ENDS sales to minors, 21 did not prohibit ENDS use or conventional smoking in private worksites, restaurants, and bars. Three states had no statewide laws prohibiting ENDS sales to minors and no statewide laws prohibiting ENDS use or conventional smoking in private worksites, restaurants, and bars. According to the Surgeon General, ENDS have the potential for public health harm or public health benefit. The possibility of public health benefit from ENDS could arise only if 1) current smokers use these devices to switch completely from combustible tobacco products and 2) the availability and use of combustible tobacco products are rapidly reduced. Therefore, when addressing potential public health harms associated with ENDS, it is important to simultaneously uphold and accelerate strategies found by the Surgeon General to prevent and reduce combustible tobacco use, including tobacco price increases, comprehensive smoke-free laws, high-impact media campaigns, barrier-free cessation treatment and services, and comprehensive statewide tobacco control programs.

      8. Electronic cigarettes for smoking cessation and reductionExternal
        McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P.
        Cochrane Database Syst Rev. 2014 ;12:CD010216.

        BACKGROUND: Electronic cigarettes (ECs) are electronic devices that heat a liquid – usually comprising propylene glycol and glycerol, with or without nicotine and flavours, stored in disposable or refillable cartridges or a reservoir – into an aerosol for inhalation. Since ECs appeared on the market in 2006 there has been a steady growth in sales. Smokers report using ECs to reduce risks of smoking, but some healthcare organisations have been reluctant to encourage smokers to switch to ECs, citing lack of evidence of efficacy and safety. Smokers, healthcare providers and regulators are interested to know if these devices can reduce the harms associated with smoking. In particular, healthcare providers have an urgent need to know what advice they should give to smokers enquiring about ECs. OBJECTIVES: To examine the efficacy of ECs in helping people who smoke to achieve long-term abstinence; to examine the efficacy of ECs in helping people reduce cigarette consumption by at least 50% of baseline levels; and to assess the occurrence of adverse events associated with EC use. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Groups Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and two other databases for relevant records from 2004 to July 2014, together with reference checking and contact with study authors. SELECTION CRITERIA: We included randomized controlled trials (RCTs) in which current smokers (motivated or unmotivated to quit) were randomized to EC or a control condition, and which measured abstinence rates or changes in cigarette consumption at six months or longer. As the field of EC research is new, we also included cohort follow-up studies with at least six months follow-up. We included randomized cross-over trials and cohort follow-up studies that included at least one week of EC use for assessment of adverse events. DATA COLLECTION AND ANALYSIS: One review author extracted data from the included studies and another checked them. Our main outcome measure was abstinence from smoking after at least six months follow-up, and we used the most rigorous definition available (continuous, biochemically validated, longest follow-up). For reduction we used a dichotomous approach (no change/reduction < 50% versus reduction by 50% or more of baseline cigarette consumption). We used a fixed-effect Mantel-Haenszel model to calculate the risk ratio (RR) with a 95% confidence interval (CI) for each study, and where appropriate we pooled data from these studies in meta-analyses. MAIN RESULTS: Our search identified almost 600 records, from which we include 29 representing 13 completed studies (two RCTs, 11 cohort). We identified nine ongoing trials. Two RCTs compared EC with placebo (non-nicotine) EC, with a combined sample size of 662 participants. One trial included minimal telephone support and one recruited smokers not intending to quit, and both used early EC models with low nicotine content. We judged the RCTs to be at low risk of bias, but under the GRADE system the overall quality of the evidence for our outcomes was rated ‘low’ or ‘very low’ because of imprecision due to the small number of trials. A ‘low’ grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A ‘very low’ grade means we are very uncertain about the estimate. Participants using an EC were more likely to have abstained from smoking for at least six months compared with participants using placebo EC (RR 2.29, 95% CI 1.05 to 4.96; placebo 4% versus EC 9%; 2 studies; GRADE: low). The one study that compared EC to nicotine patch found no significant difference in six-month abstinence rates, but the confidence intervals do not rule out a clinically important difference (RR 1.26, 95% CI: 0.68 to 2.34; GRADE: very low). A higher number of people were able to reduce cigarette consumption by at least half with ECs compared with placebo ECs (RR 1.31, 95% CI 1.02 to 1.68, 2 studies; placebo: 27% versus EC: 36%; GRADE: low) and compared with patch (RR 1.41, 95% CI 1.20 to 1.67, 1 study; patch: 44% versus EC: 61%; GRADE: very low). Unlike smoking cessation outcomes, reduction results were not biochemically verified.None of the RCTs or cohort studies reported any serious adverse events (SAEs) that were considered to be plausibly related to EC use. One RCT provided data on the proportion of participants experiencing any adverse events. Although the proportion of participants in the study arms experiencing adverse events was similar, the confidence intervals are wide (ECs vs placebo EC RR 0.97, 95% CI 0.71 to 1.34; ECs vs patch RR 0.99, 95% CI 0.81 to 1.22). The other RCT reported no statistically significant difference in the frequency of AEs at three- or 12-month follow-up between the EC and placebo EC groups, and showed that in all groups the frequency of AEs (with the exception of throat irritation) decreased significantly over time. AUTHORS’ CONCLUSIONS: There is evidence from two trials that ECs help smokers to stop smoking long-term compared with placebo ECs. However, the small number of trials, low event rates and wide confidence intervals around the estimates mean that our confidence in the result is rated ‘low’ by GRADE standards. The lack of difference between the effect of ECs compared with nicotine patches found in one trial is uncertain for similar reasons. ECs appear to help smokers unable to stop smoking altogether to reduce their cigarette consumption when compared with placebo ECs and nicotine patches, but the above limitations also affect certainty in this finding. In addition, lack of biochemical assessment of the actual reduction in smoke intake further limits this evidence. No evidence emerged that short-term EC use is associated with health risk.

      9. Characteristics of Electronic Cigarette Use Among Middle and High School Students – United States, 2015External
        Singh T, Kennedy S, Marynak K, Persoskie A, Melstrom P, King BA.
        MMWR Morb Mortal Wkly Rep. 2016 Dec 30;65(5051):1425-1429.

        Electronic cigarettes (e-cigarettes) are now the most commonly used tobacco product among U.S. youths (1,2); in 2015, 5.3% of middle school students and 16.0% of high school students reported using e-cigarettes in the past 30 days (1). However, limited information exists on the e-cigarette product types and brands used and the substances used in these products by youths. CDC and the Food and Drug Administration (FDA) analyzed data from the 2015 National Youth Tobacco Survey (NYTS) to examine the characteristics of e-cigarette use among U.S. middle (grades 6-8) and high (grades 9-12) school students in 2015, including types of products used, brands of products used, and whether substances other than nicotine were used with the products. Among respondents reporting ever having used an e-cigarette, 14.5% used only disposable e-cigarettes, 53.4% used only rechargeable/refillable e-cigarettes, and 32.1% used both types. Two of the most commonly used e-cigarette brands were blu (26.4%, 1.65 million youths) and VUSE (12.2%, 760,000 youths); half of students (50.7%, 3.18 million) did not know the brand of e-cigarette they used. One third (32.5%) of those who reported ever using an e-cigarette also reported having used e-cigarettes for substances other than nicotine. Preventing youths from beginning use of any tobacco product, including e-cigarettes, is critical to tobacco use prevention and control strategies in the United States (3). Monitoring the characteristics of e-cigarette use among youths, including product types, brands, and ingredients, is important to inform strategies to prevent and reduce e-cigarette use among youths.

      10. Vital Signs: Exposure to electronic cigarette advertising among middle school and high school students – United States, 2014External
        Singh T, Marynak K, Arrazola RA, Cox S, Rolle IV, King BA.
        MMWR Morb Mortal Wkly Rep. 2016 Jan 08;64(52):1403-8.

        INTRODUCTION: Electronic cigarette (e-cigarette) use has increased considerably among U.S. youths since 2011. Tobacco use among youths in any form, including e-cigarettes, is unsafe. Tobacco product advertising can persuade youths to start using tobacco. CDC analyzed data from the 2014 National Youth Tobacco Survey to estimate the prevalence of e-cigarette advertisement exposure among U.S. middle school and high school students. METHODS: The 2014 National Youth Tobacco Survey, a school-based survey of middle school and high school students in grades 6-12, included 22,007 participants. Exposure to e-cigarette advertisements (categorized as “sometimes,” “most of the time,” or “always”) was assessed for four sources: retail stores, Internet, TV and movies, and newspapers and magazines. Weighted exposure estimates were assessed overall and by school type, sex, race/ethnicity, and grade. RESULTS: In 2014, 68.9% of middle and high school students (18.3 million) were exposed to e-cigarette advertisements from at least one source. Among middle school students, exposure was highest for retail stores (52.8%), followed by Internet (35.8%), TV and movies (34.1%), and newspapers and magazines (25.0%). Among high school students, exposure was highest for retail stores (56.3%), followed by Internet (42.9%), TV and movies (38.4%), and newspapers and magazines (34.6%). Among middle school students, 23.4% reported exposure to e-cigarette advertising from one source, 17.4% from two sources, 13.7% from three sources, and 11.9% from four sources. Among high school students, 21.1% reported exposure to e-cigarette advertising from one source, 17.0% from two sources, 14.5% from three sources, and 18.2% from four sources. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Approximately seven in 10 U.S. middle and high school students were exposed to e-cigarette advertisements in 2014. Exposure to e-cigarette advertisements might contribute to increased use of e-cigarettes among youths. Multiple approaches are warranted to reduce youth e-cigarette use and exposure to e-cigarette advertisements, including efforts to reduce youth access to settings where tobacco products, such as e-cigarettes, are sold, and regulation of youth-oriented e-cigarette marketing.

      11. DESCRIPTION: Update of the 2009 U.S. Preventive Services Task Force (USPSTF) recommendation on counseling and interventions to prevent tobacco use and tobacco-related disease in adults, including pregnant women. METHODS: The USPSTF reviewed the evidence on interventions for tobacco smoking cessation that are relevant to primary care (behavioral interventions, pharmacotherapy, and complementary or alternative therapy) in adults, including pregnant women. POPULATION: This recommendation applies to adults aged 18 years or older, including pregnant women. RECCOMENDATIONS: The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration-approved pharmacotherapy for cessation to adults who use tobacco. (A recommendation). The USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco. (A recommendation). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women. (I statement). The USPSTF concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation in adults, including pregnant women. The USPSTF recommends that clinicians direct patients who smoke tobacco to other cessation interventions with established effectiveness and safety (previously stated). (I statement).

  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. Patient navigation for colonoscopy completion: Results of an RCTExternal
        DeGroff A, Schroy PC, Morrissey KG, Slotman B, Rohan EA, Bethel J, Murillo J, Ren W, Niwa S, Leadbetter S, Joseph D.
        Am J Prev Med. 2017 Jul 01.

        INTRODUCTION: Colorectal cancer is a leading cause of cancer-related death in the U.S. Although screening reduces colorectal cancer incidence and mortality, screening rates among U.S. adults remain less than optimal, especially among disadvantaged populations. This study examined the efficacy of patient navigation to increase colonoscopy screening. STUDY DESIGN: RCT. SETTING/PARTICIPANTS: A total of 843 low-income adults, primarily Hispanic and non-Hispanic blacks, aged 50-75 years referred for colonoscopy at Boston Medical Center were randomized into the intervention (n=429) or control (n=427) groups. Participants were enrolled between September 2012 and December 2014, with analysis following through 2015. INTERVENTION: Two bilingual lay navigators provided individualized education and support to reduce patient barriers and facilitate colonoscopy completion. The intervention was delivered largely by telephone. MAIN OUTCOME MEASURE: Colonoscopy completion within 6 months of study enrollment. RESULTS: Colonoscopy completion was significantly higher for navigated patients (61.1%) than control group patients receiving usual care (53.2%, p=0.021). Based on regression analysis, the odds of completing a colonoscopy for navigated patients was one and a half times greater than for controls (95% CI=1.12, 2.03, p=0.007). There were no differences between navigated and control groups in regard to adequacy of bowel preparation (95.3% vs 97.3%, respectively). CONCLUSIONS: Navigation significantly improved colonoscopy screening completion among a racially diverse, low-income population. Results contribute to mounting evidence demonstrating the efficacy of patient navigation in increasing colorectal cancer screening. Screening can be further enhanced when navigation is combined with other evidence-based practices implemented in healthcare systems and the community.

      2. Is participation in certain sports associated with knee osteoarthritis? A systematic reviewExternal
        Driban JB, Hootman JM, Sitler MR, Harris KP, Cattano NM.
        J Athl Train. 2017 Jun 02;52(6):497-506.

        OBJECTIVE: Information regarding the relative risks of developing knee osteoarthritis (OA) as a result of sport participation is critical for shaping public health messages and for informing knee-OA prevention strategies. The purpose of this systematic review was to investigate the association between participation in specific sports and knee OA. DATA SOURCES: We completed a systematic literature search in September 2012 using 6 bibliographic databases (PubMed; Ovid MEDLINE; Journals@Ovid; American College of Physicians Journal Club; Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Review, Database of Abstracts of Reviews of Effects; and Ovid HealthStar), manual searches (4 journals), and reference lists (56 articles). STUDY SELECTION: Studies were included if they met the following 4 criteria: (1) an aim was to investigate an association between sport participation and knee OA; (2) the outcome measure was radiographic knee OA, clinical knee OA, total knee replacement, self-reported diagnosis of knee OA, or placement on a waiting list for a total knee replacement; (3) the study design was case control or cohort; and (4) the study was written in English. Articles were excluded if the study population had an underlying condition other than knee OA. DATA EXTRACTION: One investigator extracted data (eg, group descriptions, knee OA prevalence, source of nonexposed controls). DATA SYNTHESIS: The overall knee-OA prevalence in sport participants (n = 3759) was 7.7%, compared with 7.3% among nonexposed controls (referent group n = 4730, odds ratio [OR] = 1.1). Specific sports with a significantly higher prevalence of knee OA were soccer (OR = 3.5), elite-level long-distance running (OR = 3.3), competitive weight lifting (OR = 6.9), and wrestling (OR = 3.8). Elite-sport (soccer or orienteering) and nonelite-sport (soccer or American football) participants without a history of knee injury had a greater prevalence of knee OA than nonexposed participants. CONCLUSIONS: Participants in soccer (elite and nonelite), elite-level long-distance running, competitive weight lifting, and wrestling had an increased prevalence of knee OA and should be targeted for risk-reduction strategies.

      3. Invasive cancer incidence, 2004-2013, and deaths, 2006-2015, in nonmetropolitan and metropolitan counties – United StatesExternal
        Henley SJ, Anderson RN, Thomas CC, Massetti GM, Peaker B, Richardson LC.
        MMWR Surveill Summ. 2017 Jul 07;66(14):1-13.

        PROBLEM/CONDITION: Previous reports have shown that persons living in nonmetropolitan (rural or urban) areas in the United States have higher death rates from all cancers combined than persons living in metropolitan areas. Disparities might vary by cancer type and between occurrence and death from the disease. This report provides a comprehensive assessment of cancer incidence and deaths by cancer type in nonmetropolitan and metropolitan counties. REPORTING PERIOD: 2004-2015. DESCRIPTION OF SYSTEM: Cancer incidence data from CDC’s National Program of Cancer Registries and the National Cancer Institute’s Surveillance, Epidemiology, and End Results program were used to calculate average annual age-adjusted incidence rates for 2009-2013 and trends in annual age-adjusted incidence rates for 2004-2013. Cancer mortality data from the National Vital Statistics System were used to calculate average annual age-adjusted death rates for 2011-2015 and trends in annual age-adjusted death rates for 2006-2015. For 5-year average annual rates, counties were classified into four categories (nonmetropolitan rural, nonmetropolitan urban, metropolitan with population <1 million, and metropolitan with population >/=1 million). For the trend analysis, which used annual rates, these categories were combined into two categories (nonmetropolitan and metropolitan). Rates by county classification were examined by sex, age, race/ethnicity, U.S. census region, and cancer site. Trends in rates were examined by county classification and cancer site. RESULTS: During the most recent 5-year period for which data were available, nonmetropolitan rural areas had lower average annual age-adjusted cancer incidence rates for all anatomic cancer sites combined but higher death rates than metropolitan areas. During 2006-2015, the annual age-adjusted death rates for all cancer sites combined decreased at a slower pace in nonmetropolitan areas (-1.0% per year) than in metropolitan areas (-1.6% per year), increasing the differences in these rates. In contrast, annual age-adjusted incidence rates for all cancer sites combined decreased approximately 1% per year during 2004-2013 both in nonmetropolitan and metropolitan counties. INTERPRETATION: This report provides the first comprehensive description of cancer incidence and mortality in nonmetropolitan and metropolitan counties in the United States. Nonmetropolitan rural counties had higher incidence of and deaths from several cancers related to tobacco use and cancers that can be prevented by screening. Differences between nonmetropolitan and metropolitan counties in cancer incidence might reflect differences in risk factors such as cigarette smoking, obesity, and physical inactivity, whereas differences in cancer death rates might reflect disparities in access to health care and timely diagnosis and treatment. PUBLIC HEALTH ACTION: Many cancer cases and deaths could be prevented, and public health programs can use evidence-based strategies from the U.S. Preventive Services Task Force and Advisory Committee for Immunization Practices (ACIP) to support cancer prevention and control. The U.S. Preventive Services Task Force recommends population-based screening for colorectal, female breast, and cervical cancers among adults at average risk for these cancers and for lung cancer among adults at high risk; screening adults for tobacco use and excessive alcohol use, offering counseling and interventions as needed; and using low-dose aspirin to prevent colorectal cancer among adults considered to be at high risk for cardiovascular disease based on specific criteria. ACIP recommends vaccination against cancer-related infectious diseases including human papillomavirus and hepatitis B virus. The Guide to Community Preventive Services describes program and policy interventions proven to increase cancer screening and vaccination rates and to prevent tobacco use, excessive alcohol use, obesity, and physical inactivity.

      4. Prevalence of and risk factors for diabetic peripheral neuropathy in youth with type 1 and type 2 diabetes: SEARCH for Diabetes in Youth StudyExternal
        Jaiswal M, Divers J, Dabelea D, Isom S, Bell RA, Martin CL, Pettitt DJ, Saydah S, Pihoker C, Standiford DA, Dolan LM, Marcovina S, Linder B, Liese AD, Pop-Busui R, Feldman EL.
        Diabetes Care. 2017 Jul 03.

        OBJECTIVE: We assessed the prevalence of and risk factors for diabetic peripheral neuropathy (DPN) in youth with type 1 diabetes (T1D) and type 2 diabetes (T2D) enrolled in the SEARCH for Diabetes in Youth study. RESEARCH DESIGN AND METHODS: The Michigan Neuropathy Screening Instrument (MNSI) was used to assess DPN in 1,734 youth with T1D (age 18 +/- 4 years, T1D duration 7.2 +/- 1.2 years, and HbA1c 9.1 +/- 1.9%) and 258 youth with T2D (age 22.0 +/- 3.5 years, T2D duration 7.9 +/- 2 years, and HbA1c 9.4 +/- 2.3%) who were enrolled in the SEARCH study and had >/=5 years of diabetes duration. DPN was defined as an MNSI exam score of >2. Glycemic control over time was estimated as area under the curve for HbA1c. RESULTS: The prevalence of DPN was 7% in youth with T1D and 22% in youth with T2D. Risk factors for DPN in youth with T1D were older age, longer diabetes duration, smoking, increased diastolic blood pressure, obesity, increased LDL cholesterol and triglycerides, and lower HDL cholesterol (HDL-c). In youth with T2D, risk factors were older age, male sex, longer diabetes duration, smoking, and lower HDL-c. Glycemic control over time was worse among those with DPN compared with those without for youth with T1D (odds ratio 1.53 [95% CI 1.24; 1.88]) but not for youth with T2D (1.05 [0.7; 1.56]). CONCLUSIONS: The high rates of DPN among youth with diabetes are a cause of concern and suggest a need for early screening and better risk factor management. Interventions in youth that address poor glycemic control and dyslipidemia may prevent or delay debilitating neuropathic complications.

      5. The effect of intentional weight loss on fracture risk in persons with diabetes: results from the Look AHEAD Randomized Clinical TrialExternal
        Johnson KC, Bray GA, Cheskin LJ, Clark JM, Egan CM, Foreyt JP, Garcia KR, Glasser S, Greenway FL, Gregg EW, Hazuda HP, Hergenroeder A, Hill JO, Horton ES, Jakicic JM, Jeffery RW, Kahn SE, Knowler WC, Lewis CE, Miller M, Montez MG, Nathan DM, Patricio JL, Peters AL, Pi-Sunyer X, Pownall HJ, Reboussin D, Redmon JB, Steinberg H, Wadden TA, Wagenknecht LE, Wing RR, Womack CR, Yanovski SZ, Zhang P, Schwartz AV.
        J Bone Miner Res. 2017 Jul 05.

        Intentional weight loss is an important treatment option for overweight persons with type 2 diabetes mellitus (DM), but the effects on long term fracture risk are not known. The purpose of this Look AHEAD analysis was to evaluate whether long term intentional weight loss would increase fracture risk in overweight or obese persons with DM. Look AHEAD is a multicenter, randomized clinical trial. Recruitment began in August 2001 and follow-up continued for a median of 11.3 years at 16 academic centers. 5145 persons aged 45 – 76 with DM were randomized to either an intensive lifestyle intervention (ILI) with reduced calorie consumption and increased physical activity designed to achieve and maintain >/=7% weight loss or to diabetes support and education intervention (DSE). Incident fractures were ascertained every 6 months by self-report and confirmed with central adjudication of medical records.The baseline mean age of participants was 59 years, 60% were women, 63% were Caucasian, and the mean BMI was 36 kg/m2 . Weight loss over the intervention period (median 9.6 years) was 6.0% in ILI and 3.5% in DSE. 731 participants had a confirmed incident fracture (358 in DSE v. 373 in ILI). There were no statistically significant differences in incident total or hip fracture rates between the ILI and DSE groups. However, compared to the DSE group, the ILI group had a statistically significant 39% increased risk of a frailty fracture (HR = 1.39, 95% CI 1.02, 1.89).An intensive lifestyle intervention resulting in long term weight loss in overweight / obese adults with DM was not associated with an overall increased risk of incident fracture but may be associated with an increased risk of frailty fracture. When intentional weight loss is planned, consideration of bone preservation and fracture prevention is warranted. This article is protected by copyright. All rights reserved.

      6. Serum cystatin C in youth with diabetes: The SEARCH for Diabetes in Youth studyExternal
        Kanakatti Shankar R, Dolan LM, Isom S, Saydah S, Maahs DM, Dabelea D, Reynolds K, Hirsch IB, Rodriguez BL, Mayer-Davis EJ, Marcovina S, D’Agostino R, Mauer M, Mottl AK.
        Diabetes Res Clin Pract. 2017 Jun 12;130:258-265.

        AIMS: We compared cystatin C in youth with versus without diabetes and determined factors associated with cystatin C in youth with type 1 diabetes (T1D) and type 2 diabetes (T2D). METHODS: Youth (ages 12-19years) without diabetes (N=544) were ascertained from the NHANES Study 2000-2002 and those with T1D (N=977) and T2D (N=168) from the SEARCH for Diabetes in Youth Study. Adjusted means of cystatin C concentrations were compared amongst the 3 groups. Next, we performed multivariable analyses within the T1D and T2D SEARCH samples to determine the association between cystatin C and race, sex, age, diabetes duration, HbA1c, fasting glucose, and BMI. RESULTS: Adjusted cystatin C concentrations were statistically higher in NHANES (0.85mg/L) than in either the T1D (0.75mg/L) or T2D (0.70mg/L) SEARCH groups (P<0.0001). Fasting glucose was inversely related to cystatin C only in T1D (P<0.001) and BMI positively associated only in T2D (P<0.01) while HbA1c was inversely associated in both groups. CONCLUSIONS: Cystatin C concentrations are statistically higher in youth without diabetes compared to T1D or T2D, however the clinical relevance of this difference is quite small, especially in T1D. In youth with diabetes, cystatin C varies with BMI and acute and chronic glycemic control, however their effects may be different according to diabetes type.

      7. The TNM classification of malignant tumours-towards common understanding and reasonable expectationsExternal
        O’Sullivan B, Brierley J, Byrd D, Bosman F, Kehoe S, Kossary C, Pineros M, Van Eycken E, Weir HK, Gospodarowicz M.
        Lancet Oncol. 2017 Jul;18(7):849-851.

        [No abstract]

    • Communicable Diseases RSS Word feed
      1. ABSTRACT: We report a case of Neisseria gonorrhoeae with a non-mosaic penA allele that exhibited decreased susceptibility to extended-spectrum cephalosporins, including a ceftriaxone minimum inhibitory concentration of 0.5 mug/mL. An analysis of resistance determinants suggested that the observed phenotype might have resulted from the combined effects of mutations in multiple genes.

      2. Benefit of the shorter MDR TB treatment regimen in California and modified eligibility criteriaExternal
        Barry PM, Lowenthal P, True L, Henry L, Schack G, Wendorf K, Flood J, Shah N.
        Am J Respir Crit Care Med. 2017 Jun 30.

        [No abstract]

      3. Middle East Respiratory Syndrome coronavirus and childrenExternal
        Bartenfeld M, Griese S, Uyeki T, Gerber SI, Peacock G.
        Clin Pediatr (Phila). 2017 Feb;56(2):187-189.

        [No abstract]

      4. Update: Influenza activity in the United States during the 2016-17 season and composition of the 2017-18 influenza vaccineExternal
        Blanton L, Alabi N, Mustaquim D, Taylor C, Kniss K, Kramer N, Budd A, Garg S, Cummings CN, Chung J, Flannery B, Fry AM, Sessions W, Garten R, Xu X, Elal AI, Gubareva L, Barnes J, Dugan V, Wentworth DE, Burns E, Katz J, Jernigan D, Brammer L.
        MMWR Morb Mortal Wkly Rep. 2017 Jun 30;66(25):668-676.

        During the 2016-17 influenza season (October 2, 2016-May 20, 2017) in the United States, influenza activity* was moderate. Activity remained low through November, increased during December, and peaked in February nationally, although there were regional differences in the timing of influenza activity. Influenza A(H3N2) viruses predominated through mid-March and were predominant overall for the season, but influenza B viruses were most commonly reported from late March through May. This report summarizes influenza activity in the United States during October 2, 2016-May 20, 2017dagger and updates the previous summary (1).

      5. Risk of end-stage liver disease, hepatocellular carcinoma, and liver-related death by fibrosis stage in the hepatitis C Alaska CohortExternal
        Bruden DJ, McMahon BJ, Townshend-Bulson L, Gounder P, Gove J, Plotnik J, Homan C, Hewitt A, Barbour Y, Spradling PR, Simons BC, McArdle S, Bruce M.
        Hepatology. 2017 Jul;66(1):37-45.

        Long-term prospective studies of the outcomes associated with hepatitis C virus (HCV) infection are rare and critical for assessing the potential impact of HCV treatment. Using liver biopsy as a starting point, we analyzed the development of end-stage liver disease (ESLD), hepatocellular carcinoma (HCC), and liver-related death (LRD) according to fibrosis stage among a cohort of American Indian/Alaska Native persons in Alaska. Persons were classified as having no/mild (Ishak = 0,1), moderate (Ishak = 2), or severe (Ishak = 3,4) fibrosis or cirrhosis (Ishak = 5,6). We examined time until development of ESLD, HCC, and LRD and report survival probabilities at 3, 5, 7, and 10 years. Of 407 persons, 39% (n = 150) had no/mild fibrosis, 32% (n = 131) had moderate fibrosis, 22% (n = 88) had severe fibrosis, and 9% (n = 38) had cirrhosis. The average time of follow-up was 7.3 years. Within 5 years of biopsy, 1.7% (95% confidence interval [CI]: 0.4-6.8) of persons with no/mild fibrosis developed ESLD compared with 7.9% (95% CI, 4.0-15.2), 16.4% (95% CI, 9.6-27.2), and 49.0% (95% CI, 33.0-67.7) with moderate, severe fibrosis, and cirrhosis, respectively (P < 0.01). The 5-year outcome of HCC was 1.0% (95% CI, 0.1-7.0), 1.0% (95% CI, 0.1-6.6), 1.1% (95% CI, 0.2-7.7), and 13.4% (95% CI, 4.4-36.7) among persons with no/mild fibrosis, moderate fibrosis, severe fibrosis, and cirrhosis, respectively (P < 0.01). Five years after biopsy, 0.0% (95% CI, 0.0-14.8) of persons with no/mild fibrosis had suffered an LRD compared with 1.0% (95% CI, 0.2-7.5) of persons with moderate fibrosis, 4.7% (95% CI, 1.5-14.1) with severe fibrosis, and 16.3% (95% CI, 7.0-35.1) with cirrhosis (P < 0.01). CONCLUSION: For prevention of HCC, LRD, and ESLD in the short term, HCV therapy should target individuals who have more than mild fibrosis. (Hepatology 2017;66:37-45).

      6. [No abstract]

      7. BACKGROUND: Homelessness affects an estimated 1.6 million US youth annually. Compared with housed youth, homeless youth are more likely to engage in high-risk behaviors, including inconsistent condom use, multiple sex partners, survival sex, and alcohol/drug use, putting them at increased sexually transmitted disease (STD) risk. However, there is no national estimate of STD prevalence among this population. METHODS: We identified 10 peer-reviewed articles (9 unique studies) reporting STD prevalence among homeless US youth (2000-2015). Descriptive and qualitative analyses identified STD prevalence ranges and risk factors among youth. RESULTS: Eight studies reported specific STD prevalence estimates, mainly chlamydia, gonorrhea, and syphilis. Overall STD prevalence among homeless youth ranged from 6% to 32%. STD rates for girls varied from 16.7% to 46%, and from 9% to 13.1% in boys. Most studies were conducted in the Western United States, with no studies from the Southeast or Northeast. Youths who experienced longer periods of homelessness were more likely to engage in high-risk sexual behaviors. Girls had lower rates of condom use and higher rates of STDs; boys were more likely to engage in anal and anonymous sex. Additionally, peer social networks contributed to protective effects on individual sexual risk behavior. CONCLUSIONS: Sexually transmitted disease prevalence estimates among homeless youth fluctuated greatly by study. Sexually transmitted disease risk behaviors are associated with unmet survival needs, length of homelessness, and influence of social networks. To promote sexual health and reduce STD rates, we need better estimates of STD prevalence, more geographic diversity of studies, and interventions addressing the behavioral associations identified in our review.

      8. The Metropolitan Atlanta Community Adolescent Rapid Testing Initiative Study: closing the gaps in HIV care among youth in Atlanta, Georgia, USAExternal
        Camacho-Gonzalez AF, Gillespie SE, Thomas-Seaton L, Frieson K, Hussen SA, Murray A, Gaul Z, Leong T, Graves C, Sutton MY, Chakraborty R.
        Aids. 2017 Jul 01;31 Suppl 3:S267-s275.

        OBJECTIVE: To determine the effectiveness of the Metropolitan Atlanta community adolescent rapid testing initiative (MACARTI) intervention relative to standard of care (SOC), in achieving early diagnosis, linkage, and retention among HIV-infected youth ages 18-24 years. DESIGN: MACARTI was a pilot single-center, prospective, nonrandomized study. METHODS: MACARTI combined nontraditional venue HIV testing, motivational interviewing, and case management. We collected demographic, clinical variables and calculated linkage and appointment adherence rates. We obtained SOC data from an adolescent HIV clinic. Longitudinal data were analyzed using inverse propensity treatment-weighted linear growth models; medians, interquartile ranges (IQR), means, and 95% confidence intervals are provided. RESULTS: MACARTI screened 435 participants and identified 49 (11.3%) HIV infections. The SOC arm enrolled 49 new HIV-infected individuals. The 98 participants, (49 in each arm) were: 85% men; 91% Black; mean age = 21 years (SD : 1.8). Overall, 63% were linked within 3 months of diagnosis; linkage was higher for MACARTI compared to SOC (96 vs. 57%, P < 0.001). Median linkage time for MACARTI participants compared to SOC was 0.39 (IQR : 0.20-0.72) vs. 1.77 (IQR : 1.12-12.65) months (P < 0.001). MACARTI appointment adherence was higher than SOC (86.1 vs. 77.2%, P = 0.018). In weight-adjusted models, mean CD4 T-cell counts increased and mean HIV-1 RNA levels decreased in both arms over 12 months, but the differences were more pronounced in the MACARTI arm. CONCLUSION: MACARTI successfully identified and linked HIV-infected youth in Atlanta, USA. MACARTI may serve as an effective linkage and care model for clinics serving HIV-infected youth.

      9. Genetic and epidemiologic trends of norovirus outbreaks in the United States from 2013 to 2016 demonstrated emergence of novel GII.4 recombinant virusesExternal
        Cannon JL, Barclay L, Collins NR, Wikswo ME, Castro CJ, Magana LC, Gregoricus N, Marine RL, Chhabra P, Vinje J.
        J Clin Microbiol. 2017 Jul;55(7):2208-2221.

        Noroviruses are the most frequent cause of epidemic acute gastroenteritis in the United States. Between September 2013 and August 2016, 2,715 genotyped norovirus outbreaks were submitted to CaliciNet. GII.4 Sydney viruses caused 58% of the outbreaks during these years. A GII.4 Sydney virus with a novel GII.P16 polymerase emerged in November 2015, causing 60% of all GII.4 outbreaks in the 2015-2016 season. Several genotypes detected were associated with more than one polymerase type, including GI.3, GII.2, GII.3, GII.4 Sydney, GII.13, and GII.17, four of which harbored GII.P16 polymerases. GII.P16 polymerase sequences associated with GII.2 and GII.4 Sydney viruses were nearly identical, suggesting common ancestry. Other common genotypes, each causing 5 to 17% of outbreaks in a season, included GI.3, GI.5, GII.2, GII.3, GII.6, GII.13, and GII.17 Kawasaki 308. Acquisition of alternative RNA polymerases by recombination is an important mechanism for norovirus evolution and a phenomenon that was shown to occur more frequently than previously recognized in the United States. Continued molecular surveillance of noroviruses, including typing of both polymerase and capsid genes, is important for monitoring emerging strains in our continued efforts to reduce the overall burden of norovirus disease.

      10. Water quality survey of splash pads after a waterborne salmonellosis outbreak – Tennessee, 2014External
        Clayton JL, Manners J, Miller S, Shepherd C, Dunn JR, Schaffner W, Jones TF.
        J Environ Health. 2017 ;79(10):8-13.

        Waterborne outbreaks of salmonellosis are uncommon. The Tennessee Department of Health investigated a salmonellosis outbreak of 10 cases with the only common risk factor being exposure to a single splash pad. Risks included water splashed in the face at the splash pad and no free residual chlorine in the water system. We surveyed water quality and patron behaviors at splash pads statewide. Of the 29 splash pads participating in the water quality survey, 24 (83%) used a recirculating water system. Of the 24, 5 (21%) water samples were tested by polymerase chain reaction and found to be positive for E. coli, Giardia, norovirus, or Salmonella. Among 95 patrons observed, we identified common high-risk behaviors of sitting on the fountain or spray head and putting mouth to water. Water venue regulations and improved education of patrons are important to aid prevention efforts.

      11. Cryptosporidiosis outbreak associated with a single hotelExternal
        Fill MM, Lloyd J, Chakraverty T, Sweat D, Manners J, Garman K, Hlavsa MC, Roellig D, Dunn JR, Schaffner W, Jones TF.
        J Environ Health. 2017 ;79(9):16-23.

        We investigated a gastrointestinal illness cluster among persons who attended a baseball tournament (>200 teams) during July 2015. We interviewed representatives of 19 teams; illness was reported among only the 9 (47%) teams that stayed at Hotel A (p<.01). We identified 55 primary cases. A case-control study demonstrated that pool exposure at Hotel A was significantly associated with illness (odds ratio: 7.3; 95% confidence interval: 3.6, 15.2). Eight out of nine (89%) stool specimens tested were positive for Cryptosporidium, with C. hominis IfA12 G1 subtype identified in two specimens. The environmental health assessment detected a low free available chlorine level, and pool water tested positive for E. coli and total coliforms. A possible diarrheal contamination event, substantial hotel pool use, and use of cyanuric acid might have contributed to this outbreak and magnitude. Aquatic facilities practicing proper operation and maintenance (e.g., following the Centers for Disease Control and Prevention’s Model Aquatic Health Code) can protect the public’s health.

      12. BACKGROUND: Concurrent male-male sexual partnerships have been understudied in sub-Saharan Africa and are especially important because human immunodeficiency virus (HIV) prevalence and acquisition probability are higher among men who have sex with men (MSM) than among heterosexual men and women. METHODS: We conducted a respondent-driven sampling survey of 552 men who have sex with men in Bamako, Mali from October 2014 to February 2015. Eligibility criteria included 18 years or older, history of oral or anal sex with another man in the last 6 months, residence in or around Bamako in the last 6 months, ability to communicate in French. RESULTS: HIV prevalence was 13.7%, with 86.7% of MSM with HIV unaware of their infection. Concurrent male-male sexual partnerships were common, with 60.6% of MSM having a concurrent male sexual partnerships or believing their sex partner did in the last 6 months, and 27.3% having a concurrent male sexual partnerships and believing their sex partner did in the last 6 months. Over half (52.5%) of MSM had sex with women, and 30.8% had concurrent male partnerships and sex with a woman in the last 6 months. Concurrency was more likely among MSM with limited education, telling only MSM of same-sex behaviors, high social cohesion, and not knowing anyone with HIV. CONCLUSIONS: The high proportion of HIV-infected MSM in Bamako who are unaware of their HIV infection and the high prevalence of concurrent partnerships could further the spread of HIV in Bamako. Increasing testing through peer educators conducting mobile testing could improve awareness of HIV status and limit the spread of HIV in concurrent partnerships.

      13. Recombinant GII.P16-GII.2 norovirus, Taiwan, 2016External
        Liu LT, Kuo TY, Wu CY, Liao WT, Hall AJ, Wu FT.
        Emerg Infect Dis. 2017 Jul;23(7):1180-1183.

        In Taiwan, acute gastroenteritis outbreaks caused by a new norovirus genotype GII.2 increased sharply toward the end of 2016. Unlike previous outbreaks, which often involved restaurants, GII.2 outbreaks mainly occurred in schools. Phylogenetic analysis indicates that these noroviruses are recombinant GII.P16-GII.2 strains.

      14. Association of GII.P16-GII.2 recombinant norovirus strain with increased norovirus outbreaks, Guangdong, China, 2016External
        Lu J, Fang L, Sun L, Zeng H, Li Y, Zheng H, Wu S, Yang F, Song T, Lin J, Ke C, Zhang Y, Vinje J, Li H.
        Emerg Infect Dis. 2017 Jul;23(7):1188-1190.

        An unusual prevalence of recombinant GII.2 noroviruses (GII.P16-GII.2) in Guangdong, China, at the end of 2016 caused a sharp increase in outbreaks of acute gastroenteritis. This event was another non-GII.4 epidemic that emerged after the GII.17 viruses in 2014 and 2015 and warrants global surveillance.

      15. HIV testing in nonhealthcare facilities among adolescent MSMExternal
        Marano MR, Stein R, Williams WO, Wang G, Xu S, Uhl G, Cheng Q, Rasberry CN.
        Aids. 2017 Jul 01;31 Suppl 3:S261-s265.

        OBJECTIVES: To describe the extent to which Centers for Disease Control and Prevention (CDC)-funded HIV testing in nonhealthcare facilities reaches adolescent MSM, identifies new HIV infections, and links those newly diagnosed to medical care. METHODS/DESIGN: We describe HIV testing, newly diagnosed positivity, and linkage to medical care for adolescent MSM who received a CDC-funded HIV test in a nonhealthcare facility in 2015. We assess outcomes by race/ethnicity, HIV-related risk behaviors, and US geographical region. RESULTS: Of the 703 890 CDC-funded HIV testing events conducted in nonhealthcare facilities in 2015, 6848 (0.9%) were provided to adolescent MSM aged 13-19 years. Among those tested, 1.8% were newly diagnosed with HIV, compared with 0.7% among total tests provided in nonhealthcare facilities regardless of age and sex. The odds of testing positive among black adolescent MSM were nearly four times that of white adolescent MSM in multivariable analysis (odds ratio = 3.97, P < 0.001). Among adolescent MSM newly diagnosed with HIV, 67% were linked to HIV medical care. Linkage was lower among black (59%) and Hispanic/Latino adolescent MSM (71%) compared with white adolescent MSM (88%). CONCLUSION: CDC-funded nonhealthcare facilities can reach and provide HIV tests to adolescent MSM and identify new HIV infections; however, given the low rate of HIV testing overall and high engagement in HIV-related risk behaviors, there are opportunities to increase access to HIV testing and linkage to care for HIV-positive adolescent MSM. Efforts are needed to identify and address the barriers that prevent black and Hispanic/Latino adolescent MSM from being linked to HIV medical care in a timely manner.

      16. Cervical cancer screening and prevention in 78 sexually transmitted disease clinics – United States, 2014-2015External
        McGinnis E, Meyerson BE, Meites E, Saraiya M, Griesse R, Snoek E, Haderxhanaj L, Markowitz LE, Smith W.
        Sex Transm Dis. 2017 ;19.

        BACKGROUND: Human papillomavirus (HPV) infections cause approximately 30,700 cancers annually among US men and women, cervical cancer being the most common. Human papillomavirus vaccination is recommended routinely for US girls and boys at age 11 to 12 years, and for those not previously vaccinated, through age 26 and 21 years for women and men, respectively. Our objective was to assess current cervical cancer screening and HPV vaccination practices among sexually transmitted disease (STD) clinics in the United States. METHODS: We surveyed a geographically diverse convenience sample of US STD clinics identified by members of the National Coalition of STD Directors within 65 state, territorial, and local jurisdictions. An online multiple-choice survey about clinical services was administered to clinic directors or designees during October 2014 to February 2015. RESULTS: Survey respondents included 78 clinics from 46 states and territories. Of these clinics, 31 (39.7%) offered both cervical cancer screening and HPV vaccination, 6 (7.7%) offered cervical cancer screening only, 21 (26.9%) offered HPV vaccination only, and 20 (25.6%) offered neither cervical cancer prevention service. Among those not offering the service, the most commonly reported barrier to cervical cancer screening was time constraints (25/41, 61.0%); for HPV vaccination it was reimbursement (11/26, 42.3%). CONCLUSIONS: By early 2015, in a geographically diverse group of 78 STD clinics, 39.7% provided nationally recommended HPV vaccination and cervical cancer screening, whereas 25.6% provided neither. Further research could identify strategies for STD clinics to reduce HPV-associated cancers by increasing provision of HPV vaccination and cervical cancer screening services, particularly among medically underserved populations.

      17. Cryptococcal meningitis: A neglected NTD?External
        Molloy SF, Chiller T, Greene GS, Burry J, Govender NP, Kanyama C, Mfinanga S, Lesikari S, Mapoure YN, Kouanfack C, Sini V, Temfack E, Boulware DR, Dromer F, Denning DW, Day J, Stone NR, Bicanic T, Jarvis JN, Lortholary O, Harrison TS, Jaffar S, Loyse A.
        PLoS Negl Trop Dis. 2017 Jun;11(6):e0005575.

        [No abstract]

      18. Respiratory syncytial virus in adults with severe acute respiratory illness in a high HIV prevalence settingExternal
        Moyes J, Walaza S, Pretorius M, Groome M, von Gottberg A, Wolter N, Haffejee S, Variava E, Cohen AL, Tempia S, Kahn K, Dawood H, Venter M, Cohen C, Madhi SA.
        J Infect. 2017 Jul 01.

        BACKGROUND: There are limited data on the epidemiology of respiratory syncytial virus (RSV) illness in HIV-infected adults or the elderly in Africa. We studied the epidemiology of RSV-associated severe acute respiratory illness (SARI) hospitalizations in adults in South Africa from 2009 through 2013. METHODS: Individuals admitted to sentinel surveillance hospitals were investigated by respiratory tract swabs for RSV, using a multiplex real-time polymerase chain reaction assay. The incidence of RSV-associated SARI was calculated for the one site with population denominators. RESULTS: Of 7796 participants investigated, 329 (4%) tested positive for RSV. On multivariable analysis, HIV-infected individuals with RSV-associated SARI had greater odds of being in the age groups 18-44 and 45-64 years (odd ratios (OR) 26.3; 95% confidence interval (CI) 6.2-112.1 and OR 11.4; 95% CI 2.6-50.0) compared with those >/=65 years and being female (OR 2.7; 95% CI 1.4-5.4). The relative risk of hospitalization with RSV-associated SARI was 12 to 18 times higher in HIV infected individual compared to that of HIV-uninfected. CONCLUSION: The incidence of RSV-associated SARI was higher in HIV-infected individuals and those aged 65 years and older. Further studies are warranted to describe the disease association of RSV detected in adults with SARI.

      19. Antiretroviral prescription and viral suppression in a representative sample of HIV-infected persons in care in four large metropolitan areas of the United States, Medical Monitoring Project, 2011[FIGURE DASH]2013External
        Wohl AR, Benbow N, Tejero J, Johnson C, Scheer S, Brady K, Gagner A, Hughes A, Eberhart M, Mattson C, Skarbinski J.
        J Acquir Immune Defic Syndr. 2017 Jun 15.

        BACKGROUND: Comparisons of ART prescription and viral suppression among people in HIV care across U.S. metropolitan areas are limited. 2011-2013 Medical Monitoring Project data were used to describe and compare associations between socio-demographics and ART prescription and viral suppression for persons receiving HIV care. SETTING: Chicago, Los Angeles County (LAC), Philadelphia, and San Francisco in the United States. METHODS: Bivariate and multivariable methods were used. RESULTS: The proportion of patients prescribed ART (91-93%) and virally suppressed (79-88%) was consistent although more persons were virally suppressed in San Francisco compared to the other areas, and a smaller proportion was virally suppressed in Philadelphia compared to Chicago. In the combined cohort, persons ages 30-49 (aPR=0.97, CI:0.94-0.99) were less likely than persons 50+, persons reporting non-injection drug use (aPR=0.94, CI:0.90-0.98) were less likely than non-users, and Hispanics were more likely than whites (aPR=1.04, CI:1.01-1.08) to be prescribed ART. Blacks (aPR=0.93; CI:0.87-0.99) and homeless persons (aPR=0.87; CI:0.80-0.95) were less likely to be virally suppressed in the combined cohort. In LAC, persons 30-49 were less likely than those 50+ to be prescribed ART (aPR=0.94, CI:0.90-0.98). Younger persons (18-29) (aPR=0.77; CI:0.60-0.99) and persons with less than a high school education (aPR=0.80; CI:0.67-0.95) in Philadelphia, blacks (aPR=0.90; CI:0.83-0.99) and MSW (aPR=0.89; CI:0.80-0.99) in Chicago, and homeless individuals in LAC (aPR=0.80; CI:0.67-0.94) were less likely to be virally suppressed. CONCLUSION: Data highlight the need to increase ART prescription to achieve viral suppression among younger persons, non-injection drug users, blacks, and homeless persons in U.S. metropolitan areas and underscores the importance of region-specific strategies for affected sub-groups.

      20. Outbreak of non-tuberculous mycobacteria skin or soft tissue infections associated with handling fish – New York City, 2013-2014External
        Yacisin K, Hsieh JL, Weiss D, Ackelsberg J, Lee E, Jones L, Leung YL, Li L, Yung J, Slavinski S, Hanson H, Ridpath A, Kornblum J, Lin Y, Robbe-Austerman S, Rakeman J, Siemetzki-Kapoor U, Stuber T, Greene SK.
        Epidemiol Infect. 2017 Jun 20:1-11.

        Mycobacterium marinum, a bacterium found in freshwater and saltwater, can infect persons with direct exposure to fish or aquariums. During December 2013, the New York City Department of Health and Mental Hygiene learned of four suspected or confirmed M. marinum skin or soft tissue infections (SSTIs) among persons who purchased whole fish from Chinese markets. Ninety-eight case-patients with non-tuberculous mycobacteria (NTM) SSTIs were identified with onset June 2013-March 2014. Of these, 77 (79%) were female. The median age was 62 years (range 30-91). Whole genome sequencing of clinical isolates revealed two main clusters and marked genetic diversity. Environmental samples from distributors yielded NTM though not M. marinum. We compared 56 case-patients with 185 control subjects who shopped in Chinese markets, frequency-matched by age group and sex. Risk factors for infection included skin injury to the finger or hand (odds ratio [OR]: 15.5; 95% confidence interval [CI]: 6.9-37.3), hand injury while preparing fish or seafood (OR 8.3; 95% CI 3.8-19.1), and purchasing tilapia (OR 3.6; 95% CI 1.1-13.9) or whiting (OR 2.7; 95% CI 1.1-6.6). A definitive environmental outbreak source was not identified.

    • Disaster Control and Emergency Services RSS Word feed
      1. United States notifications of travelers from Ebola-affected countriesExternal
        Kohl KS, Philen R, Arthur RR, Dott M, Avchen RN, Shaw KM, Glover MJ, Daley WR.
        Health Secur. 2017 May/Jun;15(3):261-267.

        The International Health Regulations (IHR), an international law under the auspices of the World Health Organization (WHO), mandates that countries notify other countries of “travelers under public health observation.” Between November 10, 2014, and July 12, 2015, the US Centers for Disease Control and Prevention (CDC) made 2,374 notifications to the National IHR Focal Points in 114 foreign countries of travelers who were monitored by US health departments because they had been to an Ebola-affected country in West Africa. Given that countries have preidentified focal points as points of contacts for sharing of public health information, notifications could be made by CDC to a trusted public health recipient in another country within 24 hours of receipt of the traveler’s information from a US health department. The majority of US health departments used this process, offered by CDC, to notify other countries of travelers intending to leave the United States while being monitored in their jurisdiction.

      2. Evacuations as a result of Hurricane Sandy: Analysis of the 2014 New Jersey Behavioral Risk Factor SurveyExternal
        Kulkarni PA, Gu H, Tsai S, Passannante M, Kim S, Thomas PA, Tan CG, Davidow AL.
        Disaster Med Public Health Prep. 2017 Jun 29:1-9.

        OBJECTIVE: We characterized evacuations related to Hurricane Sandy, which made landfall in New Jersey on October 29, 2012. METHODS: We analyzed data from the 2014 New Jersey Behavioral Risk Factor Survey. The proportion of respondents reporting evacuation was used to estimate the number of New Jersey adults who evacuated. We determined evacuation rates in heavily impacted and less-impacted municipalities, as well as evacuation rates for municipalities under and not under mandatory evacuation orders. We tested associations between demographic and health factors, such as certain chronic health conditions, and evacuation. RESULTS: Among respondents, 12.7% (95% CI: 11.8%-13.6%) reported evacuating, corresponding to approximately 880,000 adults. In heavily impacted municipalities, 17.0% (95% CI: 15.2%-18.7%) evacuated, compared with 10.1% (95% CI: 9.0%-11.2%) in less-impacted municipalities. In municipalities under mandatory evacuation orders, 42.5% (95% CI: 35.1%-49.8%) evacuated, compared with 11.8% (95% CI: 10.9%-12.9%) in municipalities not under mandatory orders. Female gender (odds ratio [OR]: 1.36; 95% CI: 1.14-1.64), unmarried status (OR: 1.22; 95% CI: 1.02-1.46), shorter length of residence (OR: 1.28; 95% CI: 1.03-1.60), and living in a heavily impacted municipality (OR: 1.84; 95% CI: 1.54-2.20) were significantly associated with evacuation. History of stroke (OR: 1.61; 95% CI: 1.02-2.53) was the only chronic condition associated with evacuation. CONCLUSIONS: Approximately 880,000 New Jersey adults evacuated because of Hurricane Sandy. Those in heavily impacted municipalities and municipalities under mandatory evacuation orders had higher evacuation rates; however, still fewer than half evacuated. These findings can be used for future disaster planning. (Disaster Med Public Health Preparedness. 2017;page 1 of 9).

      3. Personal protective equipment supply chain: Lessons learned from recent public health emergency responsesExternal
        Patel A, D’Alessandro MM, Ireland KJ, Burel WG, Wencil EB, Rasmussen SA.
        Health Secur. 2017 May/Jun;15(3):244-252.

        Personal protective equipment (PPE) that protects healthcare workers from infection is a critical component of infection control strategies in healthcare settings. During a public health emergency response, protecting healthcare workers from infectious disease is essential, given that they provide clinical care to those who fall ill, have a high risk of exposure, and need to be assured of occupational safety. Like most goods in the United States, the PPE market supply is based on demand. The US PPE supply chain has minimal ability to rapidly surge production, resulting in challenges to meeting large unexpected increases in demand that might occur during a public health emergency. Additionally, a significant proportion of the supply chain is produced off-shore and might not be available to the US market during an emergency because of export restrictions or nationalization of manufacturing facilities. Efforts to increase supplies during previous public health emergencies have been challenging. During the 2009 H1N1 influenza pandemic and the 2014 Ebola virus epidemic, the commercial supply chain of pharmaceutical and healthcare products quickly became critical response components. This article reviews lessons learned from these responses from a PPE supply chain and systems perspective and examines ways to improve PPE readiness for future responses.

    • Disease Reservoirs and Vectors RSS Word feed
      1. Mosquitoes on a plane: Disinsection will not stop the spread of vector-borne pathogens, a simulation studyExternal
        Mier-y-Teran-Romero L, Tatem AJ, Johansson MA.
        PLoS Negl Trop Dis. 2017 Jul 03;11(7):e0005683.

        Mosquito-borne diseases are increasingly being recognized as global threats, with increased air travel accelerating their occurrence in travelers and their spread to new locations. Since the early days of aviation, concern over the possible transportation of infected mosquitoes has led to recommendations to disinsect aircraft. Despite rare reports of mosquitoes, most likely transported on aircraft, infecting people far from endemics areas, it is unclear how important the role of incidentally transported mosquitoes is compared to the role of traveling humans. We used data for Plasmodium falciparum and dengue viruses to estimate the probability of introduction of these pathogens by mosquitoes and by humans via aircraft under ideal conditions. The probability of introduction of either pathogen by mosquitoes is low due to few mosquitoes being found on aircraft, low infection prevalence among mosquitoes, and high mortality. Even without disinsection, introduction via infected human travelers was far more likely than introduction by infected mosquitoes; more than 1000 times more likely for P. falciparum and more than 200 times more likely for dengue viruses. Even in the absence of disinsection and under the most favorable conditions, introduction of mosquito-borne pathogens via air travel is far more likely to occur as a result of an infected human travelling rather than the incidental transportation of infected mosquitoes. Thus, while disinsection may serve a role in preventing the spread of vector species and other invasive insects, it is unlikely to impact the spread of mosquito-borne pathogens.

    • Drug Safety RSS Word feed
      1. Vital Signs: Changes in opioid prescribing in the United States, 2006-2015External
        Guy GP, Zhang K, Bohm MK, Losby J, Lewis B, Young R, Murphy LB, Dowell D.
        MMWR Morb Mortal Wkly Rep. 2017 Jul 07;66(26):697-704.

        BACKGROUND: Prescription opioid-related overdose deaths increased sharply during 1999-2010 in the United States in parallel with increased opioid prescribing. CDC assessed changes in national-level and county-level opioid prescribing during 2006-2015. METHODS: CDC analyzed retail prescription data from QuintilesIMS to assess opioid prescribing in the United States from 2006 to 2015, including rates, amounts, dosages, and durations prescribed. CDC examined county-level prescribing patterns in 2010 and 2015. RESULTS: The amount of opioids prescribed in the United States peaked at 782 morphine milligram equivalents (MME) per capita in 2010 and then decreased to 640 MME per capita in 2015. Despite significant decreases, the amount of opioids prescribed in 2015 remained approximately three times as high as in 1999 and varied substantially across the country. County-level factors associated with higher amounts of prescribed opioids include a larger percentage of non-Hispanic whites; a higher prevalence of diabetes and arthritis; micropolitan status (i.e., town/city; nonmetro); and higher unemployment and Medicaid enrollment. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Despite reductions in opioid prescribing in some parts of the country, the amount of opioids prescribed remains high relative to 1999 levels and varies substantially at the county-level. Given associations between opioid prescribing, opioid use disorder, and overdose rates, health care providers should carefully weigh the benefits and risks when prescribing opioids outside of end-of-life care, follow evidence-based guidelines, such as CDC’s Guideline for Prescribing Opioids for Chronic Pain, and consider nonopioid therapy for chronic pain treatment. State and local jurisdictions can use these findings combined with Prescription Drug Monitoring Program data to identify areas with prescribing patterns that place patients at risk for opioid use disorder and overdose and to target interventions with prescribers based on opioid prescribing guidelines.

    • Environmental Health RSS Word feed
      1. Paternal and maternal urinary phthalate metabolite concentrations and birth weight of singletons conceived by subfertile couplesExternal
        Messerlian C, Braun JM, Minguez-Alarcon L, Williams PL, Ford JB, Mustieles V, Calafat AM, Souter I, Toth T, Hauser R.
        Environ Int. 2017 Jun 27;107:55-64.

        BACKGROUND: Prenatal phthalate exposure has been inconsistently associated with fetal growth and infant birth weight. However, the effect of exposure during the paternal and maternal preconception period remains understudied. OBJECTIVES: To investigate associations of paternal and maternal preconception and maternal prenatal urinary phthalate metabolite concentrations with birth weight. METHODS: The study comprised 364 singletons born to 364 mothers and 195 fathers (195 couples) from the EARTH Study, a prospective cohort of couples from Boston, MA. Births were categorized by mode of conception: in-vitro fertilization based (IVF) (n=208) or non-IVF based (n=156, intrauterine insemination or non-medically assisted/natural conception). We measured urinary concentrations of eleven phthalate metabolites in maternal (n=1425) and paternal (n=489) preconception and maternal prenatal (n=781) samples. Birth weight was abstracted from delivery records. Covariate-adjusted associations between loge-phthalate metabolite concentrations and birth weight were evaluated separately by mode of conception using multivariable linear regression. RESULTS: Each loge-unit increase in paternal urinary concentration of the sum of di(2-ethylhexyl) phthalate (SigmaDEHP) metabolites was associated with a 90 gram (95% CI: -165, -15) decrease in birth weight among IVF singletons, but not among non-IVF singletons (18g; 95% CI: -76, 113). Additional adjustment for maternal prenatal SigmaDEHP concentrations modestly strengthened findings among IVF singletons. While few associations were found with maternal preconception phthalate metabolites, we observed an inverse relationship between several maternal prenatal urinary phthalate metabolite concentrations and birth weight among IVF singletons in covariate-adjusted models. However, with further adjustment for specific paternal phthalate metabolite concentrations, these associations were attenuated and no longer significant. CONCLUSIONS: Paternal preconception urinary concentration of SigmaDEHP metabolites was associated with a decrease in birth weight among IVF-conceived singletons. These results, if replicated, highlight the importance of preconception health, especially among subfertile couples.

      2. Perfluoroalkyl substances during pregnancy and offspring weight and adiposity at birth: Examining mediation by maternal fasting glucose in the Healthy Start StudyExternal
        Starling AP, Adgate JL, Hamman RF, Kechris K, Calafat AM, Ye X, Dabelea D.
        Environ Health Perspect. 2017 Jun 26;125(6):067016.

        BACKGROUND: Certain perfluoroalkyl and polyfluoroalkyl substances (PFAS) are widespread, persistent environmental contaminants. Prenatal PFAS exposure has been associated with lower birth weight; however, impacts on body composition and factors responsible for this association are unknown. OBJECTIVES: We aimed to estimate associations between maternal PFAS concentrations and offspring weight and adiposity at birth, and secondarily to estimate associations between PFAS concentrations and maternal glucose and lipids, and to evaluate the potential for these nutrients to mediate associations between PFAS and neonatal outcomes. METHODS: Within the Healthy Start prospective cohort, concentrations of 11 PFAS, fasting glucose, and lipids were measured in maternal mid-pregnancy serum (). Infant body composition was measured using air displacement plethysmography. Associations between PFAS and birth weight and adiposity, and between PFAS and maternal glucose and lipids, were estimated via linear regression. Associations were decomposed into direct and indirect effects. RESULTS: Five PFAS were detectable in of participants. Maternal perfluorooctanoate (PFOA) and perfluorononanoate (PFNA) concentrations were inversely associated with birth weight. Adiposity at birth was approximately 10% lower in the highest categories of PFOA, PFNA, and perfluorohexane sulfonate (PFHxS) compared to the lowest categories. PFOA, PFNA, perfluorodecanoate (PFDeA), and PFHxS were inversely associated with maternal glucose. Up to 11.6% of the effect of PFAS on neonatal adiposity was mediated by maternal glucose concentrations. Perfluorooctane sulfonate (PFOS) was not significantly associated with any outcomes studied. CONCLUSIONS: Follow-up of offspring will determine the potential long-term consequences of lower weight and adiposity at birth associated with prenatal PFAS exposure.

    • Epidemiology and Surveillance RSS Word feed
      1. Surveillance among men who have sex with men in the United States: A comparison of web-based and venue-based samplesExternal
        Chen YT, Bowles K, An Q, DiNenno E, Finlayson T, Hoots B, Paz-Bailey G, Wejnert C.
        AIDS Behav. 2017 Jul 04.

        Although men who have sex with men (MSM) recruited through web-based and venue-based sampling methods have been compared, no large web-based and venue-based samples using similar survey instruments have been examined in the U.S. This study describes the differences in sociodemographic characteristics and risk behaviors between the 2012 Web-based HIV Behavioral Survey (n = 3221) and 2011 National HIV Behavioral Surveillance (n = 9256). Compared with participants in the venue-based sample, participants in the web-based sample were older, less likely to be black or Hispanic, more likely to have higher socioeconomic status, and more likely to have anal sex without a condom with their last male sex partner. Web-based participants were less likely to have multiple male sex partners, ever injected drugs, been tested for HIV in the past 12 months, and received free condoms than venue-based participants. The method for sampling MSM into a behavioral survey should consider the sub-population of MSM to be reached.

    • Food Safety RSS Word feed
      1. Fish-associated foodborne disease outbreaks: United States, 1998-2015External
        Barrett KA, Nakao JH, Taylor EV, Eggers C, Gould LH.
        Foodborne Pathog Dis. 2017 Jul 06.

        Each year in the United States, approximately 260,000 people get sick from contaminated fish. Fish is also the most commonly implicated food category in outbreaks. We reviewed the Centers for Disease Control and Prevention Foodborne Disease Outbreak Surveillance System for outbreaks resulting from consumption of fish during the period 1998-2015. We found 857 outbreaks associated with fish, resulting in 4815 illnesses, 359 hospitalizations, and 4 deaths. The median number of illnesses per outbreak was three (range: 2-425). The annual number of fish-associated outbreaks declined from an average of 62 per year during the period 1998-2006 to 34 per year during the period 2007-2015. Hawaii (221 outbreaks [26%]) and Florida (203 [24%]) reported the most outbreaks. Among 637 outbreaks (74%) with a confirmed etiology, scombrotoxin (349 [55%]) and ciguatoxin (227 [36%]) were by far most common. Most outbreak-associated illnesses were caused by scombrotoxin (1299 [34%]), Salmonella (978 [26%]), and ciguatoxin (894 [23%]). Most hospitalizations were caused by Salmonella (97 [31%]) and ciguatoxin (96 [31%]). Norovirus (105 average illnesses; range: [6-380]) and Salmonella (54 [3-425]) caused the largest outbreaks. Fish types implicated most often were tuna (37%), mahi-mahi (10%), and grouper (9%). The etiology-fish pairs responsible for the most outbreaks were scombrotoxin and tuna (223 outbreaks), scombrotoxin and mahi-mahi (64), and ciguatoxin and grouper (54). The pairs responsible for the most illnesses were scombrotoxin and tuna (720 illnesses) and Salmonella and tuna (660). Of the 840 outbreaks (98%) with a single location of food preparation, 52% were associated with fish prepared in a restaurant and 33% with fish prepared in a private home. Upstream control measures targeted to the most common etiologies and controls during processing and preparation could further reduce outbreaks caused by fish.

      2. Multistate outbreak of Salmonella anatum infections linked to imported hot peppers – United States, May-July 2016External
        Hassan R, Rounds J, Sorenson A, Leos G, Concepcion-Acevedo J, Griswold T, Tesfai A, Blessington T, Hardy C, Basler C.
        MMWR Morb Mortal Wkly Rep. 2017 Jun 30;66(25):663-667.

        Foodborne salmonellosis causes an estimated 1 million illnesses and 400 deaths annually in the United States (1). Salmonella Anatum is one of the top 20 Salmonella serotypes in the United States. During 2013-2015 there were approximately 300-350 annual illnesses reported to PulseNet, the national molecular subtyping network for foodborne disease surveillance. In June 2016, PulseNet identified a cluster of 16 Salmonella Anatum infections with an indistinguishable pulsed-field gel electrophoresis (PFGE) pattern from four states.* In April 2016, the same PFGE pattern had been uploaded to PulseNet from an isolate obtained from an Anaheim pepper, a mild to medium hot pepper. Hot peppers include many pepper varieties, such as Anaheim, jalapeno, poblano, and serrano, which can vary in heat level from mild to very hot depending on the variety and preparation. This rare PFGE pattern had been seen only 24 times previously in the PulseNet database, compared with common PFGE patterns for this serotype which have been seen in the database hundreds of times. Local and state health departments, CDC, and the Food and Drug Administration (FDA) investigated to determine the cause of the outbreak. Thirty-two patients in nine states were identified with illness onsets from May 6-July 9, 2016. Whole-genome sequencing (WGS) was performed to characterize clinical isolates and the Anaheim pepper isolate further. The combined evidence indicated that fresh hot peppers were the likely source of infection; however, a single pepper type or source farm was not identified. This outbreak highlights challenges in reconciling epidemiologic and WGS data, and the difficulties of identifying ingredient-level exposures through epidemiologic investigations alone.

      3. PulseNet International: Vision for the implementation of whole genome sequencing (WGS) for global food-borne disease surveillanceExternal
        Nadon C, Van Walle I, Gerner-Smidt P, Campos J, Chinen I, Concepcion-Acevedo J, Gilpin B, Smith AM, Man Kam K, Perez E, Trees E, Kubota K, Takkinen J, Nielsen EM, Carleton H.
        Euro Surveill. 2017 Jun 08;22(23).

        PulseNet International is a global network dedicated to laboratory-based surveillance for food-borne diseases. The network comprises the national and regional laboratory networks of Africa, Asia Pacific, Canada, Europe, Latin America and the Caribbean, the Middle East, and the United States. The PulseNet International vision is the standardised use of whole genome sequencing (WGS) to identify and subtype food-borne bacterial pathogens worldwide, replacing traditional methods to strengthen preparedness and response, reduce global social and economic disease burden, and save lives. To meet the needs of real-time surveillance, the PulseNet International network will standardise subtyping via WGS using whole genome multilocus sequence typing (wgMLST), which delivers sufficiently high resolution and epidemiological concordance, plus unambiguous nomenclature for the purposes of surveillance. Standardised protocols, validation studies, quality control programmes, database and nomenclature development, and training should support the implementation and decentralisation of WGS. Ideally, WGS data collected for surveillance purposes should be publicly available, in real time where possible, respecting data protection policies. WGS data are suitable for surveillance and outbreak purposes and for answering scientific questions pertaining to source attribution, antimicrobial resistance, transmission patterns, and virulence, which will further enable the protection and improvement of public health with respect to food-borne disease.

      4. Two outbreaks of trichinellosis linked to consumption of walrus meat – Alaska, 2016-2017External
        Springer YP, Casillas S, Helfrich K, Mocan D, Smith M, Arriaga G, Mixson L, Castrodale L, McLaughlin J.
        MMWR Morb Mortal Wkly Rep. 2017 Jul 07;66(26):692-696.

        During 1975-2012, CDC surveillance identified 1,680 trichinellosis cases in the United States with implicated food items; among these cases, 1,219 were attributed to consumption of raw or pork products, and 461 were attributed to nonpork products. Although trichinellosis in the United States has historically been associated with consumption of pork, multiple nonporcine species of wild game also are competent hosts for Trichinella spp. and have been collectively implicated in the majority of trichinellosis cases since the late 1990s (1-4) (Figure 1). During July 2016-May 2017, the Alaska Division of Public Health (ADPH) investigated two outbreaks of trichinellosis in the Norton Sound region associated with consumption of raw or undercooked walrus (Odobenus rosmarus) meat; five cases were identified in each of the two outbreaks. These were the first multiple-case outbreaks of walrus-associated trichinellosis in Alaska since 1992 (Figure 2). Health care providers should inquire about consumption of commercially prepared and personally harvested meats when evaluating suspected trichinellosis cases, especially in areas where consumption of wild game is commonplace.

    • Genetics and Genomics RSS Word feed
      1. Respiratory Syncytial Virus (RSV) infects respiratory epithelial cells and deregulates host gene expression by many mechanisms including expression of RSV G protein (RSV G). RSV G protein encodes a central conserved region (CCR) containing a CX3C motif that functions as a fractalkine mimic. Disruption of the CX3C motif (a.a. 182-186) located in the CCR of the G protein has been shown to affect G protein function in vitro and the severity of RSV disease pathogenesis in vivo. We show that infection of polarized Calu3 respiratory cells with recombinant RSV having point mutations in Cys173 and 176 (C173/176S) (rA2-GC12), or Cys186 (C186S) (rA2-GC4) is associated with a decline in the integrity of polarized Calu-3 cultures and decreased virus production. This is accompanied with downregulation of miRNAs let-7f and miR-24 and upregulation of interferon lambda (IFNlambda), a primary antiviral cytokine for RSV in rA2-GC12/rA2-GC4 infected cells. These results suggest that residues in the cysteine noose region of RSV G protein can modulate IFN lambda expression accompanied by downregulation of miRNAs, and are important for RSV G protein function and targeting.

      2. Phylogeography of Burkholderia pseudomallei isolates, Western HemisphereExternal
        Gee JE, Gulvik CA, Elrod MG, Batra D, Rowe LA, Sheth M, Hoffmaster AR.
        Emerg Infect Dis. 2017 Jul;23(7):1133-1138.

        The bacterium Burkholderia pseudomallei causes melioidosis, which is mainly associated with tropical areas. We analyzed single-nucleotide polymorphisms (SNPs) among genome sequences from isolates of B. pseudomallei that originated in the Western Hemisphere by comparing them with genome sequences of isolates that originated in the Eastern Hemisphere. Analysis indicated that isolates from the Western Hemisphere form a distinct clade, which supports the hypothesis that these isolates were derived from a constricted seeding event from Africa. Subclades have been resolved that are associated with specific regions within the Western Hemisphere and suggest that isolates might be correlated geographically with cases of melioidosis. One isolate associated with a former World War II prisoner of war was believed to represent illness 62 years after exposure in Southeast Asia. However, analysis suggested the isolate originated in Central or South America.

      3. Molecular characterization of Mycoplasma pneumoniae infections in two rural populations of Thailand from 2009 to 2012External
        Whistler T, Sawatwong P, Diaz MH, Benitez AJ, Wolff BJ, Sapchookul P, Thamthitiwat S, Winchell JM.
        J Clin Microbiol. 2017 Jul;55(7):2222-2233.

        Studies on Mycoplasma pneumoniae in Thailand have focused on urban centers and have not included molecular characterization. In an attempt to provide a more comprehensive understanding of this organism, we conducted a systematic random sampling to identify 3,000 nasopharyngeal swab specimens collected from January 2009 through July 2012 during population-based surveillance for influenza-like illness in two rural provinces. M. pneumoniae was detected by real-time PCR in 175 (5.8%) specimens. Genotyping was performed using the major adhesion protein (P1) and multilocus variable-number tandem-repeat analysis (MLVA). Of the 157 specimens typed, 97 were P1 type 1 and 60 were P1 type 2. Six different MLVA profiles were identified in 149 specimens, with 4/5/7/2 (40%) and 3/5/6/2 (26%) predominating. There was no discrete seasonality to M. pneumoniae infections. Examination of the 23S rRNA sequence for known polymorphisms conferring macrolide resistance revealed that all 141 tested to possess the genotype associated with macrolide susceptibility.

    • Health Economics RSS Word feed
      1. Vaccine purchase cost has grown substantially over the last few decades. A closer look at vaccine prices reveals that not all vaccines shared the same increasing pattern. Various factors, such as vaccine attributes, competition, and supply shortages, could relate to price changes. In this study, we examined whether a variety of factors influenced the prices of noninfluenza childhood vaccines purchased in the public sector from 1996 to 2014. The association differed among price-capped vaccines and combination vaccines. There was an increasing time trend in real prices for non-price-capped vaccines, which was mostly offset by the effect of market longevity. The effect of competition in lowering prices was more pronounced among non-price-capped vaccines when manufacturer and vaccine component fixed effects were excluded. Supply shortage, manufacturer name change, and number of vaccine doses in series showed no effect. The results may help policy makers better understand price behaviors and make more informed decisions in vaccine planning and financing.

      2. Estimating the cost of school sealant programs with minimal dataExternal
        Griffin SO, Jones K, Naavaal S, O’Connell JM, Demopoulos C, Arlotta D.
        J Public Health Dent. 2017 Jul 04.

        OBJECTIVE: Develop methodology to estimate the annual cost of resources used by school sealant programs (SSPs) and demonstrate its use. METHODS: We used existing literature and expert opinion to identify SSP cost components and the most appropriate units for their measurement (e.g., per operator) and collection frequency (e.g., per day). For equipment and reusable instruments, costs were sufficiently homogenous across SSPs that we could provide default per unit cost estimates (2016 US$) that SSPs can use in lieu of collecting their own data. We also provide default costs for supply items such that SSPs can estimate total supply costs with program-specific information on sealant material used, as well as number of: sealant stations, operators, service delivery days, children screened/sealed, and number of teeth sealed. For the remaining three categories (labor, mileage, and administrative), costs varied substantially by SSP and required us to develop and pilot collection logs for program-specific data. RESULTS: The annual cost per sealant station ranged from $584 to $797 depending on program characteristics. For a hypothetical SSP that staffed each of two stations with two operators (hygienist and assistant) compensated at the national rate, hourly labor costs would equal $77.97. Assuming this SSP used disposable instruments, light-cured sealants and delivered sealants (3 per child) to 60 percent of the 3,390 children screened over 100 service days, infection control/supply costs per child would equal $5.30. CONCLUSION: This methodology allows SSPs to estimate costs with minimal data collection and time.

    • Healthcare Associated Infections RSS Word feed
      1. National Healthcare Safety Network (NHSN) Dialysis Event Surveillance Report for 2014External
        Nguyen DB, Shugart A, Lines C, Shah AB, Edwards J, Pollock D, Sievert D, Patel PR.
        Clin J Am Soc Nephrol. 2017 Jun 29.

        BACKGROUND AND OBJECTIVES: Persons receiving outpatient hemodialysis are at risk for bloodstream and vascular access infections. The Centers for Disease Control and Prevention conducts surveillance for these infections through the National Healthcare Safety Network. We summarize 2014 data submitted to National Healthcare Safety Network Dialysis Event Surveillance. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Dialysis facilities report three types of dialysis events (bloodstream infections; intravenous antimicrobial starts; and pus, redness, or increased swelling at the hemodialysis vascular access site). Denominator data consist of the number of hemodialysis outpatients treated at the facility during the first 2 working days of each month. We calculated dialysis event rates stratified by vascular access type (e.g., arteriovenous fistula, arteriovenous graft, or central venous catheter) and standardized infection ratios (comparing individual facility observed with predicted numbers of infections) for bloodstream infections. We described pathogens identified among bloodstream infections. RESULTS: A total of 6005 outpatient hemodialysis facilities reported dialysis event data for 2014 to the National Healthcare Safety Network. These facilities reported 160,971 dialysis events, including 29,516 bloodstream infections, 149,722 intravenous antimicrobial starts, and 38,310 pus, redness, or increased swelling at the hemodialysis vascular access site events; 22,576 (76.5%) bloodstream infections were considered vascular access related. Most bloodstream infections (63.0%) and access-related bloodstream infections (69.8%) occurred in patients with a central venous catheter. The rate of bloodstream infections per 100 patient-months was 0.64 (0.26 for arteriovenous fistula, 0.39 for arteriovenous graft, and 2.16 for central venous catheter). Other dialysis event rates were also highest among patients with a central venous catheter. Facility bloodstream infection standardized infection ratio distribution was positively skewed with a median of 0.84. Staphylococcus aureus was the most commonly isolated bloodstream infection pathogen (30.6%), and 39.5% of S. aureus isolates tested were resistant to methicillin. CONCLUSIONS: The 2014 National Healthcare Safety Network Dialysis Event data represent nearly all United States outpatient dialysis facilities. Rates of infection and other dialysis events were highest among patients with a central venous catheter compared with other vascular access types. Surveillance data can help define the epidemiology of important infections in this patient population.

    • Immunity and Immunization RSS Word feed
      1. BACKGROUND: Chronic hepatitis B virus (HBV) infection occurs in 90% of infants infected perinatally but is prevented when a hepatitis B vaccine is given within 24h of birth (HepB-BD), followed by 2-3 additional doses. METHODS: Using Spearman’s rho correlation coefficients (rho), we analyzed global and regional data to assess correlations between HepB-BD coverage, institutional delivery rates (IDR), skilled birth attendance (SBA) rates, and other potential co-variates. RESULTS: Significant correlations were observed worldwide between HepB-BD and SBA rates (rho=0.44, p<0.001), IDR (rho=0.42, p<0.001), adult literacy rate (rho=0.37, p=0.003), total health expenditure per capita (rho=0.24, p=0.03) and live births (rho=-0.27, p=0.014). HepB-BD, IDR, and SBA rates were significantly correlated in the World Health Organization African, South-East Asia and Western Pacific Regions. CONCLUSIONS: Increasing IDR and SBA rates, training and supervising staff, increasing community awareness, and using HepB-BD outside the cold chain where needed would increase HepB-BD coverage and prevent chronic infections.

      2. Progress and challenges in measles and rubella elimination in the WHO European RegionExternal
        Datta SS, O’Connor PM, Jankovic D, Muscat M, Ben Mamou MC, Singh S, Kaloumenos T, Reef S, Papania M, Butler R.
        Vaccine. 2017 Jun 23.

        INTRODUCTION: Despite availability of safe and cost-effective vaccines to prevent it, measles remains one of the significant causes of death among children under five years of age globally. The World Health Organization (WHO) European Region has seen a drastic decline in measles and rubella cases in recent years, and a few of the once common measles genotypes are no longer detected. Buoyed by this success, all Member States of the Region reconfirmed their commitment in 2010 to eliminating measles and rubella, and made this a central objective of the European Vaccine Action Plan 2015-2020 (EVAP). Nevertheless, sporadic outbreaks continue, recently affecting primarily adolescents and young adults with no vaccination or an incomplete vaccination history. The European Regional Verification Commission for Measles and Rubella Elimination was established in 2011 to evaluate the status of measles and rubella elimination based on documentation submitted annually by each country’s national verification committee. DISCUSSION: Each country’s commitment to eliminate measles and rubella is influenced by competing health priorities, and in some cases lack of capacity and resources. All countries need to improve case-base surveillance for both measles and rubella, ensure documentation of each outbreak and strengthen the link between epidemiology and laboratory data. Achieving high coverage with measles- and rubella-containing vaccines will require a multisectoral approach to address the root causes of lower uptake in identified communities including service delivery challenges or vaccine safety concerns caused by circulating myths about vaccination. CONCLUSIONS: The WHO European Region has made steady progress towards eliminating measles and rubella and over half of the countries interrupted endemic transmission of both diseases by 2015. The programmatic challenges in disease surveillance, vaccination service delivery and communication in the remaining endemic countries should be addressed through periodic evaluation of the strategies by all stakeholders and exploring additional opportunities to accelerate the ongoing elimination activities.

      3. Knowledge of influenza vaccination recommendation and early vaccination uptake during the 2015-16 season among adults aged >/= 18years – United StatesExternal
        Lu PJ, Srivastav A, Santibanez TA, Stringer M, Bostwick M, Dever JA, Kurtz M, Williams WW.
        Vaccine. 2017 Jul 01.

        BACKGROUND: Since 2010, the Advisory Committee on Immunization Practices (ACIP) has recommended that all persons aged >/=6months receive annual influenza vaccination. METHODS: We analyzed data from the 2015 National Internet Flu Survey (NIFS), to assess knowledge and awareness of the influenza vaccination recommendation and early influenza vaccination coverage during the 2015-16 season among adults. Predictive marginals from a multivariable logistic regression model were used to identify factors independently associated with adults’ knowledge and awareness of the vaccination recommendation and early vaccine uptake during the 2015-16 influenza season. RESULTS: Among the 3301 respondents aged >/=18years, 19.6% indicated knowing that influenza vaccination is recommended for all persons aged >/=6months. Of respondents, 62.3% indicated awareness that there was a recommendation for influenza vaccination, but did not indicate correct knowledge of the recommended age group. Overall, 39.9% of adults aged >/=18years reported having an influenza vaccination. Age 65years and older, being female, having a college or higher education, not being in work force, having annual household income >/=$75,000, reporting having received an influenza vaccination early in the 2015-16 season, having children aged </=17years in the household, and having high-risk conditions were independently associated with a higher correct knowledge of the influenza vaccination recommendation. CONCLUSIONS: Approximately 1 in 5 had correct knowledge of the recommendation that all persons aged >/=6months should receive an influenza vaccination annually, with some socio-economic groups being even less aware. Clinic based education in combination with strategies known to increase uptake of recommended vaccines, such as patient reminder/recall systems and other healthcare system-based interventions are needed to improve vaccination, which could also improve awareness.

      4. BACKGROUND: Seasonal influenza vaccine uptake in China is low. This study aims to assess the role of community healthcare workers (HCWs) in increasing vaccination among high risk groups in China. METHODS: We analyzed data from four knowledge, attitude and practice (KAP) studies on seasonal influenza vaccination in China targeting guardians of young children, pregnant women, adults aged >/=60years, and HCWs from 2012 to 2014. RESULTS: Thirty-one percent of pregnant women and 78% adults aged >/=60years reported willingness to follow HCWs’ recommendations for influenza vaccination. Guardians were more likely to vaccinate their children if they received HCWs’ recommendations (35% vs. 17%, p<0.001). Community HCWs were more likely to recommend seasonal influenza vaccination than hospital HCWs (58% vs. 28%, p<0.001). CONCLUSION: Study results suggest the value of incorporating community HCWs’ recommendation for seasonal influenza vaccination into existing primary public health programs to increase vaccination coverage among high risk groups in China.

      5. Estimated severe pneumococcal disease cases and deaths before and after pneumococcal conjugate vaccine introduction in children younger than 5 years of age in South AfricaExternal
        von Mollendorf C, Tempia S, von Gottberg A, Meiring S, Quan V, Feldman C, Cloete J, Madhi SA, O’Brien KL, Klugman KP, Whitney CG, Cohen C.
        PLoS One. 2017 ;12(7):e0179905.

        INTRODUCTION: Streptococcus pneumoniae is a leading cause of severe bacterial infections globally. A full understanding of the impact of pneumococcal conjugate vaccine (PCV) on pneumococcal disease burden, following its introduction in 2009 in South Africa, can support national policy on PCV use and assist with policy decisions elsewhere. METHODS: We developed a model to estimate the national burden of severe pneumococcal disease, i.e. disease requiring hospitalisation, pre- (2005-2008) and post-PCV introduction (2012-2013) in children aged 0-59 months in South Africa. We estimated case numbers for invasive pneumococcal disease using data from the national laboratory-based surveillance, adjusted for specimen-taking practices. We estimated non-bacteraemic pneumococcal pneumonia case numbers using vaccine probe study data. To estimate pneumococcal deaths, we applied observed case fatality ratios to estimated case numbers. Estimates were stratified by HIV status to account for the impact of PCV and HIV-related interventions. We assessed how different assumptions affected estimates using a sensitivity analysis. Bootstrapping created confidence intervals. RESULTS: In the pre-vaccine era, a total of approximately 107,600 (95% confidence interval [CI] 83,000-140,000) cases of severe hospitalised pneumococcal disease were estimated to have occurred annually. Following PCV introduction and the improvement in HIV interventions, 41,800 (95% CI 28,000-50,000) severe pneumococcal disease cases were estimated in 2012-2013, a rate reduction of 1,277 cases per 100,000 child-years. Approximately 5000 (95% CI 3000-6000) pneumococcal-related annual deaths were estimated in the pre-vaccine period and 1,900 (95% CI 1000-2500) in 2012-2013, a mortality rate difference of 61 per 100,000 child-years. CONCLUSIONS: While a large number of hospitalisations and deaths due to pneumococcal disease still occur among children 0-59 months in South Africa, we found a large reduction in this estimate that is temporally associated with PCV introduction. In HIV-infected individuals the scale-up of other interventions, such as improvements in HIV care, may have also contributed to the declines in pneumococcal burden.

    • Injury and Violence RSS Word feed
      1. Birth order and injury-related infant mortality in the U.SExternal
        Ahrens KA, Rossen LM, Thoma ME, Warner M, Simon AE.
        Am J Prev Med. 2017 Jun 27.

        INTRODUCTION: The purpose of this study was to evaluate the risk of death during the first year of life due to injury, such as unintentional injury and homicide, by birth order in the U.S. METHODS: Using national birth cohort-linked birth-infant death data (births, 2000-2010; deaths, 2000-2011), risks of infant mortality due to injury in second-, third-, fourth-, and fifth or later-born singleton infants were compared with first-born singleton infants. Risk ratios were estimated using log-binomial models adjusted for maternal age, marital status, race/ethnicity, and education. The statistical analyses were conducted in 2016. RESULTS: Approximately 40%, 32%, 16%, 7%, and 4% of singleton live births were first, second, third, fourth, and fifth or later born, respectively. From 2000 to 2011, a total of 15,866 infants died as a result of injury (approximately 1,442 deaths per year). Compared with first-born infants (2.9 deaths per 10,000 live births), second or later-born infants were at increased risk of infant mortality due to injury (second, 3.6 deaths; third, 4.2 deaths; fourth, 4.8 deaths; fifth or later, 6.4 deaths). The corresponding adjusted risk ratios were as follows: second, 1.84 (95% CI=1.76, 1.91); third, 2.42 (95% CI=2.30, 2.54); fourth, 2.96 (95% CI=2.77, 3.16); and fifth or later, 4.26 (95% CI=3.96, 4.57). CONCLUSIONS: Singleton infants born second or later were at increased risk of mortality due to injury during their first year of life in the U.S. This study’s findings highlight the importance of investigating underlying mechanisms behind this increased risk.

      2. Research on the translation and implementation of Stepping On in three Wisconsin communitiesExternal
        Schlotthauer AE, Mahoney JE, Christiansen AL, Gobel VL, Layde P, Lecey V, Mack KA, Shea T, Clemson L.
        Front Public Health. 2017 ;5:128.

        OBJECTIVE: Falls are a leading cause of injury death. Stepping On is a fall prevention program developed in Australia and shown to reduce falls by up to 31%. The original program was implemented in a community setting, by an occupational therapist, and included a home visit. The purpose of this study was to examine aspects of the translation and implementation of Stepping On in three community settings in Wisconsin. METHODS: The investigative team identified four research questions to understand the spread and use of the program, as well as to determine whether critical components of the program could be modified to maximize use in community practice. The team evaluated program uptake, participant reach, program feasibility, program acceptability, and program fidelity by varying the implementation setting and components of Stepping On. Implementation setting included type of host organization, rural versus urban location, health versus non-health background of leaders, and whether a phone call could replace the home visit. A mixed methodology of surveys and interviews completed by site managers, leaders, guest experts, participants, and content expert observations for program fidelity during classes was used. RESULTS: The study identified implementation challenges that varied by setting, including securing a physical therapist for the class and needing more time to recruit participants. There were no implementation differences between rural and urban locations. Potential differences emerged in program fidelity between health and non-health professional leaders, although fidelity was high overall with both. Home visits identified more home hazards than did phone calls and were perceived as of greater benefit to participants, but at 1 year no differences were apparent in uptake of strategies discussed in home versus phone visits. CONCLUSION: Adaptations to the program to increase implementation include using a leader who is a non-health professional, and omitting the home visit. Our research demonstrated that a non-health professional leader can conduct Stepping On with adequate fidelity, however non-health professional leaders may benefit from increased training in certain aspects of Stepping On. A phone call may be substituted for the home visit, although short-term benefits are greater with the home visit.

    • Laboratory Sciences RSS Word feed
      1. Analysis of false-negative human immunodeficiency virus rapid tests performed on oral fluid in 3 international clinical research studiesExternal
        Curlin ME, Gvetadze R, Leelawiwat W, Martin M, Rose C, Niska RW, Segolodi TM, Choopanya K, Tongtoyai J, Holtz TH, Samandari T, McNicholl JM.
        Clin Infect Dis. 2017 Jun 15;64(12):1663-1669.

        Background: The OraQuick Advance Rapid HIV-1/2 Test is a point-of-care test capable of detecting human immunodeficiency virus (HIV)-specific antibodies in blood and oral fluid. To understand test performance and factors contributing to false-negative results in longitudinal studies, we examined results of participants enrolled in the Botswana TDF/FTC Oral HIV Prophylaxis Trial, the Bangkok Tenofovir Study, and the Bangkok MSM Cohort Study, 3 separate clinical studies of high-risk, HIV-negative persons conducted in Botswana and Thailand. Methods: In a retrospective observational analysis, we compared oral fluid OraQuick (OFOQ) results among participants becoming HIV infected to results obtained retrospectively using enzyme immunoassay and nucleic acid amplification tests on stored specimens. We categorized negative OFOQ results as true-negative or false-negative relative to nucleic acid amplification test and/or enzyme immunoassay, and determined the delay in OFOQ conversion relative to the estimated time of infection. We used log-binomial regression and generalized estimating equations to examine the association between false-negative results and participant, clinical, and testing-site factors. Results.: Two-hundred thirty-three false-negative OFOQ results occurred in 80 of 287 seroconverting individuals. Estimated OFOQ conversion delay ranged from 14.5 to 547.5 (median, 98.5) days. Delayed OFOQ conversion was associated with clinical site and test operator (P < .05), preexposure prophylaxis (P = .01), low plasma viral load (P < .02), and time to kit expiration (P < .01). Participant age, sex, and HIV subtype were not associated with false-negative results. Long OFOQ conversion delay time was associated with antiretroviral exposure and low plasma viral load. Conclusions: Failure of OFOQ to detect HIV-1 infection was frequent and multifactorial in origin. In longitudinal trials, negative oral fluid results should be confirmed via testing of blood samples.

      2. Progressive T cell depletion during chronic human immunodeficiency virus (HIV) infection is a key mechanism that leads to the development of AIDS. Recent studies have suggested that most T cells in the tissue die through pyroptosis triggered by abortive infection, i.e. infection of resting T cells where HIV failed to complete reverse transcription. However, the contribution of abortive infection to T cell loss and how quickly abortively infected cells die in vivo, key parameters for a quantitative understanding of T cell population dynamics, are not clear. Here, we infected rhesus macaques with simian-human immunodeficiency viruses (SHIV) and followed the dynamics of both plasma SHIV RNA and total cell-associated SHIV DNA. Fitting mathematical models to the data, we estimate that upon infection a majority of CD4+ T cells become abortively infected (approximately 65% on average) and die at a relatively fast rate of 0.27 day-1 (half-life: 2.6 days). This confirms the importance of abortive infection in driving T cell depletion. Further, we find evidence suggesting that an immune response maybe restricting viral infection 1-3 weeks after infection. Our study serves as a step-forward towards a quantitative understanding of the mechanisms driving T cell depletion during HIV infection.IMPORTANCE In HIV infected patients, progressive CD4+ T cell loss ultimately leads to the development of AIDS. The mechanisms underlying this T cell loss are not clear. Recent experimental data suggests that the majority of CD4+ T cells in tissue die through abortive infection where accumulation of incomplete HIV transcripts triggers cell death. To investigate the role of abortive infection in driving CD4+ T cell loss in vivo, we infected macaques with a simian-human immunodeficiency viruses (SHIV) and followed the viral kinetics of both plasma RNA and cell-associated DNA during infection. Fitting mathematical models, we estimated that a large fraction of infected cells die through abortive infection and have a half-life of approximately 2.6 days. Our results provide the first in vivo quantitative estimates of parameters characterizing abortive infection and supports the notion that abortive infection represents an important mechanism underlying progressive CD4+ T cell depletion in vivo.

      3. ABSTRACT: In September 2015, the Centers for Disease Control and Prevention were notified of a suspected outbreak investigation of lymphogranuloma venereum (LGV) cases by the Michigan Department of Health and Human Services. The Centers for Disease Control and Prevention offered support with a laboratory-developed polymerase chain reaction test for LGV. This note describes the laboratory workflow and procedures used for the laboratory confirmation of LGV infection.

      4. BACKGROUND: Pneumocystis pneumonia (PCP) is a serious risk for HIV-positive patients. Asymptomatic infection or colonisation with P. jirovecii has been shown to occur frequently. PCR assays frequently identify such cases, due to their high sensitivity. Quantitative real-time PCR (qPCR) gene copy number cut-off values have been suggested to differentiate colonisation and infection; these need to be standardised for routine use. We compared the results of qPCR with an immunofluorescence assay (IFA) to determine a specific cut-off value. METHODS: From March 2005 through June 2009, induced sputum specimens were collected from adult patients who were clinically suspected of having PCP, at the Chris Hani Baragwanath Hospital in Gauteng, South Africa. Laboratory diagnosis of PCP was done by a conventional direct IFA and a qPCR assay. A receiver operating characteristic (ROC) analysis was performed to determine a suitable copy number cut-off value. RESULTS: P. jirovecii was identified in 51% (156/305) and 67% (204/305) of specimens using IFA and qPCR, respectively. The cut-off value for the qPCR that best predicted the IFA results was 78 copies/5 mul (area under ROC curve 0.92). The sensitivity and specificity of qPCR using this cut-off was 94.6% and 89.1%, respectively, compared with the IFA. DISCUSSION: The results of the ROC curve analysis indicate an excellent predictive value of the qPCR using the proposed cut-off. However, the IFA test is an imperfect gold standard and so this cut-off should not be used in isolation; clinical data should also contribute to the interpretation of the qPCR result.

      5. Evaluation of a TaqMan Array Card for detection of central nervous system infectionsExternal
        Onyango CO, Loparev V, Lidechi S, Bhullar V, Schmid DS, Radford K, Lo MK, Rota P, Johnson BW, Munoz J, Oneko M, Burton D, Black CM, Neatherlin J, Montgomery JM, Fields B.
        J Clin Microbiol. 2017 Jul;55(7):2035-2044.

        Infections of the central nervous system (CNS) are often acute, with significant morbidity and mortality. Routine diagnosis of such infections is limited in developing countries and requires modern equipment in advanced laboratories that may be unavailable to a number of patients in sub-Saharan Africa. We developed a TaqMan array card (TAC) that detects multiple pathogens simultaneously from cerebrospinal fluid. The 21-pathogen CNS multiple-pathogen TAC (CNS-TAC) assay includes two parasites (Balamuthia mandrillaris and Acanthamoeba), six bacterial pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Mycoplasma pneumoniae, Mycobacterium tuberculosis, and Bartonella), and 13 viruses (parechovirus, dengue virus, Nipah virus, varicella-zoster virus, mumps virus, measles virus, lyssavirus, herpes simplex viruses 1 and 2, Epstein-Barr virus, enterovirus, cytomegalovirus, and chikungunya virus). The card also includes human RNase P as a nucleic acid extraction control and an internal manufacturer control, GAPDH (glyceraldehyde-3-phosphate dehydrogenase). This CNS-TAC assay can test up to eight samples for all 21 agents within 2.5 h following nucleic acid extraction. The assay was validated for linearity, limit of detection, sensitivity, and specificity by using either live viruses (dengue, mumps, and measles viruses) or nucleic acid material (Nipah and chikungunya viruses). Of 120 samples tested by individual real-time PCR, 35 were positive for eight different targets, whereas the CNS-TAC assay detected 37 positive samples across nine different targets. The CNS-TAC assays showed 85.6% sensitivity and 96.7% specificity. Therefore, the CNS-TAC assay may be useful for outbreak investigation and surveillance of suspected neurological disease.

      6. Evaluation of the molecular mechanisms associated with cytotoxicity and inflammation after pulmonary exposure to different metal-rich welding particlesExternal
        Shoeb M, Kodali V, Farris B, Bishop LM, Meighan T, Salmen R, Eye T, Roberts JR, Zeidler-Erdely P, Erdely A, Antonini JM.
        Nanotoxicology. 2017 Jun 29:1-34.

        Welding generates a complex aerosol of incidental nanoparticles and cytotoxic metals, such as chromium (Cr), manganese (Mn), nickel (Ni), and iron (Fe). The goal was to use both in vivo and in vitro methodologies to determine the mechanisms by which different welding fumes may damage the lungs. Sprague-Dawley rats were treated by intratracheal instillation (ITI) with 2.0 mg of gas metal arc-mild steel (GMA-MS) or manual metal arc-stainless steel (MMA-SS) fumes or saline (vehicle control). At 1, 3, and 10 days, bronchoalveolar lavage (BAL) was performed to measure lung toxicity. To assess molecular mechanisms of cytotoxicity, RAW264.7 cells were exposed to both welding fumes for 24 hours (0-100 mug/ml). Fume composition was different: MMA-SS (41% Fe, 29% Cr, 17% Mn, 3% Ni) versus GMA-MS (85% Fe, 14% Mn). BAL indicators of lung injury and inflammation were increased by MMA-SS at all time points and by GMA-MS at 3 and 10 days after exposure. RAW264.7 cells exposed to MMA-SS had elevated generation of reactive oxygen species (ROS), protein-HNE (P-HNE) adduct formation, activation of ERK1/2, and expression of cyclooxygenase-2 (COX-2) compared to GMA-MS and control. Increased generation of ROS due to MMA-SS exposure was confirmed by increased expression of Nrf2 and heme oxygenase-1 (HO-1). Results of in vitro studies provide evidence that stainless steel welding fume mediate inflammatory responses via activation of ROS/P-HNE/ERK1/2/Nrf2 signaling pathways. These findings were corroborated by elevated expression of COX-2, Nrf2, and HO-1 in homogenized lung tissue collected 1 day after in vivo exposure.

      7. A macaque model for rectal lymphogranuloma venereum and non-lymphogranuloma venereum Chlamydia trachomatis: Impact on rectal simian/human immunodeficiency virus acquisitionExternal
        Vishwanathan SA, Aubert RD, Morris MR, Zhao C, Philips C, Khalil GM, Deyounks F, Kelley K, Ritter JM, Chen CY, Kersh EN, McNicholl JM.
        Sex Transm Dis. 2017 ;20.

        BACKGROUND: Sustained genital tract inflammation caused by sexually transmitted infections (STIs) is known to increase risk of vaginal human immunodeficiency virus (HIV) infections but, to our knowledge, there are no nonhuman primate studies that have evaluated its link to rectal HIV acquisition. METHODS: Rhesus macaques inoculated with Chlamydia trachomatis (CT) (serovars LGV-L2 and CT-E; n = 7) or saline (n = 7) received up to 20 rectal challenges twice a week of simian/HIV immunodeficiency virus (SHIVSF162p3). SHIV viremia was determined by real-time PCR and Chlamydia infection by APTIMA Combo 2 testing. The rectal cytokine-chemokine levels were evaluated by multiplex bead assays. RESULTS: Rectal Chlamydia infection was maintained throughout the study. We did not observe significant differences (P = 1.0) in frequency of SHIV acquisition between the STI and control arms. It took fewer SHIV challenges to infect the STI animals although the difference was not significant (P = 0.59). There were no significant differences in peak plasma viremia between STI and control arms (P = 0.63). The association of plasma viremia with rectal shedding was significantly different by arm (P = 0.038). CONCLUSIONS: In the first such study in a macaque model, we did not observe an increased risk of SHIV acquisition due to rectal Chlamydia coinfection. This macaque model can be further developed and expanded to better investigate the impact of different rectal STIs on HIV acquisition.

      8. Induction of slug by chronic exposure to single-walled carbon nanotubes promotes tumor formation and metastasisExternal
        Wang P, Voronkova M, Luanpitpong S, He X, Riedel H, Dinu CZ, Wang L, Rojanasakul Y.
        Chem Res Toxicol. 2017 Jun 20.

        Carbon nanotubes (CNTs) represent a major class of engineered nanomaterials that are being used in diverse fields. However, their use has increasingly become a concern because of their carcinogenic potential. Accumulating evidence has demonstrated that certain types of CNTs are carcinogenic or tumor-promoting in animal models. However, the underlying molecular and cellular mechanisms are unclear. Here, we report that chronic exposure to single-walled (SW) CNTs results in the induction of Slug, a key transcription factor that induces an epithelial-mesenchymal transition (EMT), in human lung epithelial cells. We show that SWCNT-induced Slug upregulation plays a critical role in the aggressive phenotype of SWCNT-exposed cells, which includes increased cell migration, invasion, and anchorage-independent cell growth. Our in vivo studies also show that SWCNT-induced Slug upregulation and EMT activation play a pivotal role in tumor formation and metastasis. Our findings illustrate a direct link between CNT-induced Slug upregulation, EMT activation, and tumor formation and metastasis, and they highlight the potential of CNT-induced Slug upregulation as a target for future risk assessment and prevention of CNT-associated diseases.

    • Maternal and Child Health RSS Word feed
      1. A population-based study of effects of genetic loci on orofacial cleftsExternal
        Moreno Uribe LM, Fomina T, Munger RG, Romitti PA, Jenkins MM, Gjessing HK, Gjerdevik M, Christensen K, Wilcox AJ, Murray JC, Lie RT, Wehby GL.
        J Dent Res. 2017 Jun 01:22034517716914.

        Prior genome-wide association studies for oral clefts have focused on clinic-based samples with unclear generalizability. Prior samples were also small for investigating effects by cleft type and exclusively studied isolated clefts (those occurring without other birth defects). We estimated the effects of 17 top loci on cleft types in both isolated and nonisolated cases in the largest consortium to date of European-descent population-based studies. Our analytic approach focused on a mother-child dyad case-control design, but it also allowed analyzing mother-only or child-only genotypes to maximize power. Our total sample included 1,875 cases with isolated clefts, 459 cases with nonisolated clefts, and 3,749 controls. After correcting for multiple testing, we observed significant associations between fetal single-nucleotide polymorphisms (SNPs) at IRF6, PAX7, 8q21.3, 8q24, KIAA1598-VAX1, and MAFB and isolated cleft lip only (CLO) and cleft lip and palate (CLP). Significant associations were observed between isolated CLO and fetal SNPs near TPM1 and NOG1 and between CLP and fetal SNPs at ABCA4-ARHGAP29, THADA, FOXE1, and SPRY2. Overall, effects were similar for isolated CLO and CLP, except for ABCA4-ARHGAP29. A protective effect was observed for the fetal NOG1 SNP on cleft palate only, opposite in direction to the effect on CLO. For most fetal SNPs, a dose-response allelic effect was observed. No evidence of parent-of-origin or maternal genome effects was observed. Overall, effect direction and magnitude were similar between isolated and nonisolated clefts, suggesting that several loci are modifiers of cleft risk in both isolated and nonisolated forms. Our results provide reliable estimates of the effects of top loci on risks of oral clefts in a population of European descent.

    • Nutritional Sciences RSS Word feed
      1. Impact of knowledge of health conditions on sugar-sweetened beverage intake varies among US adultsExternal
        Park S, Lundeen EA, Pan L, Blanck HM.
        Am J Health Promot. 2017 Jan 01:890117117717381.

        PURPOSE: This study examined associations between knowledge of sugar-sweetened beverage (SSB)-related health conditions and SSB intake among US adults. DESIGN: Quantitative, cross-sectional study. SUBJECT: The 2014 SummerStyles survey data for 4163 US adults (>/=18 years) were used. MEASURES: The outcome measure was frequency of SSB intake (regular soda, fruit drinks, sports or energy drinks, sweetened coffee/tea drinks). Exposure measures were knowledge of 6 SSB-related health conditions: weight gain, diabetes, cavities, high cholesterol, heart disease, and hypertension. ANALYSIS: Six logistic regression models were used to estimate adjusted odds ratios (ORs) for consuming SSBs >/=2 times/d according to knowledge of SSB-related health conditions. RESULTS: Overall, 37.8% of adults reported consuming SSBs >/=2 times/d. Although most adults identified that weight gain (80.2%), diabetes (73.6%), and cavities (71.8%) are related to drinking SSBs, fewer adults identified high cholesterol (24.1%), heart disease (31.5%), and hypertension (33.0%) as being related to drinking SSBs. Crude analyses indicated that lower SSB intake was significantly associated with knowledge of the associations between SSBs and weight gain, diabetes, cavities, and heart disease. However, after adjustment for covariates, only lack of knowledge of the association between heart disease and SSBs was significantly associated with consuming SSBs >/=2 times/d (OR = 1.29) than non-SSB consumers. CONCLUSIONS: The finding that knowledge of SSB-related health conditions, in general, was not associated with high SSB intake suggests that knowledge on SSB-related health conditions alone may not be sufficient for adult behavior change.

    • Occupational Safety and Health RSS Word feed
      1. OBJECTIVE: We describe the magnitude and distribution of violent work-related deaths among taxi and limousine drivers, a high-risk population. METHODS: We analyzed rates using the Bureau of Labor Statistics Census of Fatal Occupational Injuries (CFOI) for all violent work-related deaths in the taxi and limousine industry from 2003 to 2013. We described demographics, work characteristics, and other injury details, examining temporal trends for nativity and race/ethnicity. RESULTS: Men (adjusted rate ratio [RRadj] 6.1 [95% confidence interval [CI] 2.6-14.1]), blacks (RRadj 2.3 [95% CI 1.6-3.4]), Hispanics (RRadj 2.1 [95% CI 1.3-3.4]), and drivers in the South (RRadj 2.7 [95% CI 1.9-3.9]) had significantly higher fatality rates than comparison groups. Over time, the rates remained substantially higher compared with all workers. CONCLUSIONS: The taxi and limousine industry continues to face a disproportionately dangerous working environment. Recommended safety measures implemented uniformly by cities, companies, and drivers could mitigate disparities.

    • Occupational Safety and Health – Mining RSS Word feed
      1. Evaluation of high blood pressure and obesity among US coal miners participating in the Enhanced Coal Workers’ Health Surveillance ProgramExternal
        Casey ML, Fedan KB, Edwards N, Blackley DJ, Halldin CN, Wolfe AL, Laney AS.
        J Am Soc Hypertens. 2017 Jun 20.

        Since 2005, the Enhanced Coal Workers’ Health Surveillance Program (ECWHSP) has offered respiratory examinations to coal miners in a mobile examination unit. As little is known about the cardiovascular health of coal miners, we describe the prevalence of high blood pressure (BP) and obesity among ECWHSP participants. During 2015, 1402 ECWHSP health examinations were performed. The prevalence of BP consistent with hypertension (systolic BP >/= 140 mm Hg or diastolic BP >/= 90 mm Hg), prehypertension (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg), and hypertensive crisis (systolic BP >/= 180 mm Hg or diastolic BP >/= 110 mm Hg) were calculated and compared with the US adult population using standardized morbidity ratios (SMRs). Most participants were male (N = 1317, 94%), White (N = 1303, 93%) and non-Hispanic (N = 1316, 94%). Thirty-one percent (N = 440) of participants had BP in the hypertensive range and 87% (N = 1215) were overweight/obese. Twenty-four participants (2%) had a BP reading consistent with a hypertensive crisis. Prevalence of obesity (52%, SMR = 1.52, 95% confidence interval = 1.41-1.64) and BP consistent with hypertension (31%, SMR = 1.60, 95% confidence interval = 1.45-1.76) was higher than the US adult population.The prevalence of obesity and BP consistent with hypertension in this population of coal miners is substantial, indicating a need for cardiovascular health interventions in coal mining communities.

      2. Examination of space/volume requirements for US underground coal mine refuge alternativesExternal
        Porter WL, Dempsey PG, Jansky JH.
        Theor Issues Ergon Sci. 2017 ;18(5):388-403.

        The Mine Safety and Health Administration requires that 1.4 m2 (15 ft2) of floor space is to be provided for each person inside a refuge alternative (RA). However, the amount of floor space needed for a person to reside inside an RA and perform basic tasks is unknown. During testing, participants entered into an RA or a simulated RA of various space/volume configurations and performed several simulated tasks that are representative of the survivability tasks performed within an RA. The results indicate that the floor space requirements were generally adequate for the tasks studied. Certain tasks such as changing scrubber cartridges, using toilets, and moving about the RA were impacted by the minimum height tested (0.6 m). As such, RAs of this height will require critical design consideration as a whole and the supplies provided for use inside of the RA to ensure the ability to use an RA.

    • Physical Activity RSS Word feed
      1. Walking for transportation or leisure among U.S. women and men – National Health Interview Survey, 2005-2015External
        Ussery EN, Carlson SA, Whitfield GP, Watson KB, Berrigan D, Fulton JE.
        MMWR Morb Mortal Wkly Rep. 2017 Jun 30;66(25):657-662.

        Physical activity confers considerable health benefits, but only half of U.S. adults report participating in levels of aerobic physical activity consistent with guidelines (1,2). Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities identified walking as an important public health strategy to increase physical activity levels (3). A previous report showed that the self-reported prevalence of walking for transportation or leisure increased by 6 percentage points from 2005 to 2010 (4), but it is unknown whether this increase has been sustained. CDC analyzed National Health Interview Survey (NHIS) data from 2005 (26,551 respondents), 2010 (23,313), and 2015 (28,877) to evaluate trends in the age-adjusted prevalence of self-reported walking among adults aged >/=18 years. The prevalence of walking increased steadily among women, from 57.3% in 2005, to 62.5% in 2010, and to 65.1% in 2015 (significant linear trend). Among men, a significant linear increase in reported walking was observed, from 54.3% in 2005, to 61.8% in 2010, and to 62.8% in 2015, although the increase stalled between 2010 and 2015 (significant linear and quadratic trends). Community design policies and practices that encourage pedestrian activity and programs tailored to the needs of specific population subgroups remain important strategies for promoting walking (3).

    • Public Health Law RSS Word feed
      1. This paper discusses recent changes to state legal frameworks for mandatory vaccination in the context of school and healthcare worker vaccination. It then discusses state laws that allow pharmacists the authority to vaccinate.

      2. Collaborating for health: Health in All Policies and the lawExternal
        Pepin D, Winig BD, Carr D, Jacobson PD.
        J Law Med Ethics. 2017 Mar;45(1_suppl):60-64.

        This article introduces and defines the Health in All Policies (HiAP) concept and examines existing state legislation, with a focus on California. The article starts with an overview of HiAP and then analyzes the status of HiAP legislation, specifically addressing variations across states. Finally, the article describes California’s HiAP approach and discusses how communities can apply a HiAP framework not only to improve health outcomes and advance health equity, but also to counteract existing laws and policies that contribute to health inequities.

      3. Legal epidemiology: The science of lawExternal
        Ramanathan T, Hulkower R, Holbrook J, Penn M.
        J Law Med Ethics. 2017 Mar;45(1_suppl):69-72.

        The importance of legal epidemiology in public health law research has undoubtedly grown over the last five years. Scholars and practitioners together have developed guidance on best practices for the field, including: placing emphasis on transdisciplinary collaborations; creating valid, reliable, and repeatable research; and publishing timely products for use in decision-making and change. Despite the energy and expertise researchers have brought to this important work, they name significant challenges in marshalling the diverse skill sets, quality controls, and funding to implement legal epidemiology activities. The Centers for Disease Control and Prevention (CDC) has worked to develop cross-cutting research and translation on issues of national priority in legal epidemiology, and has explored ways to overcome some of these challenges. As such, this article describes a case study of the use of law to characterize states’ prior authorization policies regarding medication used to treat attention-deficit/hyperactivity disorder (ADHD), a central component of a broader effort to improve behavior therapy options for young children with ADHD. This article highlights the types of legal epidemiology work we have undertaken, the application of this work to an emerging public health problem, and the lessons learned in creating impactful research for the field.

    • Public Health Leadership and Management RSS Word feed
      1. How is CDC funded to respond to public health emergencies? Federal appropriations and budget execution process for non-financial expertsExternal
        Fischer LS, Santibanez S, Jones G, Anderson B, Merlin T.
        Health Secur. 2017 May/Jun;15(3):307-311.

        The federal budgeting process affects a wide range of people who work in public health, including those who work for government at local, state, and federal levels; those who work with government; those who operate government-funded programs; and those who receive program services. However, many people who are affected by the federal budget are not aware of or do not understand how it is appropriated or executed. This commentary is intended to give non-financial experts an overview of the federal budget process to address public health emergencies. Using CDC as an example, we provide: (1) a brief overview of the annual budget formulation and appropriation process; (2) a description of execution and implementation of the federal budget; and (3) an overview of emergency supplemental appropriations, using as examples the 2009 H1N1 influenza pandemic, the 2014-15 Ebola outbreak, and the 2016 Zika epidemic. Public health emergencies require rapid coordinated responses among Congress, government agencies, partners, and sometimes foreign, state, and local governments. It is important to have an understanding of the appropriation process, including supplemental appropriations that might come into play during public health emergencies, as well as the constraints under which Congress and federal agencies operate throughout the federal budget formulation process and execution.

    • Substance Use and Abuse RSS Word feed
      1. Menthol levels in cigarettes from eight manufacturersExternal
        Ai J, Taylor KM, Lisko JG, Tran H, Watson CH, Holman MR.
        Tob Control. 2017 Jun 30.

        [No abstract]

      2. Tobacco use in top-grossing movies – United States, 2010-2016External
        Tynan MA, Polansky JR, Titus K, Atayeva R, Glantz SA.
        MMWR Morb Mortal Wkly Rep. 2017 Jul 07;66(26):681-686.

        The Surgeon General has concluded that there is a causal relationship between depictions of smoking in the movies and the initiation of smoking among young persons (1). The more youths see smoking on screen, the more likely they are to start smoking; youths who are heavily exposed to onscreen smoking imagery are approximately two to three times as likely to begin smoking as are youths who receive less exposure (1,2). A Healthy People 2020 objective is to reduce the proportion of youths exposed to onscreen tobacco marketing in movies and television (Tobacco Use Objective 18.3) (3). To assess the recent extent of tobacco use imagery in youth-rated movies (G, PG, PG-13*), 2010-2016 data from Thumbs Up! Thumbs Down! (TUTD), a project of Breathe California of Sacramento-Emigrant Trails were analyzed and compared with previous reports.dagger In 2016, 41% of movies that were among the 10 top-grossing movies in any calendar week included tobacco use, compared with 45% in 2010. Among youth-rated movies, 26% included tobacco use in 2016 (including 35% of PG-13 movies) compared with 31% in 2010 (including 43% of PG-13 movies). The steady decline in the number of tobacco incidents in youth-rated movies from 2005-2010 stopped after 2010. The total number of individual occurrences of tobacco use in a movie (tobacco incidents) in top-grossing movies increased 72%, from 1,824 in 2010 to 3,145 in 2016, with an increase of 43% (from 564 to 809) occurring among PG-13 rated movies. Reducing tobacco use in youth-related movies could help prevent the initiation of tobacco use among young persons.

      3. Alcohol and cocaine use among Latino and African American MSM in 6 US citiesExternal
        Zaller N, Yang C, Operario D, Latkin C, McKirnan D, O’Donnell L, Fernandez M, Seal D, Koblin B, Flores S, Spikes P.
        J Subst Abuse Treat. 2017 September;80:26-32.

        [No abstract]

    • Zoonotic and Vectorborne Diseases RSS Word feed
      1. Bites from the same dog, different outcomes for two patients: a case reportExternal
        Huang XY, Li XL, Wu SY, Gu YL, Lv XJ, Klena JD, Xu BL.
        Infect Dis Poverty. 2017 Jul 05;6(1):107.

        BACKGROUND: Rabies is a serious reemerging zoonosis in China. At present human rabies cases are primarily diagnosed based on clinical presentation. CASE PRESENTATION: In August 2012, a woman and her son were attacked by a stray dog in Henan, China. The son received rabies postexposure prophylaxis (wound treatment followed by vaccine, no immunoglobulin), however, the mother did not. Rabies infection was subsequently laboratory confirmed in the mother and she died in December; her son is alive and healthy after 2 years of follow-up. CONCLUSION: This report documents that the timely utilization of postexposure prophylaxis is a required measure in preventing rabies after exposure to an animal bite.

      2. More is not automatically better. Generation and accumulation of information reflecting the complexity of zoonotic diseases as ecological systems do not necessarily lead to improved interpretation of the obtained information and understanding of these complex systems. The traditional conceptual framework for analysis of diseases ecology is neither designed for, nor adaptable enough, to absorb the mass of diverse sources of relevant information. The multidirectional and multidimensional approaches to analyses form an inevitable part in defining a role of zoonotic pathogens and animal hosts considering the complexity of their inter-relations. And the more data we have, the more involved the interpretation needs to be. The keyword for defining the roles of microbes as pathogens, animals as hosts, and environmental parameters as infection drivers is “functional importance.” Microbes can act as pathogens toward their host only if/when they recognize the animal organism as the target. The same is true when the host recognizes the microbe as a pathogen rather than harmless symbiont based on the context of its occurrence in that host. Here, we propose conceptual tools developed in the realm of the interdisciplinary sciences of complexity and biosemiotics for extending beyond the currently dominant mindset in ecology and evolution of infectious diseases. We also consider four distinct hierarchical levels of perception guiding how investigators can approach zoonotic agents, as a subject of their research, representing differences in emphasizing particular elements and their relations versus more unified systemic approaches.

      3. Babesiosis surveillance – Wisconsin, 2001-2015External
        Stein E, Elbadawi LI, Kazmierczak J, Davis JP.
        MMWR Morb Mortal Wkly Rep. 2017 Jul 07;66(26):687-691.

        Babesiosis is an emerging zoonotic disease caused primarily by Babesia microti, an intraerythocytic protozoan. Babesia microti, like the causal agents for Lyme disease and anaplasmosis, is endemic to the northeastern and upper midwestern United States where it is usually transmitted by the blacklegged tick, Ixodes scapularis. Although babesiosis is usually a mild to moderate illness, older or immunocompromised persons can develop a serious malaria-like illness that can be fatal without prompt treatment. The most common initial clinical signs and symptoms of babesiosis (fever, fatigue, chills, and diaphoresis) are nonspecific and present diagnostic challenges that can contribute to delays in diagnosis and effective treatment with atovaquone and azithromycin (1). Results of one study revealed a mean delay of 12-14 days from symptom onset to treatment (2). Knowledge of the incidence and geographic distribution of babesiosis can raise the index of clinical suspicion and facilitate more prompt diagnosis and lifesaving treatment (1). The first known case of babesiosis in Wisconsin was detected in 1985 (3), and babesiosis became officially reportable in the state in 2001. Wisconsin babesiosis surveillance data for 2001-2015 were analyzed in 3-year intervals to compare demographic, epidemiologic, and laboratory features among patients with cases of reported babesiosis. To determine possible reasons for an increase in reported Babesia infection, trends in electronic laboratory reporting and diagnosis by polymerase chain reaction testing (PCR) were examined. Between the first and last 3-year analysis intervals, there was a 26-fold increase in the incidence of confirmed babesiosis, in addition to geographic expansion. These trends might be generalizable to other states with endemic disease, similar suburbanization and forest fragmentation patterns, and warming average temperatures (4). Accurate surveillance in states where babesiosis is endemic is necessary to estimate the increasing burden of babesiosis and other tickborne diseases and to develop appropriate public health interventions for prevention and practice.

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CDC Science Clips Production Staff

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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.

Page last reviewed: January 31, 2019