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Issue 44, November 7, 2017


CDC Science Clips: Volume 9, Issue 44, November 7, 2017

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

  1. Top Articles of the Week

    Selected weekly by a senior CDC scientist from the standard sections listed below. This week featuring CDC-authored articles from a special issue of the American Journal of Tropical Medicine and Hygiene on the topic.
    Public Health Progress in Haiti: Achievements, Challenges, and Lessons Learned since the 2010 Earthquake
    The names of CDC authors are indicated in bold text.
    • Communicable Diseases
      • Retention throughout the HIV care and treatment cascade: from diagnosis to antiretroviral treatment of adults and children living with HIV-Haiti, 1985-2015
        Auld AF, Valerie P, Robin EG, Shiraishi RW, Dee J, Antoine M, Desir Y, Desforges G, Delcher C, Duval N, Joseph N, Francois K, Griswold M, Domercant JW, Patrice Joseph YA, Van Onacker JD, Deyde V, Lowrance DW, And The Groupe d’Analyses S.
        Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):57-70.
        Monitoring retention of people living with HIV (PLHIV) in the HIV care and treatment cascade is essential to guide program strategy and evaluate progress toward globally-endorsed 90-90-90 targets (i.e., 90% of PLHIV diagnosed, 81% on sustained antiretroviral therapy (ART), and 73% virally suppressed). We describe national retention from diagnosis throughout the cascade for patients receiving HIV services in Haiti during 1985-2015, with a focus on those receiving HIV services during 2008-2015. Among the 266,256 newly diagnosed PLHIV during 1985-2015, 49% were linked-to-care, 30% started ART, and 18% were retained on ART by the time of database closure. Similarly, among the 192,187 newly diagnosed HIV-positive patients during 2008-2015, 50% were linked to care, 31% started ART, and 19% were retained on ART by the time of database closure. Most patients (90-92%) at all cascade steps were adults (>/= 15 years old), among whom the majority (60-61%) were female. During 2008-2015, outcomes varied significantly across 42 administrative districts (arrondissements) of residence; cumulative linkage-to-care ranged from 23% to 69%, cumulative ART initiation among care enrollees ranged from 2% to 80%, and cumulative ART retention among ART enrollees ranged from 30% to 88%. Compared with adults, children had lower cumulative incidence of ART initiation among care enrollees (64% versus 47%) and lower cumulative retention among ART enrollees (64% versus 50%). Cumulative linkage-to-care was low and should be prioritized for improvement. Variations in outcomes by arrondissement and between adults and children require further investigation and programmatic response.

      • Trends in tuberculosis case notification and treatment success, Haiti, 2010-2015
        Charles M, Richard M, Joseph P, Bury MR, Perrin G, Louis FJ, Fitter DL, Marston BJ, Deyde V, Boncy J, Morose W, Pape JW, Lowrance DW.
        Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):49-56.
        Since the 2010 earthquake, tuberculosis (TB) control has been a major priority for health sector response and recovery efforts in Haiti. The goal of this study was to analyze trends in TB case notification in Haiti from the aggregate data reported by the National TB Control Program to understand the effects of such efforts. A total of 95,745 TB patients were registered for treatment in Haiti between 2010 and 2015. Three regions, the West, Artibonite, and North departments accounted for 68% of the TB cases notified during the period. Patients in the 15-34 age groups represented 53% (50,560) of all cases. Case notification rates of all forms of TB increased from 142.7/100,000 in 2010 to 153.4 in 2015, peaking at 163.4 cases/100,000 in 2013. Case notification for smear-positive pulmonary TB increased from 85.5 cases/100,000 to 105.7 cases/100,000, whereas treatment success rates remained stable at 79-80% during the period. Active TB case finding efforts in high-risk communities and the introduction of new diagnostics have contributed to increasing TB case notification trends in Haiti from 2010 to 2015. Targeted interventions and novel strategies are being implemented to reach high-risk populations and underserved communities.

    • Disaster Control and Emergency Services
      • Applying a new framework for public health systems recovery following emergencies and disasters: The example of Haiti following a major earthquake and cholera outbreak
        Fitter DL, Delson DB, Guillaume FD, Schaad AW, Moffett DB, Poncelet JL, Lowrance D, Gelting R.
        Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):4-11.
        Emergencies can often directly impact health systems of an affected region or country, especially in resource-constrained areas. Health system recovery following an emergency is a complex and dynamic process. Health system recovery efforts have often been structured around the World Health Organization’s health systems building blocks as demonstrated by the Post-Disaster Needs Assessment. Although this structure is valuable and well known, it can overlook the intricacies of public health systems. We retrospectively examine public health systems recovery, a subset of the larger health system, following the 2010 Haiti earthquake and cholera outbreak, through the lens of the 10 essential public health services. This framework illustrates the comprehensive nature of and helps categorize the activities necessary for a well-functioning public health system and can complement other assessments. Outlining the features of a public health system for recovery in structured manner can also help lay the foundation for sustainable long-term development leading to a more robust and resilient health system.

    • Environmental Health
      • Assessment of drinking water sold from private sector kiosks in post-earthquake Port-au-Prince, Haiti
        Patrick M, Steenland M, Dismer A, Pierre-Louis J, Murphy JL, Kahler A, Mull B, Etheart MD, Rossignol E, Boncy J, Hill V, Handzel T.
        Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):84-91.
        Consumption of drinking water from private vendors has increased considerably in Port-au-Prince, Haiti, in recent decades. A major type of vendor is private kiosks, advertising reverse osmosis-treated water for sale by volume. To describe the scale and geographical distribution of private kiosks in metropolitan Port-au-Prince, an inventory of private kiosks was conducted from July to August 2013. Coordinates of kiosks were recorded with global positioning system units and a brief questionnaire was administered with the operator to document key kiosk characteristics. To assess the quality of water originating from private kiosks, water quality analyses were also conducted on a sample of those inventoried as well as from the major provider company sites. The parameters tested were Escherichia coli, free chlorine residual, pH, turbidity, and total dissolved solids. More than 1,300 kiosks were inventoried, the majority of which were franchises of four large provider companies. Approximately half of kiosks reported opening within 12 months of the date of the inventory. The kiosk treatment chain and sales price was consistent among a majority of the kiosks. Of the 757 kiosks sampled for water quality, 90.9% of samples met World Health Organization (WHO) microbiological guideline at the point of sale for nondetectable E. coli in a 100-mL sample. Of the eight provider company sites tested, all samples met the WHO microbiological guideline. Because of the increasing role of the private sector in drinking water provision in Port-au-Prince and elsewhere in Haiti, this assessment was an important first step for government regulation of this sector.

    • Health Economics
      • Cost evaluation of a government-conducted oral cholera vaccination campaign-Haiti, 2013
        Routh JA, Sreenivasan N, Adhikari BB, Andrecy LL, Bernateau M, Abimbola T, Njau J, Jackson E, Juin S, Francois J, Tohme RA, Meltzer MI, Katz MA, Mintz ED.
        Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):37-42.
        The devastating 2010 cholera epidemic in Haiti prompted the government to introduce oral cholera vaccine (OCV) in two high-risk areas of Haiti. We evaluated the direct costs associated with the government’s first vaccine campaign implemented in August-September 2013. We analyzed data for major cost categories and assessed the efficiency of available campaign resources to vaccinate the target population. For a target population of 107,906 persons, campaign costs totaled $624,000 and 215,295 OCV doses were dispensed. The total vaccine and operational cost was $2.90 per dose; vaccine alone cost $1.85 per dose, vaccine delivery and administration $0.70 per dose, and vaccine storage and transport $0.35 per dose. Resources were greater than needed-our analyses suggested that approximately 2.5-6 times as many persons could have been vaccinated during this campaign without increasing the resources allocated for vaccine delivery and administration. These results can inform future OCV campaigns in Haiti.

    • Immunity and Immunization
      • Expansion of vaccination services and strengthening vaccine-preventable diseases surveillance in Haiti, 2010-2016
        Tohme RA, Francois J, Cavallaro KF, Paluku G, Yalcouye I, Jackson E, Wright T, Adrien P, Katz MA, Hyde TB, Faye P, Kimanuka F, Dietz V, Vertefeuille J, Lowrance D, Dahl B, Patel R.
        Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):28-36.
        Following the 2010 earthquake, Haiti was at heightened risk for vaccine-preventable diseases (VPDs) outbreaks due to the exacerbation of long-standing gaps in the vaccination program and subsequent risk of VPD importation from other countries. Therefore, partners supported the Haitian Ministry of Health and Population to improve vaccination services and VPD surveillance. During 2010-2016, three polio, measles, and rubella vaccination campaigns were implemented, achieving a coverage > 90% among children and maintaining Haiti free of those VPDs. Furthermore, Haiti is on course to eliminate maternal and neonatal tetanus, with 70% of communes achieving tetanus vaccine two-dose coverage > 80% among women of childbearing age. In addition, the vaccine cold chain storage capacity increased by 91% at the central level and 285% at the department level, enabling the introduction of three new vaccines (pentavalent, rotavirus, and pneumococcal conjugate vaccines) that could prevent an estimated 5,227 deaths annually. Haiti moved from the fourth worst performing country in the Americas in 2012 to the sixth best performing country in 2015 for adequate investigation of suspected measles/rubella cases. Sentinel surveillance sites for rotavirus diarrhea and meningococcal meningitis were established to estimate baseline rates of those diseases prior to vaccine introduction and to evaluate the impact of vaccination in the future. In conclusion, Haiti significantly improved vaccination services and VPD surveillance. However, high dependence on external funding and competing vaccination program priorities are potential threats to sustaining the improvements achieved thus far. Political commitment and favorable economic and legal environments are needed to maintain these gains.

    • Parasitic Diseases
      • Translating research into reality: Elimination of lymphatic filariasis from Haiti
        Lammie PJ, Eberhard ML, Addiss DG, Won KY, Beau de Rochars M, Direny AN, Milord MD, Lafontant JG, Streit TG.
        Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):71-75.
        Research provides the essential foundation of disease elimination programs, including the global program to eliminate lymphatic filariasis (GPELF). The development and validation of new diagnostic tools and intervention strategies, critical steps in the evolution of GPELF, required a global effort. Lymphatic filariasis research in Haiti involved many partners and was directly linked to the development of the national elimination program and to the success achieved to date. Ongoing research efforts involving many partners will continue to be important in resolving the challenges faced by the program today in its final efforts to achieve elimination.

      • Haiti’s commitment to malaria elimination: Progress in the face of challenges, 2010-2016
        Lemoine JF, Boncy J, Filler S, Kachur SP, Fitter D, Chang MA.
        Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):43-48.
        Haiti is committed to malaria elimination by 2020. Following a 2010 earthquake and cholera epidemic, Haiti capitalized on investments in its health system to refocus on malaria elimination. Efforts, including expanding diagnostics, ensuring efficacy of standard treatments, building institutional capacity, and strengthening surveillance were undertaken to complement the broad health system strengthening activities. These efforts led to the adoption and scale-up of malaria rapid diagnostic tests as a diagnostic modality. In addition, drug-resistant monitoring has been established in the country, along with the development of molecular testing capacity for the Plasmodium falciparum parasite at the National Public Health Laboratory. The development and piloting of surveillance activities to include an enhanced community-based approach for testing and treatment of patients has increased the ability of the Ministry of Health to map foci of transmission and respond promptly to outbreaks. The reinforcement of evidence-based approaches coupled with strong collaboration among the Ministry of Health and partners has demonstrated that malaria elimination by 2020 is a realistic prospect.

    • Public Health Leadership and Management
      • Building and rebuilding: The national public health laboratory systems and services before and after the earthquake and cholera epidemic, Haiti, 2009-2015
        Jean Louis F, Buteau J, Boncy J, Anselme R, Stanislas M, Nagel MC, Juin S, Charles M, Burris R, Antoine E, Yang C, Kalou M, Vertefeuille J, Marston BJ, Lowrance DW, Deyde V.
        Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):21-27.
        Before the 2010 devastating earthquake and cholera outbreak, Haiti’s public health laboratory systems were weak and services were limited. There was no national laboratory strategic plan and only minimal coordination across the laboratory network. Laboratory capacity was further weakened by the destruction of over 25 laboratories and testing sites at the departmental and peripheral levels and the loss of life among the laboratory health-care workers. However, since 2010, tremendous progress has been made in building stronger laboratory infrastructure and training a qualified public health laboratory workforce across the country, allowing for decentralization of access to quality-assured services. Major achievements include development and implementation of a national laboratory strategic plan with a formalized and strengthened laboratory network; introduction of automation of testing to ensure better quality of results and diversify the menu of tests to effectively respond to outbreaks; expansion of molecular testing for tuberculosis, human immunodeficiency virus, malaria, diarrheal and respiratory diseases; establishment of laboratory-based surveillance of epidemic-prone diseases; and improvement of the overall quality of testing. Nonetheless, the progress and gains made remain fragile and require the full ownership and continuous investment from the Haitian government to sustain these successes and achievements.

      • Strengthening national disease surveillance and response-Haiti, 2010-2015
        Juin S, Schaad N, Lafontant D, Joseph GA, Barzilay E, Boncy J, Barrais R, Louis FJ, Jean Charles NL, Corvil S, Barthelemy N, Dismer A, Pierre JS, Archer RW, Antoine M, Marston B, Katz M, Dely P, Adrien P, Fitter DL, Lowrance D, Patel R.
        Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):12-20.
        Haiti’s health system has faced many challenges over the years, with competing health priorities in the context of chronic financial and human resource limitations. As a result, the existing notifiable disease surveillance system was unable to provide the most basic epidemiologic data for public health decision-making and action. In the wake of the January 2010 earthquake, the Haitian Ministry of Public Health and Population collaborated with the U.S. Centers for Disease Control and Prevention, the Pan American Health Organization, and other local and international partners to implement a functional national surveillance system. More than 7 years later, it is important to take the opportunity to reflect on progress made on surveillance and response in Haiti, including disease detection, reporting, outbreak investigation, and response. The national epidemiologic surveillance network that started with 51 sites in 2010 has been expanded to 357 sites as of December 2015. Disease outbreaks identified via the surveillance system, or other surveillance approaches, are investigated by epidemiologists trained by the Ministry of Health’s Field Epidemiology Training Program. Other related surveillance modules have been developed on the same model and electronic platform, allowing the country to document the impact of interventions, track progress, and monitor health problems. Sustainability remains the greatest challenge since most of the funding for surveillance come from external sources.

      • Public Health Progress in Haiti
        Lowrance DW, Tappero JW, Poncelet JL, Etienne C, Frieden TR, Delsoins D.
        Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):1-3.

        [No abstract]

    • Zoonotic and Vectorborne Diseases
      • The health impact of rabies in Haiti and recent developments on the path toward elimination, 2010-2015
        Wallace R, Etheart M, Ludder F, Augustin P, Fenelon N, Franka R, Crowdis K, Dely P, Adrien P, Pierre-Louis J, Osinubi M, Orciari L, Vigilato M, Blanton J, Patel R, Lowrance D, Liverdieu A, Coetzer A, Boone J, Lindenmayer J, Millien M.
        Am J Trop Med Hyg. 2017 Oct;97(4_Suppl):76-83.
        Haiti, a Caribbean country of 10.5 million people, is estimated to have the highest burden of canine-mediated human rabies deaths in the Western Hemisphere, and one of the highest rates of human rabies deaths in the world. Haiti is also the poorest country in the Western Hemisphere and has numerous economic and health priorities that compete for rabies-control resources. As a result, primary rabies-control actions, including canine vaccination programs, surveillance systems for human and animal rabies, and appropriate postbite treatment, have not been fully implemented at a national scale. After the 2010 earthquake that further hindered the development of public health program infrastructure and services, the U.S. Centers for Disease Control and Prevention worked with the Ministry of Public Health and Population and key health development partners (including the Pan-American Health Organization) to provide technical expertise and funding for general disease surveillance systems, laboratory capacity, and selected disease control programs; including rabies. In 2011, a cross-ministerial rabies consortium was convened with participation from multiple international rabies experts to develop a strategy for successful rabies control in Haiti. The consortium focused on seven pillars: 1) enhancement of laboratory diagnostic capacity, 2) development of comprehensive animal surveillance system, 3) development of comprehensive human rabies surveillance system, 4) educational outreach, 5) sustainable human rabies biologics supply, 6) achievement of sustained canine vaccination rates of >/= 70%, and 7) finalization of a national rabies control strategy. From 2010 until 2015, Haiti has seen improvements in the program infrastructure for canine rabies control. The greatest improvements were seen in the area of animal rabies surveillance, in support of which an internationally recognized rabies laboratory was developed thereby leading to an 18-fold increase in the detection of rabid animals. Canine rabies vaccination practices also improved, from a 2010 level of approximately 12% to a 2015 dog population coverage level estimated to be 45%. Rabies vaccine coverage is still below the goal of 70%, however, the positive trend is encouraging. Gaps exist in the capacity to conduct national surveillance for human rabies cases and access to human rabies vaccine is lacking in many parts of the country. However, control has improved over the past 5 years as a result of the efforts of Haiti’s health and agriculture sectors with assistance from multiple international organizations. Haiti is well situated to eliminate canine-mediated human rabies deaths in the near future and should serve as a great example to many developing countries struggling with similar barriers and limitations.

  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
      1. Patterns of prostate-specific antigen test use in the U.S., 2005-2015
        Berkowitz Z, Li J, Richards TB, Marcus PM.
        Am J Prev Med. 2017 Oct 16.
        INTRODUCTION: Recommendations for prostate-specific antigen-based screening for prostate cancer are placing increasing emphasis on men aged 55-69 years. The goal of the current study is to describe patterns of population-based prostate-specific antigen testing with details about that age group. METHODS: National Health Interview Surveys from 2005 to 2015 were analyzed in 2017 to estimate routine prostate-specific antigen testing in the past year from self-reported data by age group (40-54, 55-69, >/=70 years), and also by risk group, defined as African American men or men with a family history of prostate cancer versus other men. Differences between successive survey years by age and risk groups were assessed by predicted margins and rate ratios with 99% CIs, using logistic regressions. RESULTS: Prostate-specific antigen testing among men aged 55-69 years decreased from a high of 43.1% (95% CI=40.3, 46.1) in 2008 to a low of 32.8% (95% CI=30.8, 34.7) in 2013, with no significant change in 2015 at 33.8% (95% CI=31.3, 36.4). Men aged >/=70 years had consistently high prevalence in all survey years, ranging from 51.1% in 2008 to 36.4% in 2015. African American men, men with a family history of prostate cancer, and other men showed a 5% absolute decrease over time, but this reduction was significant only in other men. CONCLUSIONS: Despite decreases, the absolute change in prostate-specific antigen testing for men aged 55-69 years was small (9.3%) over the study period. Men aged >/=70 years, for whom the benefits are unlikely to exceed the harms, continue to have consistently high testing prevalence.

      2. Vital Signs: Trends in incidence of cancers associated with overweight and obesity – United States, 2005-2014
        Steele CB, Thomas CC, Henley SJ, Massetti GM, Galuska DA, Agurs-Collins T, Puckett M, Richardson LC.
        MMWR Morb Mortal Wkly Rep. 2017 Oct 03;66(39):1052-1058.
        BACKGROUND: Overweight and obesity are associated with increased risk of at least 13 different types of cancer. METHODS: Data from the United States Cancer Statistics for 2014 were used to assess incidence rates, and data from 2005 to 2014 were used to assess trends for cancers associated with overweight and obesity (adenocarcinoma of the esophagus; cancers of the breast [in postmenopausal women], colon and rectum, endometrium, gallbladder, gastric cardia, kidney, liver, ovary, pancreas, and thyroid; meningioma; and multiple myeloma) by sex, age, race/ethnicity, state, geographic region, and cancer site. Because screening for colorectal cancer can reduce colorectal cancer incidence through detection of precancerous polyps before they become cancerous, trends with and without colorectal cancer were analyzed. RESULTS: In 2014, approximately 631,000 persons in the United States received a diagnosis of a cancer associated with overweight and obesity, representing 40% of all cancers diagnosed. Overweight- and obesity-related cancer incidence rates were higher among older persons (ages >/=50 years) than younger persons; higher among females than males; and higher among non-Hispanic black and non-Hispanic white adults compared with other groups. Incidence rates for overweight- and obesity-related cancers during 2005-2014 varied by age, cancer site, and state. Excluding colorectal cancer, incidence rates increased significantly among persons aged 20-74 years; decreased among those aged >/=75 years; increased in 32 states; and were stable in 16 states and the District of Columbia. CONCLUSIONS: The burden of overweight- and obesity-related cancer is high in the United States. Incidence rates of overweight- and obesity-related cancers except colorectal cancer have increased in some age groups and states. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: The burden of overweight- and obesity-related cancers might be reduced through efforts to prevent and control overweight and obesity. Comprehensive cancer control strategies, including use of evidence-based interventions to promote healthy weight, could help decrease the incidence of these cancers in the United States.

    • Communicable Diseases
      1. Human adenovirus surveillance – United States, 2003-2016
        Binder AM, Biggs HM, Haynes AK, Chommanard C, Lu X, Erdman DD, Watson JT, Gerber SI.
        MMWR Morb Mortal Wkly Rep. 2017 Oct 06;66(39):1039-1042.
        Human adenoviruses (HAdVs) are nonenveloped, double-stranded DNA viruses in the family Adenoviridae; seven species (A-G) and >60 genotypes are known to cause human infection. Clinical manifestations associated with HAdV infection include fever, acute respiratory illness, gastroenteritis, and conjunctivitis. HAdV infection can be severe, particularly among immunocompromised patients, and can cause respiratory failure, disseminated infection, hemorrhagic cystitis, neurologic disease, and death. Illness tends to occur sporadically and without demonstrated seasonality. Outbreaks of HAdV have been reported globally in communities, and in closed or crowded settings, including dormitories, health care settings, and among military recruits, for whom a vaccine against HAdV type 4 (HAdV-4) and HAdV type 7 (HAdV-7) has been developed. CDC summarized HAdV detections voluntarily reported through the National Adenovirus Type Reporting System (NATRS) after initiation of surveillance in 2014 to describe trends in reported HAdVs circulating in the United States. Reporting laboratories were also encouraged to report available results for specimens collected before surveillance began. Overall, the number of reporting laboratories and HAdV type identifications reported to NATRS has increased substantially from the start of official reporting in 2014 through 2016; this report describes specimens collected during 2003-2016. The most commonly reported HAdV types were HAdV type 3 (HAdV-3) and HAdV type 2 (HAdV-2), although HAdV types reported fluctuated considerably from year to year. In the United States, information on recently circulating HAdV types is needed to inform diagnostic and surveillance activities by clinicians and public health practitioners. Routine reporting to NATRS by all U.S. laboratories with the capacity to type HAdVs could help strengthen this surveillance system.

      2. Update: Influenza activity – United States and worldwide, May 21-September 23, 2017
        Blanton L, Wentworth DE, Alabi N, Azziz-Baumgartner E, Barnes J, Brammer L, Burns E, Davis CT, Dugan VG, Fry AM, Garten R, Grohskopf LA, Gubareva L, Kniss K, Lindstrom S, Mustaquim D, Olsen SJ, Roguski K, Taylor C, Trock S, Xu X, Katz J, Jernigan D.
        MMWR Morb Mortal Wkly Rep. 2017 Oct 06;66(39):1043-1051.
        During May 21-September 23, 2017, the United States experienced low-level seasonal influenza virus activity; however, beginning in early September, CDC received reports of a small number of localized influenza outbreaks caused by influenza A(H3N2) viruses. In addition to influenza A(H3N2) viruses, influenza A(H1N1)pdm09 and influenza B viruses were detected during May-September worldwide and in the United States. Influenza B viruses predominated in the United States from late May through late June, and influenza A viruses predominated beginning in early July. The majority of the influenza viruses collected and received from the United States and other countries during that time have been characterized genetically or antigenically as being similar to the 2017 Southern Hemisphere and 2017-18. Northern Hemisphere cell-grown vaccine reference viruses; however, a smaller proportion of the circulating A(H3N2) viruses showed similarity to the egg-grown A(H3N2) vaccine reference virus which represents the A(H3N2) viruses used for the majority of vaccine production in the United States. Also, during May 21-September 23, 2017, CDC confirmed a total of 33 influenza variant virus infections; two were influenza A(H1N2) variant (H1N2v) viruses (Ohio) and 31 were influenza A(H3N2) variant (H3N2v) viruses (Delaware [1], Maryland [13], North Dakota [1], Pennsylvania [1], and Ohio [15]). An additional 18 specimens from Maryland have tested presumptive positive for H3v and further analysis is being conducted at CDC.

      3. Primary HPV testing recommendations of US providers, 2015
        Cooper CP, Saraiya M.
        Prev Med. 2017 Dec;105:372-377.
        OBJECTIVE: To investigate the HPV testing recommendations of US physicians who perform cervical cancer screening. METHODS: Data from the 2015 DocStyles survey of U.S. health care providers were analyzed using multivariate logistic regression to identify provider characteristics associated with routine recommendation of primary HPV testing for average-risk, asymptomatic women >/=30years old. The analysis was limited to primary care physicians and obstetrician-gynecologists who performed cervical cancer screening (N=843). RESULTS: Primary HPV testing for average-risk, asymptomatic women >/=30years old was recommended by 40.8% of physicians who performed cervical cancer screening, and 90.1% of these providers recommended primary HPV testing for women of all ages. The screening intervals most commonly recommended for primary HPV testing with average-risk, asymptomatic women >/=30years old were every 3years (35.5%) and annually (30.2%). Physicians who reported that patient HPV vaccination status influenced their cervical cancer screening practices were almost four times more likely to recommend primary HPV testing for average-risk, asymptomatic women >/=30years old than other providers (Adj OR=3.96, 95% CI=2.82-5.57). CONCLUSION: Many US physicians recommended primary HPV testing for women of all ages, contrary to guidelines which limit this screening approach to women >/=25years old. The association between provider recommendation of primary HPV testing and patient HPV vaccination status may be due to anticipated reductions in the most oncogenic HPV types among vaccinated women.

      4. HIV testing at visits to physicians’ offices in the U.S., 2009-2012
        Ham DC, Lecher S, Gvetadze R, Huang YA, Peters P, Hoover KW.
        Am J Prev Med. 2017 Nov;53(5):634-645.
        INTRODUCTION: HIV testing serves as an entry point for HIV care services for those who test HIV positive, and prevention services for those who test HIV negative. The Centers for Disease Control and Prevention recommends routine testing of adults and adolescents in healthcare settings. To identify missed opportunities for HIV testing at U.S. physicians’ offices, data from the National Ambulatory Care Surveys from 2009 to 2012 were analyzed. METHODS: The mean annual number and percentage of visits with an HIV test among HIV-uninfected nonpregnant females and males aged 15-65 years was estimated using weighted survey data. Factors associated with HIV testing at visits to physicians’ offices were identified. RESULTS: The mean annual number of U.S. physicians’ office visits with an HIV test conducted was 1,396,736 (0.4% of all visits) among nonpregnant females and 986,891 (0.5% of all visits) among males. For both nonpregnant females and males, HIV testing prevalence was highest among those aged 20-29 years (1.3% of all visits by nonpregnant females; 1.7% of all visits by males) and non-Hispanic blacks (1.1% of all visits by nonpregnant females; 1.0% of all visits by males). An HIV test was not conducted at 98.5% of visits at which venipuncture was performed for both nonpregnant females and males. CONCLUSIONS: Important opportunities exist to increase HIV testing coverage at U.S. physicians’ offices. Structural interventions, such as routine opt-out testing policies, electronic medical record notifications, and use of non-clinical staff for testing could be implemented to increase HIV testing in these settings.

      5. Evidence-based guidelines for supportive care of patients with Ebola virus disease
        Lamontagne F, Fowler RA, Adhikari NK, Murthy S, Brett-Major DM, Jacobs M, Uyeki TM, Vallenas C, Norris SL, Fischer WA, Fletcher TE, Levine AC, Reed P, Bausch DG, Gove S, Hall A, Shepherd S, Siemieniuk RA, Lamah MC, Kamara R, Nakyeyune P, Soka MJ, Edwin A, Hazzan AA, Jacob ST, Elkarsany MM, Adachi T, Benhadj L, Clement C, Crozier I, Garcia A, Hoffman SJ, Guyatt GH.
        Lancet. 2017 Oct 17.
        The 2013-16 Ebola virus disease outbreak in west Africa was associated with unprecedented challenges in the provision of care to patients with Ebola virus disease, including absence of pre-existing isolation and treatment facilities, patients’ reluctance to present for medical care, and limitations in the provision of supportive medical care. Case fatality rates in west Africa were initially greater than 70%, but decreased with improvements in supportive care. To inform optimal care in a future outbreak of Ebola virus disease, we employed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to develop evidence-based guidelines for the delivery of supportive care to patients admitted to Ebola treatment units. Key recommendations include administration of oral and, as necessary, intravenous hydration; systematic monitoring of vital signs and volume status; availability of key biochemical testing; adequate staffing ratios; and availability of analgesics, including opioids, for pain relief.

      6. Pilot evaluation of the ability of men who have sex with men to self-administer rapid HIV tests, prepare dried blood spot cards, and interpret test results, Atlanta, Georgia, 2013
        MacGowan RJ, Chavez PR, Gravens L, Wesolowski LG, Sharma A, McNaghten AD, Freeman A, Sullivan PS, Borkowf CB, Michele Owen S.
        AIDS Behav. 2017 Oct 20.
        In the United States, an estimated 67% of new HIV diagnoses are among men who have sex with men (MSM), however 25% of HIV-positive MSM in the 2014 National HIV Behavioral Surveillance Survey were unaware of their infection. HIV self-testing (HIVST) with rapid diagnostic tests (RDTs) may facilitate access to HIV testing. We evaluated the ability of 22 MSM to conduct two HIV RDTs (OraQuick (R) In-Home HIV Test and a home-use prototype of Sure Check (R) HIV 1/2 Assay), interpret sample images of test results, and collect a dried blood spot (DBS) specimen. While some participants did not follow every direction, most participants were able to conduct HIVST and correctly interpret their results. Interpretation of panels of RDT images was especially difficult when the “control” line was missing, and 27% of DBS cards produced were rated as of bad quality. Modifications to the DBS instructions were necessary prior to evaluating the performance of these tests in real-world settings.

      7. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea
        Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K, Langley JM, Wanke C, Warren CA, Cheng AC, Cantey J, Pickering LK.
        Clin Infect Dis. 2017 Oct 19.
        These guidelines are intended for use by healthcare professionals who care for children and adults with suspected or confirmed infectious diarrhea. They are not intended to replace physician judgement regarding specific patients or clinical or public health situations. This document does not provide detailed recommendations on infection prevention and control aspects related to infectious diarrhea.

      8. Comparing drivers and dynamics of tuberculosis in California, Florida, New York, and Texas
        Shrestha S, Hill AN, Marks SM, Dowdy DW.
        Am J Respir Crit Care Med. 2017 Oct 15;196(8):1050-1059.
        RATIONALE: There is substantial state-to-state heterogeneity in tuberculosis (TB) in the United States; better understanding this heterogeneity can inform effective response to TB at the state level, the level at which most TB control efforts are coordinated. OBJECTIVES: To characterize drivers of state-level heterogeneity in TB epidemiology in the four U.S. states that bear half the country’s TB burden: California, Florida, New York, and Texas. METHODS: We constructed an individual-based model of TB in the four U.S. states and calibrated the model to state-specific demographic and age- and nativity-stratified TB incidence data. We used the model to infer differences in natural history of TB and in future projections of TB. MEASUREMENTS AND MAIN RESULTS: We found that differences in both demographic makeup (particularly the size and composition of the foreign-born population) and TB transmission dynamics contribute to state-level differences in TB epidemiology. The projected median annual rate of decline in TB incidence in the next decade was substantially higher in Texas (3.3%; 95% range, -5.6 to 10.9) than in California (1.7%; 95% range, -3.8 to 7.1), Florida (1.5%; 95% range, -7.4 to 14), and New York (1.9%; 95% range, -6.4 to 9.8). All scenarios projected a flattening of the decline in TB incidence by 2025 without additional resources or interventions. CONCLUSIONS: There is substantial state-level heterogeneity in TB epidemiology in the four states, which reflect both demographic factors and potential differences in the natural history of TB. These differences may inform resource allocation decisions in these states.

      9. World Health Organization global health sector strategy on sexually transmitted infections: An evidence-to-action summary for Colombia
        Taylor M, Alonso-Gonzalez M, Gomez B, Korenromp E, Broutet N.
        Revista Colombiana de Obstetricia y Ginecologia. 2017 ;68(3):193-201.
        Curable and incurable sexually transmitted infections (STI) are acquired by hundreds of millions of people worldwide each year. Undiagnosed and untreated STIs cause a range of negative health outcomes including adverse birth outcomes, infertility and other long term sequelae such as cervical cancer. In 2016, the World Health Organization (WHO) launched the Global STI Strategy (2016- 2021). The WHO Global STI Strategy’s public health approach focuses on three causative organisms of STIs that need immediate action and for which cost-effective interventions exist: (a) Neisseria gonorrhoeae as a cause of infertility, a risk factor for coinfection with other STIs and because of increasing bacterial resistance to antibiotic treatment, (b) Treponema pallidum given the contribution of syphilis to adverse birth outcomes including stillbirth and neonatal death and (c) Human papillomavirus due to its link to cervical cancer. The range of actions recommended for countries includes: (a) strengthening surveillance, with program monitoring and progress evaluation, (b) STI prevention, (c) early diagnosis of STIs, (d) patient and partner management, and (e) approaches to reach the most vulnerable populations. This summary describes the WHO Global STI Strategy alongside findings from a STI surveillance workshop held in Colombia in May of 2017. Observations related to the Global STI Strategy and findings from the STI estimation workshop are described here for stakeholders in Colombia to consider as they identify opportunities to improve STI services and surveillance.

      10. Mortality burden from seasonal influenza and 2009 H1N1 pandemic influenza in Beijing, China, 2007-2013
        Wu S, Wei Z, Greene CM, Yang P, Su J, Song Y, Iuliano AD, Wang Q.
        Influenza Other Respir Viruses. 2017 Oct 20.
        BACKGROUND: Data about influenza mortality burden in northern China are limited. This study estimated mortality burden in Beijing associated with seasonal influenza from 2007-2013 and the 2009 H1N1 pandemic. METHODS: We estimated influenza-associated excess mortality by fitting a negative binomial model using weekly mortality data as the outcome of interest with the percent of influenza positive samples by type/subtype as predictor variables. RESULTS: From 2007 to 2013, an average of 2,375 (CI 1,002-8,688) deaths was attributed to influenza per season, accounting for 3% of all deaths. Overall, 81% of the deaths attributed to influenza occurred in adults aged >/=65 years, and the influenza-associated mortality rate in this age group was higher than the rate among those aged <65 years (113.6 [CI 49.5-397.4] versus 4.4 [CI 1.7-18.6] per 100,000, p<0.05). The mortality rate associated with the 2009 H1N1 pandemic in 2009/10 was comparable to that of seasonal influenza during the seasonal years (19.9 [CI 10.4-33.1] vs. 17.2 [CI 7.2-67.5] per 100,000). People aged <65 years represented a greater proportion of all deaths during the influenza A(H1N1)pdm09 pandemic period than during the seasonal epidemics (27.0% vs. 17.7%, p<0.05). CONCLUSIONS: Influenza is an important contributor to mortality in Beijing, especially among those aged >/=65 years. These results support current policies to give priority to older adults for seasonal influenza vaccination and help to define the populations at highest risk for death that could be targeted for pandemic influenza vaccination.

    • Environmental Health
      1. Quantification of mold contamination in multi-level buildings using the Environmental Relative Moldiness Index
        Vesper S, Cox-Ganser JM, Wymer L, Park JH.
        J Occup Environ Hyg. 2017 Oct 20:0.
        The goal of this study was to evaluate the possible use of the Environmental Relative Moldiness Index (ERMI) to quantify mold contamination in multi-level, office buildings. Settled-dust samples were collected in multi-level, office buildings and the ERMI value for each sample determined. In the first study, a comparison was made between two identical four-story buildings. There were health complaints in one building but none in the other building. In the second study, mold contamination was evaluated on levels 6 through 19 of an office building with a history of water problems and health complaints. In the first study, the average ERMI value in the building with health complaints was 5.33 which was significantly greater than the average ERMI value, 0.55, in the non-complaint building. In the second study, the average ERMI values ranged from a low of -0.58 on level 8 to a high of 5.66 on level 17, one of the top five ranked levels for medical symptoms or medication use. The mold populations of ten (six Group 1 and four Group 2) of the 36-ERMI molds were in significantly greater concentrations in the higher compared to lower ERMI environments. The ERMI metric may be useful in the quantification of water-damage and mold growth in multi-level buildings.

    • Genetics and Genomics
      1. Pilot screening study of targeted genetic polymorphisms for association with seasonal influenza hospital admission
        Carter TC, Hebbring SJ, Liu J, Mosley JD, Shaffer CM, Ivacic LC, Kopitzke S, Stefanski EL, Strenn R, Sundaram ME, Meece J, Brilliant MH, Ferdinands JM, Belongia EA.
        J Med Virol. 2017 Oct 20.
        Host response to influenza is highly variable, suggesting a potential role of host genetic variation. To investigate the host genetics of severe influenza in a targeted fashion, 32 single nucleotide polymorphisms (SNPs) within viral immune response genes were evaluated for association with seasonal influenza hospitalization in an adult study population with European ancestry. SNP allele and genotype frequencies were compared between hospitalized influenza patients (cases) and population controls in a case-control study that included a discovery group (26 cases and 993 controls) and two independent, validation groups (one with 84 cases and 4,076 controls; the other with 128 cases and 9,187 controls). Cases and controls had similar allele frequencies for variant rs12252 in interferon-inducible transmembrane protein 3 (IFITM3) (P > 0.05), and the study did not replicate the previously reported association of rs12252 with hospitalized influenza. In the discovery group, the preliminary finding of an association with a nonsense polymorphism (rs8072510) within the schlafen family member 13 (SFLN13) gene (P = 0.0099) was not confirmed in either validation group. Neither rs12252 nor rs8072510 showed an association according to the presence of clinical risk factors for influenza complications (P > 0.05), suggesting that these factors did not modify associations between the SNPs and hospitalized influenza. No other SNPs showed a statistically significant association with hospitalized influenza. Further research is needed to identify genetic factors involved in host response to seasonal influenza infection and to assess whether rs12252, a low-frequency variant in Europeans, contributes to influenza severity in populations with European ancestry.

      2. Molecular characterization of Cryptococcus neoformans and Cryptococcus gattii from environmental sources and genetic comparison with clinical isolates in Apulia, Italy
        Montagna MT, De Donno A, Caggiano G, Serio F, De Giglio O, Bagordo F, D’Amicis R, Lockhart SR, Cogliati M.
        Environ Res. 2017 Oct 17;160:347-352.
        The present study investigated the environmental distribution of Cryptococcus neoformans and C. gattii species complex molecular types, mating types and sequence types in Apulia, a region of Southern Italy. A total of 2078 specimens from arboreal and animal sources were analyzed. The percentage of positive samples was similar among both arboreal and animal specimens: 4.2% vs. 5.1% for C. neoformans species complex and 0.6% vs. 1.4% for C. gattii species complex. Molecular typing identified 78 isolates as VNI (76 alphaA and two aA), one as AD-hybrid alphaADa, and 16 as VGI aB. VNI isolates presented 10 different sequence types (STs) and VGI isolates two. The most frequent STs among C. neoformans and C. gattii species complex isolates were ST23 (51%) and ST156 (90%), respectively. Comparison with molecular types and STs results obtained from 21 clinical isolates collected in Apulia showed that one C. neoformans VNI clinical isolate shared an identical sequence type of one arboreal isolate (ST61) and that one C. gattii VGI clinical isolate matched with the main ST (ST156) present in the environment. In addition, molecular type VNIV was found only among clinical isolates and was absent in the investigated environmental area. In conclusion, the present study identified which C. neoformans and C. gattii species complex genotypes are circulating in Apulia, defined their ecological niches and revealed the relationship with clinical cases. It represents a basal study for addressing future investigations and public health interventions in the region.

      3. Pre-vaccine circulating group a rotavirus strains in under 5 years children with acute diarrhea during 1999-2013 in Cameroon
        Ndombo PK, Ndze VN, Fokunang C, Ashukem TN, Boula A, Kinkela MN, Ndode CE, Seheri ML, Bowen MD, Waku-Kouomou D, Esona MD.
        Virology (Lond). 2017 Aug;1(4).
        The aim of this review was to assess all the studies on rotavirus G and P characterization during the pre-vaccine period (1999-2013) in Cameroon to have a better basis for post-vaccine introduction evaluations. A retrospective study was done through a comprehensive review of published (PubMed, Google Scholar) and accessible unpublished data on rotavirus G and P genotypes circulating in five regions of Cameroon. Descriptive data were expressed as frequencies tables and proportions. A total of 1844 rotavirus positive cases were analyzed. In all, 1534 strains were characterized for the P (VP4) specificity. Six different VP4 genotypes were observed, including P [4], P [6], P [8], P [9], P [10] and P [14]. The most predominant P genotypes were P [8] at 42.6%, and P [6] at 37.9%. Mixed infections were observed at 5.3%, whereas 4.1% of the strains were P non-typeable. A total of 1518 rotavirus strains were characterized for the G (VP7) specificity. VP7 genotypes G1, G2, G3, G4, G5, G6, G8, G9, G10 and G12 were observed. G1 (35.3%), G3 (19.5%), G2 (14.9%) and G12 (10.1%) were the predominant G genotypes while G5 and G10 were least prevalent at 0.06% each. Approximately 5.1% of all strains were G non-typeable whereas 5.3% were mixed G genotypes. A total of 1472 strains were characterized for both G and P genes, from which 38 different G-P combinations were observed. Overall, G1P [8] (22%) was identified as the predominant rotavirus strain circulating in Cameroon followed by G3P [6] (15%). In conclusion, we observed that the genotypes identified in Cameroon during 1999-2013 were partially covered by the two WHO recommended rotavirus vaccines. This review provides comprehensive up-to-date information on rotavirus strain surveillance in Cameroon during the pre-vaccination era.

      4. Molecular diagnostic tools have played an important role in improving our understanding of the transmission of Cryptosporidium spp. and Giardia duodenalis, which are two of the most important waterborne parasites in industrialized nations. Genotyping tools are frequently used in the identification of host-adapted Cryptosporidium species and G. duodenalis assemblages, allowing the assessment of infection sources in humans and public health potential of parasites found in animals and the environment. In contrast, subtyping tools are more often used in case linkages, advanced tracking of infections sources, and assessment of disease burdens attributable to anthroponotic and zoonotic transmission. More recently, multilocus typing tools have been developed for population genetic characterizations of transmission dynamics and delineation of mechanisms for the emergence of virulent subtypes. With the recent development in next generation sequencing techniques, whole genome sequencing and comparative genomic analysis are increasingly used in characterizing Cryptosporidium spp. and G. duodenalis. The use of these tools in epidemiologic studies has identified significant differences in the transmission of Cryptosporidium spp. in humans between developing countries and industrialized nations, especially the role of zoonotic transmission in human infection. Geographic differences are also present in the distribution of G. duodenalis assemblages A and B in humans. In contrast, there is little evidence for widespread zoonotic transmission of giardiasis in both developing and industrialized countries. Differences in virulence have been identified among Cryptosporidium species and subtypes, and possibly between G. duodenalis assemblages A and B, and genetic recombination has been identified as one mechanism for the emergence of virulent C. hominis subtypes. These recent advances are providing insight into the epidemiology of waterborne protozoan parasites in both developing and developed countries.

      5. Genome Sequences of Crimean-Congo hemorrhagic fever virus strains isolated in South Africa, Namibia, and Turkey
        Zivcec M, Albarino CG, Guerrero LI, Ksiazek TG, Nichol ST, Swanepoel R, Rollin PE, Spiropoulou CF.
        Genome Announc. 2017 Oct 19;5(42).
        We report here the full-length sequences of 16 historical isolates of Crimean-Congo hemorrhagic fever orthonairovirus (CCHFV) obtained in Turkey, Namibia, and South Africa. The strains may be useful for future work to develop molecular diagnostics or viral evolution studies.

    • Immunity and Immunization
      1. Reports of postural orthostatic tachycardia syndrome after human papillomavirus vaccination in the vaccine adverse event reporting system
        Arana J, Mba-Jonas A, Jankosky C, Lewis P, Moro PL, Shimabukuro TT, Cano M.
        J Adolesc Health. 2017 Nov;61(5):577-582.
        PURPOSE: Human papillomavirus (HPV) vaccination prevents infections with HPV strains that cause certain cancers. Reports of postural orthostatic tachycardia syndrome (POTS) following HPV vaccination have raised safety concerns. We reviewed POTS reports submitted to the Vaccine Adverse Event Reporting System (VAERS). METHODS: We searched the VAERS database for reports of POTS following any type of HPV vaccination (bivalent, quadrivalent, or nonavalent) from June 2006 to August 2015. We reviewed reports and applied established POTS diagnostic criteria. We calculated unadjusted POTS case reporting rates based on HPV vaccine doses distributed and conducted empirical Bayesian data mining to screen for disproportional reporting of POTS following HPV vaccination. RESULTS: Among 40,735 VAERS reports following HPV vaccination, we identified 29 POTS reports that fully met diagnostic criteria. Of these, 27 (93.1%) were in females and mean age was 14 years (range 12-32). Median time from vaccination to start of symptoms was 43 days (range 0-407); most (18, 75.0%) had onset between 0 and 90 days. Symptoms frequently reported concomitantly included headache (22, 75.9%) and dizziness (21, 72.4%). Twenty (68.9%) reports documented a history of pre-existing medical conditions, of which chronic fatigue (5, 17.2%), asthma (4, 13.8%), and chronic headache (3, 10.3%) were most common. Approximately one POTS case is reported for every 6.5 million HPV vaccine doses distributed in the United States. No empirical Bayesian data mining safety signals for POTS and HPV vaccination were detected. CONCLUSIONS: POTS is rarely reported following HPV vaccination. Our review did not detect any unusual or unexpected reporting patterns that would suggest a safety problem.

      2. Drinking water to prevent postvaccination presyncope in adolescents: A randomized trial
        Kemper AR, Barnett ED, Walter EB, Hornik C, Pierre-Joseph N, Broder KR, Silverstein M, Harrington T.
        Pediatrics. 2017 Oct 23.
        BACKGROUND AND OBJECTIVES: Postvaccination syncope can cause injury. Drinking water prephlebotomy increases peripheral vascular tone, decreasing risk of blood-donation presyncope and syncope. This study evaluated whether drinking water prevaccination reduces postvaccination presyncope, a potential syncope precursor. METHODS: We conducted a randomized trial of subjects aged 11 to 21 years receiving >/=1 intramuscular vaccine in primary care clinics. Intervention subjects were encouraged to drink 500 mL of water, with vaccination recommended 10 to 60 minutes later. Control subjects received usual care. Presyncope symptoms were assessed with a 12-item survey during the 20-minutes postvaccination. Symptoms were classified with a primary cutoff sensitive for presyncope, and a secondary, more restrictive cutoff requiring greater symptoms. Results were adjusted for clustering by recruitment center. RESULTS: There were 906 subjects randomly assigned to the control group and 901 subjects randomly assigned to the intervention group. None had syncope. Presyncope occurred in 36.2% of subjects by using the primary definition, and in 8.0% of subjects by using the restrictive definition. There were no significant differences in presyncope by intervention group for the primary (1-sided test, P = .24) or restrictive outcome (1-sided test, P = .17). Among intervention subjects vaccinated within 10 to 60 minutes after drinking all 500 mL of water (n = 519), no reduction in presyncope was observed for the primary or restrictive outcome (1-sided tests, P = .13, P = .17). In multivariable regression analysis, presyncope was associated with younger age, history of passing out or nearly passing out after a shot or blood draw, prevaccination anxiety, receiving >1 injected vaccine, and greater postvaccination pain. CONCLUSIONS: Drinking water before vaccination did not prevent postvaccination presyncope. Predictors of postvaccination presyncope suggest opportunities for presyncope and syncope prevention interventions.

      3. Patterns of childhood immunization and all-cause mortality
        McCarthy NL, Sukumaran L, Newcomer S, Glanz J, Daley MF, McClure D, Klein NP, Irving S, Jackson ML, Lewin B, Weintraub E.
        Vaccine. 2017 Oct 20.
        BACKGROUND: Evidence supports the safety of the recommended childhood immunization schedule as a whole. However, additional research is warranted as parents’ refusing or delaying vaccinations has increased in recent years. All-cause mortality has been identified as a priority outcome to study in the context of the recommended immunization schedule. METHODS: We included children born January 1, 2004 through December 31, 2009, enrolled in the Vaccine Safety Datalink (VSD) from birth through 18 months of age. We examined vaccination patterns during the first 18 months of life among 8 vaccines, and identified deaths occurring between 19 and 48 months of age. We excluded children with complex chronic conditions, contraindications to vaccination, and deaths due to injuries, congenital anomalies, or diseases with onset prior to 19 months of age. We calculated mortality rates among children with different patterns of immunization, and incidence rate ratios (IRR) using the Cox proportional hazards model for children vaccinated according to the schedule versus undervaccinated children, adjusting for outpatient healthcare utilization, influenza vaccination, sex, and VSD site. RESULTS: Among 312,388 children in the study, 199,661 (64%) were vaccinated according to the schedule, and 112,727 (36%) were delayed or not vaccinated for at least one vaccine dose. Of 18 deaths eligible for analysis, 11 occurred in children following the schedule (2.28 per 100,000 person-years), and seven occurred in undervaccinated children (2.57 per 100,000 person-years). Mortality rates among children following the schedule were not significantly different from those of undervaccinated children when excluding deaths with unknown causes (IRR=1.29, 95% CI=0.33-4.99), as well as when including deaths with unknown causes (IRR=0.84, 95% CI=0.32-2.99). CONCLUSION: Although there were few deaths, our results do not indicate a difference in risk of all-cause mortality among fully vaccinated versus undervaccinated children. Our findings support the safety of the currently recommended immunization schedule with regard to all-cause mortality.

      4. Impact of rotavirus vaccine on all-cause diarrhea and rotavirus hospitalizations in Madagascar
        Rahajamanana VL, Raboba JL, Rakotozanany A, Razafindraibe NJ, Andriatahirintsoa E, Razafindrakoto AC, Mioramalala SA, Razaiarimanga C, Weldegebriel GG, Burnett E, Mwenda JM, Seheri M, Mphahlele MJ, Robinson AL.
        Vaccine. 2017 Sep 25.
        BACKGROUND: Rotavirus vaccine was introduced into the Extended Program on Immunization in Madagascar in May 2014. We analyzed trends in prevalence of all cause diarrhea and rotavirus hospitalization in children <5years of age before and after vaccine introduction and assessed trend of circulating rotavirus genotypes at Centre Hospitalier Universitaire Mere Enfant Tsaralalana (CHU MET). METHODS: From January 2010 to December 2016, we reviewed the admission logbook to observe the rate of hospitalization caused by gastroenteritis among 19619 children <5years of age admitted at the hospital. In June 2013-December 2016, active rotavirus surveillance was also conducted at CHUMET with support from WHO. Rotavirus antigen was detected by EIA from stool specimen of children who are eligible for rotavirus gastroenteritis surveillance at sentinel site laboratory and rotavirus positive specimens were further genotyped at Regional Reference Laboratory by RT-PCR. RESULTS: Diarrhea hospitalizations decreased after rotavirus vaccine introduction. The median proportion of annual hospitalizations due to diarrhea was 26% (range: 31-22%) before vaccine introduction; the proportion was 25% the year of vaccine introduction, 17% in 2015 and 16% in 2016. Rotavirus positivity paralleled patterns observed in diarrhea. Before vaccine introduction, 56% of stool specimens tested positive for rotavirus; the percent positive was 13% in 2015, 12% in 2016. Diverse genotypes were detected in the pre-vaccine period; the most common were G3P[8] (n=53; 66%), G2P[4] (n=12; 15%), and G1P[8] (n=11; 14%). 6 distinct genotypes were found in 2015; the most common genotype was G2P[4] (n=10; 67%), the remaining, 5, G12[P8], G3[P8], G1G3[P4], G3G12[P4][P8] and G1G3[NT] had one positive specimen each. CONCLUSIONS: Following rotavirus vaccine introduction all-cause diarrhea and rotavirus-specific hospitalizations declined dramatically. The most common genotypes detected in the pre-vaccine period were G3P[8] and G2P[4] in 2015, the post vaccine period.

      5. The effect of antipyretics on immune response and fever following receipt of inactivated influenza vaccine in young children
        Walter EB, Hornik CP, Grohskopf L, McGee CE, Todd CA, Museru OI, Harrington L, Broder KR.
        Vaccine. 2017 Oct 19.
        BACKGROUND: Antipyretics reduce fever following childhood vaccinations; after inactivated influenza vaccine (IIV) they might ameliorate fever and thereby decrease febrile seizure risk, but also possibly blunt the immune response. We assessed the effect of antipyretics on immune responses and fever following IIV in children ages 6 through 47 months. METHODS: Over the course of three seasons, one hundred forty-two children, receiving either a single or the first of 2 recommended doses of IIV, were randomized to receive either oral acetaminophen suspension (n=59) or placebo (n=59) (double-blinded) or ibuprofen (n=24) (open-label) immediately following IIV and every 4-8 h thereafter for 24 h. Blood samples were obtained at enrollment and 4 weeks following the last recommended IIV dose. Responses to IIV were assessed by hemagglutination inhibition assay (HAI). Seroprotection was defined as an HAI titer >/=1:40 and seroconversion as a titer >/=1:40 if baseline titer <1:10 or four-fold rise if baseline titer >/=1:10. Participants were monitored for fever and other solicited symptoms on the day of and day following IIV. RESULTS: Significant differences in seroconversion and post-vaccination seroprotection were not observed between children included in the different antipyretic groups and the placebo group for the vaccine antigens included in IIV over the course of the studies. Frequencies of solicited symptoms, including fever, were similar between treatment groups and the placebo group. CONCLUSIONS: Significant blunting of the immune response was not observed when antipyretics were administered to young children receiving IIV. Studies with larger sample sizes are needed to definitively establish the effect of antipyretics on IIV immunogenicity.

    • Injury and Violence
      1. Nine-point plan to improve care of the injured patient: A case study from Kenya
        Bachani AM, Botchey I, Paruk F, Wako D, Saidi H, Aliwa B, Kibias S, Hyder AA.
        Surgery. 2017 Oct 16.
        BACKGROUND: Injury rates in low- and middle-income countries are among the greatest in the world, with >90% of unintentional injury occurring in low- or middle-income countries. The risk of death from injuries is 6 times more in low- and middle-income countries than in high-income countries. This increased rate of injury is partly due to the lack of availability and access to timely and appropriate medical care for injured individuals. Kenya, like most low- and middle-income countries, has seen a 5-fold increase in injury fatalities throughout the past 4 decades, in large part related to the absence of a coordinated, integrated system of trauma care. METHODS: We aimed to assess the trauma-care system in Kenya and to develop and implement a plan to improve it. A trauma system profile was performed to understand the landscape for the care of the injured patient in Kenya. This process helped identify key gaps in care ranging from prehospital to hospital-based care. RESULTS: In response to this observation, a 9-point plan to improve trauma care in Kenya was developed and implemented in close collaboration with local stakeholders. The 9-point plan was centered on engagement of the stakeholders, generation of key data to guide and improve services, capacity development for prehospital and hospital care, and strengthening policy and legislation. CONCLUSION: There is an urgent need for coordinated strategies to provide appropriate and timely medical care to injured individuals in low- or middle-income countries to decrease the burden of injuries and related fatalities. Our work in Kenya shows that such an integrated system of trauma care could be achieved through a step-by-step integrated and multifaceted approach that emphasizes engagement of local stakeholders and evidence-based approaches to ensure effectiveness, efficiency, and sustainability of system-wide improvements. This plan and lessons learned in its development and implementation could be adaptable to other similar settings to improve the care of the injured patient in low- or middle-income countries.

      2. Suicide trends among and within urbanization levels by sex, race/ethnicity, age group, and mechanism of death – United States, 2001-2015
        Ivey-Stephenson AZ, Crosby AE, Jack SP, Haileyesus T, Kresnow-Sedacca MJ.
        MMWR Surveill Summ. 2017 Oct 06;66(18):1-16.
        PROBLEM/CONDITION: Suicide is a public health problem and one of the top 10 leading causes of death in the United States. Substantial geographic variations in suicide rates exist, with suicides in rural areas occurring at much higher rates than those occurring in more urban areas. Understanding demographic trends and mechanisms of death among and within urbanization levels is important to developing and targeting future prevention efforts. REPORTING PERIOD: 2001-2015. DESCRIPTION OF SYSTEM: Mortality data from the National Vital Statistics System (NVSS) include demographic, geographic, and cause of death information derived from death certificates filed in the 50 states and the District of Columbia. NVSS was used to identify suicide deaths, defined by International Classification of Diseases, 10th Revision (ICD-10) underlying cause of death codes X60-X84, Y87.0, and U03. This report examines annual county level trends in suicide rates during 2001-2015 among and within urbanization levels by select demographics and mechanisms of death. Counties were collapsed into three urbanization levels using the 2006 National Center for Health Statistics classification scheme. RESULTS: Suicide rates increased across the three urbanization levels, with higher rates in nonmetropolitan/rural counties than in medium/small or large metropolitan counties. Each urbanization level experienced substantial annual rate changes at different times during the study period. Across urbanization levels, suicide rates were consistently highest for men and non-Hispanic American Indian/Alaska Natives compared with rates for women and other racial/ethnic groups; however, rates were highest for non-Hispanic whites in more metropolitan counties. Trends indicate that suicide rates for non-Hispanic blacks were lowest in nonmetropolitan/rural counties and highest in more urban counties. Increases in suicide rates occurred for all age groups across urbanization levels, with the highest rates for persons aged 35-64 years. For mechanism of death, greater increases in rates of suicide by firearms and hanging/suffocation occurred across all urbanization levels; rates of suicide by firearms in nonmetropolitan/rural counties were almost two times that of rates in larger metropolitan counties. INTERPRETATION: Suicide rates in nonmetropolitan/rural counties are consistently higher than suicide rates in metropolitan counties. These trends also are observed by sex, race/ethnicity, age group, and mechanism of death. PUBLIC HEALTH ACTION: Interventions to prevent suicides should be ongoing, particularly in rural areas. Comprehensive suicide prevention efforts might include leveraging protective factors and providing innovative prevention strategies that increase access to health care and mental health care in rural communities. In addition, distribution of socioeconomic factors varies in different communities and needs to be better understood in the context of suicide prevention.

    • Laboratory Sciences
      1. Characterizing workforces exposed to current and emerging non-carbonaceous nanomaterials in the U.S
        Babik KR, Dahm MM, Dunn KH, Dunn KL, Schubauer-Berigan MK.
        J Occup Environ Hyg. 2017 Oct 20:0.
        OBJECTIVE: Toxicology studies suggest that exposure to certain types of engineered nanomaterials (ENMs) may cause adverse health effects, but little is known about the workforce in the United States that produces or uses these materials. In addition, occupational exposure control strategies in this industry are not well characterized. This study identified US ENM manufacturers and users (other than carbon nanotubes and nanofibers, which have been characterized elsewhere), determined workforce size, characterized types and quantities of materials used, occupational exposure control strategies, and the feasibility of occupational ENM exposure studies. METHODS: Eligible companies were identified and information was collected through phone surveys on nanomaterials produced or used, workforce size, location, work practices, and exposure control strategies. The companies were classified into groups for additional examinations. RESULTS: Forty-nine companies producing or using ENMs in the US were identified. These companies employed at least 1500 workers. Most companies produced or used some form of nanoscale metal. More than half of the eligible companies were suppliers for the coatings, composite materials, or general industries. Each company provided information about worker exposure reduction strategies through engineering controls, administrative controls, or personal protective equipment. Production-scale companies reported greater use of specific exposure control strategies for ENMs than laboratory-scale companies. CONCLUSIONS: Workplaces producing or using ENMs report using engineering and administrative controls as well as personal protective equipment to control worker exposure. Industrywide exposure assessment studies appear feasible due to workforce size. However, more effort must be taken to target industries using specific ENMs based on known toxicological effects and health risks.

      2. Immunopurification of acetylcholinesterase from red blood cells for detection of nerve agent exposure
        Dafferner AJ, Schopfer LM, Xiao G, Cashman JR, Yerramalla U, Johnson RC, Blake TA, Lockridge O.
        Chem Res Toxicol. 2017 Oct 16;30(10):1897-1910.
        Nerve agents and organophosphorus pesticides make a covalent bond with the active site serine of acetylcholinesterase (AChE), resulting in inhibition of AChE activity and toxic symptoms. AChE in red blood cells (RBCs) serves as a surrogate for AChE in the nervous system. Mass spectrometry analysis of adducts on RBC AChE could provide evidence of exposure. Our goal was to develop a method of immunopurifying human RBC AChE in quantities adequate for detecting exposure by mass spectrometry. For this purpose, we immobilized 3 commercially available anti-human acetylcholinesterase monoclonal antibodies (AE-1, AE-2, and HR2) plus 3 new monoclonal antibodies. The monoclonal antibodies were characterized for binding affinity, epitope mapping by pairing analysis, and nucleotide and amino acid sequences. AChE was solubilized from frozen RBCs with 1% (v/v) Triton X-100. A 16 mL sample containing 5.8 mug of RBC AChE was treated with a quantity of soman model compound that inhibited 50% of the AChE activity. Native and soman-inhibited RBC AChE samples were immunopurified on antibody-Sepharose beads. The immunopurified RBC AChE was digested with pepsin and analyzed by liquid chromatography tandem mass spectrometry on a 6600 Triple-TOF mass spectrometer. The aged soman-modified PheGlyGluSerAlaGlyAlaAlaSer (FGESAGAAS) peptide was detected using a targeted analysis method. It was concluded that all 6 monoclonal antibodies could be used to immunopurify RBC AChE and that exposure to nerve agents could be detected as adducts on the active site serine of RBC AChE.

      3. Diesel engines serve many purposes in modern oil and gas extraction activities. Diesel particulate matter (DPM) emitted from diesel engines is a complex aerosol that may cause adverse health effects depending on exposure dose and duration. This study reports on personal breathing zone (PBZ) and area measurements for DPM (expressed as elemental carbon) during oil and gas extraction operations including drilling, completions (which includes hydraulic fracturing) and servicing work. Researchers at the National Institute for Occupational Safety and Health (NIOSH) collected 104 full-shift air samples (49 PBZ and 55 area) in Colorado, North Dakota, Texas, and New Mexico during a four year period from 2008-2012 The arithmetic mean (AM) of the full shift TWA PBZ samples was 10 microg/m3; measurements ranged from 0.1 to 52 microg/m3. The geometric mean (GM) for the PBZ samples was 7 microg/m3. The AM of the TWA area measurements was 17 microg/m3 and ranged from 0.1 to 68 microg/m3. The GM for the area measurements was 9.5 microg/m3. Differences between the GMs of the PBZ samples and area samples were not statistically different (P>0.05). Neither the Occupational Safety and Health Administration (OSHA), NIOSH, nor the American Conference of Governmental Industrial Hygienists (ACGIH) have established occupational exposure limits (OEL) for DPM. However, the State of California, Department of Health Services lists a time-weighted average (TWA) OEL for DPM as elemental carbon (EC) exposure of 20 microg/m3. Five of 49 (10.2%) PBZ TWA measurements exceeded the 20 microg/m3 EC criterion. These measurements were collected on Sandmover and Transfer Belt (T-belt) Operators, Blender and Chemical Truck Operators, and Water Transfer Operators during hydraulic fracturing operations. Recommendations to minimize DPM exposures include elimination (locating diesel-driven pumps away from well sites), substitution, (use of alternative fuels), engineering controls using advanced emissions controls technologies, administrative controls (configuration of well sites), hazard communication and worker training.

      4. Pulmonary toxicity following acute coexposures to diesel particulate matter and alpha-quartz crystalline silica in the Sprague-Dawley rat
        Farris BY, Antonini JM, Fedan JS, Mercer RR, Roach KA, Chen BT, Schwegler-Berry D, Kashon ML, Barger MW, Roberts JR.
        Inhalation Toxicology. 2017 ;29(7):322-339.
        The effects of acute pulmonary coexposures to silica and diesel particulate matter (DPM), which may occur in various mining operations, were investigated in vivo. Rats were exposed by intratracheal instillation (IT) to silica (50 or 233??g), DPM (7.89 or 50??g) or silica and DPM combined in phosphate-buffered saline (PBS) or to PBS alone (control). At one day, one week, one month, two months and three months postexposure bronchoalveolar lavage and histopathology were performed to assess lung injury, inflammation and immune response. While higher doses of silica caused inflammation and injury at all time points, DPM exposure alone did not. DPM (50??g) combined with silica (233??g) increased inflammation at one week and one-month postexposure and caused an increase in the incidence of fibrosis at one month compared with exposure to silica alone. To assess susceptibility to lung infection following coexposure, rats were exposed by IT to 233??g silica, 50??g DPM, a combination of the two or PBS control one week before intratracheal inoculation with 5 ? 105 Listeria monocytogenes. At 1, 3, 5, 7 and 14 days following infection, pulmonary immune response and bacterial clearance from the lung were evaluated. Coexposure to DPM and silica did not alter bacterial clearance from the lung compared to control. Although DPM and silica coexposure did not alter pulmonary susceptibility to infection in this model, the study showed that noninflammatory doses of DPM had the capacity to increase silica-induced lung injury, inflammation and onset/incidence of fibrosis.

      5. Evaluating optical hazards from plasma arc cutting
        Glassford E, Burr G.
        J Occup Environ Hyg. 2017 Oct 23:0.
        The Health Hazard Evaluation Program of the National Institute for Occupational Safety and Health evaluated a steel building materials manufacturer. The employer requested the evaluation because of concerns about optical radiation hazards from a plasma arc cutting system and the need to clarify eye protection requirements for plasma operators, other employees, and visitors. The strength of the ultraviolet radiation, visible radiation (light), and infrared radiation generated by the plasma arc cutter was measured at various distances from the source and at different operating amperages. Investigators also observed employees performing the plasma arc cutting. Optical radiation above safe levels for the unprotected eyes in the ultraviolet-C, ultraviolet-B, and visible light ranges were found during plasma arc cutting. In contrast, infrared and ultraviolet-A radiation levels during plasma arc cutting were similar to background levels. The highest non-ionizing radiation exposures occurred when no welding curtains were used. A plasma arc welding curtain in place did not eliminate optical radiation hazards to the plasma arc operator or to nearby employees. In most instances, the measured intensities for visible light, UV-C, and UV-B resulted in welding shade lens numbers that were lower than those stipulated in the OSHA Filter Lenses for Protection Against Radiant Energy table in 29 CFR 1910.133(a)(5). (1) Investigators recommended using a welding curtain that enclosed the plasma arc, posting optical radiation warning signs in the plasma arc cutter area, installing audible or visual warning cues when the plasma arc cutter was operating, and using welding shades that covered the plasma arc cutter operator’s face to protect skin from ultraviolet radiation hazards.

    • Maternal and Child Health
      1. Trends in risk of pregnancy loss among US women, 1990-2011
        Rossen LM, Ahrens KA, Branum AM.
        Paediatr Perinat Epidemiol. 2017 Oct 20.
        BACKGROUND: Pregnancy loss can have physical and psychological consequences for women and their families. Though a previous study described an increase in the risk of self-reported pregnancy loss from 1970 to 2000, more recent examinations from population-based data of US women are lacking. METHODS: We used data from the 1995, 2002, 2006-2010, 2011-2015 National Survey of Family Growth on self-reported pregnancy loss (miscarriage, stillbirth, ectopic pregnancy) among US women (15-44 years) who reported at least one pregnancy conceived during 1990-2011 that did not result in induced termination (n = 20 012 women; n = 42 526 pregnancies). Trends in the risk of self-reported pregnancy loss and early pregnancy loss (<12 weeks) were estimated, separately, by year of pregnancy conception (limited to 1990-2011 to ensure a sufficient sample of pregnancies for each year and maternal age group) using log-Binomial and Poisson models, adjusted for maternal- and pregnancy-related factors. RESULTS: Among all self-reported pregnancies, excluding induced terminations, the risk of pregnancy loss was 19.7% and early pregnancy loss was 13.5% during 1990-2011. Risk of pregnancy loss increased by a relative 2% (rate ratio [RR] 1.02, 95% confidence interval [CI] 1.01, 1.02) per year in unadjusted models and 1% per year (RR 1.01, 95% CI 1.00, 1.02) during 1990-2011, after adjustment for maternal characteristics and pregnancy-related factors. In general, trends were similar for early pregnancy loss. CONCLUSION: From 1990 to 2011, risk of self-reported pregnancy loss increased among US women. Further work is needed to better understand the drivers of this increase in reported pregnancy loss in the US.

      2. Childhood polybrominated diphenyl ether (PBDE) exposure and executive function in children in the HOME Study
        Vuong AM, Yolton K, Poston KL, Xie C, Webster GM, Sjodin A, Braun JM, Dietrich KN, Lanphear BP, Chen A.
        Int J Hyg Environ Health. 2017 Oct 16.
        Prenatal exposure to polybrominated diphenyl ethers (PBDEs) have been reported to impair executive function in children, but little is known whether childhood PBDE exposures play a role. Using the Health Outcomes and Measures of the Environment (HOME) Study, a prospective birth cohort in the greater Cincinnati area, we investigated the association between repeated measures of PBDEs during childhood and executive function at 8 years in 208 children and whether effect modification by child sex was present. We used child serum collected at 1, 2, 3, 5, and 8 years to measure PBDEs. The Behavior Rating Inventory of Executive Function was completed by parents to assess executive function at 8 years. We used multiple informant models to examine childhood PBDEs during several exposure windows. Null associations were observed between early childhood PBDEs and executive function. However, we observed significant adverse associations between a 10-fold increase in concurrent concentrations of BDE-28 (beta=4.6, 95% CI 0.5, 8.7) and BDE-153 (beta=4.8, 95% CI 0.8, 8.8) with behavioral regulation. In addition, PBDEs at 8 years were significantly associated with poorer emotional and impulse control. No associations were noted between childhood PBDEs and metacognition or global executive function. However, child sex significantly modified the associations, with significantly poorer executive function among males with higher concurrent BDE-153, and null associations in females. Our study findings suggest that concurrent PBDE exposures during childhood may be associated with poorer executive function, specifically behavior regulation. Males may also be more sensitive to adverse associations of concurrent PBDEs on executive function.

    • Occupational Safety and Health
      1. Evaluation of an improved prototype mini-baghouse to control the release of respirable crystalline silica from sand movers
        Alexander BM, Esswein EJ, Gressel MG, Kratzer JL, Feng HA, Miller AL, Cauda E, Heil G.
        J Occup Environ Hyg. 2017 Oct 20:0.
        The OSHA final rule on respirable crystalline silica (RCS) will require hydraulic fracturing companies to implement engineering controls to limit workers’ exposure to RCS. RCS is generated by pneumatic transfer of quartz-containing sand during hydraulic fracturing operations. Chronic inhalation of RCS can lead to serious disease, including silicosis and lung cancer. NIOSH research identified at least seven sources where RCS aerosols were generated at hydraulic fracturing sites. NIOSH researchers developed an engineering control to address one of the largest sources of RCS aerosol generation, RCS escaping from thief hatches on the top of sand movers. The control, the NIOSH Mini-Baghouse Retrofit Assembly (NMBRA), mounts on the thief hatches. Unlike most commercially-available engineering controls, the NMBRA has no moving parts and requires no power source. This article details the results of an evaluation of generation 3 of the NMBRA at a sand mine in Arkansas from May 19 – 21, 2015. During the evaluation, 168 area air samples were collected at 12 locations on and around a sand mover with and without the NMBRA installed. Analytical results for respirable dust and RCS indicated the use of the NMBRA effectively reduced concentrations of both respirable dust and RCS downwind of the thief hatches. Reductions of airborne respirable dust were estimated at 99+%; reductions in airborne RCS ranged from 98-99%. Analysis of bulk samples of the dust showed the likely presence of freshly fractured quartz, a particularly hazardous form of RCS. Use of an improved filter fabric and a larger area of filter cloth led to substantial improvements in filtration and pressures during these trials, as compared to the generation 2 NMBRA. Planned future design enhancements, including a weather cover, will increase the performance and durability of the NMBRA. Future trials are planned to evaluate the long-term operability of the technology.

      2. Carbon monoxide exposure in workplaces, including coffee processing facilities
        Hawley B, Cox-Ganser JM, Cummings KJ.
        Am J Respir Crit Care Med. 2017 Oct 15;196(8):1080-1081.

        [No abstract]

      3. Ambulance disinfection using Ultraviolet Germicidal Irradiation (UVGI): Effects of fixture location and surface reflectivity
        Lindsley WG, McClelland TL, Neu DT, Martin SB, Mead KR, Thewlis RE, Noti JD.
        J Occup Environ Hyg. 2017 Oct 23:0.
        Ambulances are frequently contaminated with infectious microorganisms shed by patients during transport that can be transferred to subsequent patients and emergency medical service workers. Manual decontamination is tedious and time-consuming, and persistent contamination is common even after cleaning. Ultraviolet germicidal irradiation (UVGI) has been proposed as a terminal disinfection method for ambulance patient compartments. However, no published studies have tested the use of UVGI in ambulances. The objectives of this study were to investigate the efficacy of a UVGI system in an ambulance patient compartment and to examine the impact of UVGI fixture position and the UV reflectivity of interior surfaces on the time required for disinfection. A UVGI fixture was placed in the front, middle or back of an ambulance patient compartment, and the UV irradiance was measured at 49 locations. Aluminum sheets and UV-reflective paint were added to examine the effects of increasing surface reflectivity on disinfection time. Disinfection tests were conducted using Bacillus subtilis spores as a surrogate for pathogens. Our results showed that the UV irradiance varied considerably depending upon the surface location. For example, with the UVGI fixture in the back position and without the addition of UV-reflective surfaces, the most irradiated location received a dose of UVGI sufficient for disinfection in 16 seconds, but the least irradiated location required 15 hours. Because the overall time required to disinfect all of the interior surfaces is determined by the time required to disinfect the surfaces receiving the lowest irradiation levels, the patient compartment disinfection times for different UVGI configurations ranged from 16.5 hours to 59 minutes depending upon the UVGI fixture position and the interior surface reflectivity. These results indicate that UVGI systems can reduce microbial surface contamination in ambulance compartments, but the systems must be rigorously validated before deployment. Optimizing the UVGI fixture position and increasing the UV reflectivity of the interior surfaces can substantially improve the performance of a UVGI system and reduce the time required for disinfection.

      4. Occupational exposures and subclinical interstitial lung disease. The mesa (multi-ethnic study of atherosclerosis) air and lung studies
        Sack CS, Doney BC, Podolanczuk AJ, Hooper LG, Seixas NS, Hoffman EA, Kawut SM, Vedal S, Raghu G, Barr RG, Lederer DJ, Kaufman JD.
        Am J Respir Crit Care Med. 2017 Oct 15;196(8):1031-1039.
        RATIONALE: The impact of a broad range of occupational exposures on subclinical interstitial lung disease (ILD) has not been studied. OBJECTIVES: To determine whether occupational exposures to vapors, gas, dust, and fumes (VGDF) are associated with high-attenuation areas (HAA) and interstitial lung abnormalities (ILA), which are quantitative and qualitative computed tomography (CT)-based measurements of subclinical ILD, respectively. METHODS: We performed analyses of participants enrolled in MESA (Multi-Ethnic Study of Atherosclerosis), a population-based cohort aged 45-84 years at recruitment. HAA was measured at baseline and on serial cardiac CT scans in 5,702 participants. ILA was ascertained in a subset of 2,312 participants who underwent full-lung CT scanning at 10-year follow-up. Occupational exposures were assessed by self-reported VGDF exposure and by job-exposure matrix (JEM). Linear mixed models and logistic regression were used to determine whether occupational exposures were associated with log-transformed HAA and ILA. Models were adjusted for age, sex, race/ethnicity, education, employment status, tobacco use, and scanner technology. MEASUREMENTS AND MAIN RESULTS: Each JEM score increment in VGDF exposure was associated with 2.64% greater HAA (95% confidence interval [CI], 1.23-4.19%). Self-reported vapors/gas exposure was associated with an increased odds of ILA among those currently employed (1.76-fold; 95% CI, 1.09-2.84) and those less than 65 years old (1.97-fold; 95% CI, 1.16-3.35). There was no consistent evidence that occupational exposures were associated with progression of HAA over the follow-up period. CONCLUSIONS: JEM-assigned and self-reported exposures to VGDF were associated with measurements of subclinical ILD in community-dwelling adults.

      5. The effect of perceived overqualification on job satisfaction and career satisfaction among immigrants: Does host national identity matter?
        Wassermann M, Fujishiro K, Hoppe A.
        International Journal of Intercultural Relations. 2017 ;61:77-87.
        Overqualification is a form of person-job misfit that is common among those who reside in a foreign country. It is associated with poor work-related well-being and can inhibit full adjustment to the host society. The goal of our study is to examine the impact of perceived overqualification on job satisfaction and career satisfaction among immigrants. Furthermore, we investigated immigrants? host national identity as a moderator of the impact of perceived overqualification on job satisfaction and career satisfaction. We analysed longitudinal online survey data from 124 Italian and Spanish immigrants who migrated to Germany between 2000 and 2014. Regression analyses show that perceived overqualification is negatively associated with job satisfaction six months later. Furthermore, host national identity moderates the association between perceived overqualification and job satisfaction: low overqualification is beneficial for job satisfaction whereas high overqualification is a threat for job satisfaction, especially for immigrants who identify strongly with the host society. We do not find corresponding direct and moderating effects on career satisfaction. We conclude that indicators of acculturation, such as host national identity, are worth considering in order to understand the impact of person-job misfit on work-related well-being among immigrants. ? 2017 Elsevier Ltd

    • Parasitic Diseases
      1. Cluster randomized trial comparing school-based mass drug administration schedules in areas of western Kenya with moderate initial prevalence of Schistosoma mansoni infections
        Karanja DM, Awino EK, Wiegand RE, Okoth E, Abudho BO, Mwinzi PN, Montgomery SP, Secor WE.
        PLoS Negl Trop Dis. 2017 Oct 23;11(10):e0006033.
        BACKGROUND: Mass drug administration (MDA) using praziquantel is the WHO-recommended approach for control of schistosomiasis. However, few studies have compared the impact of different schedules of MDA on the resultant infection levels. We wished to evaluate whether annual MDA was more effective than less frequent treatments for reducing community-level prevalence and intensity of Schistosoma mansoni infections. METHODS: We performed a cluster randomized trial (ISRCTN 14849830) of 3 different MDA frequencies over a 5 year period in 75 villages with moderate (10%-24%) initial prevalence of S. mansoni in school children in western Kenya. Praziquantel was distributed by school teachers to students either annually, the first 2 years, or every other year over a 4 year period. Prevalence and intensity of infection were measured by stool examination in 9-12 year old students using the Kato-Katz method at baseline, each treatment year, and for the final evaluation at year 5. S. mansoni prevalence and intensity were also measured in first year students at baseline and year 5. RESULTS: Twenty-five schools were randomly assigned to each arm. S. mansoni prevalence and infection intensity in 9-12 year old students significantly decreased within each arm from baseline to year 5 but there were no differences between arms. There were no differences in infection levels in first year students either within or between arms. CONCLUSIONS: Strategies employing 2 or 4 rounds of MDA had a similar impact in schools with moderate initial prevalence, suggesting that schistosomiasis control can be sustained by school-based MDA, even if provided only every other year.

    • Statistics as Topic
      1. Comparing the historical limits method with regression models for weekly monitoring of national notifiable diseases reports
        Zhou H, Burkom H, Strine TW, Katz S, Jajosky R, Anderson W, Ajani U.
        J Biomed Inform. 2017 Oct 17.
        To compare the performance of the standard Historical Limits Method (HLM), with a modified HLM (MHLM), the Farrington-like Method (FLM), and the Serfling-like Method (SLM) in detecting simulated outbreak signals. We used weekly time series data from 12 infectious diseases from the U.S. Centers for Disease Control and Prevention’s National Notifiable Diseases Surveillance System (NNDSS). Data from 2006-2010 were used as baseline and from 2011-2014 were used to test the four detection methods. MHLM outperformed HLM in terms of background alert rate, sensitivity, and alerting delay. On average, SLM and FLM had higher sensitivity than MHLM. Among the four methods, the FLM had the highest sensitivity and lowest background alert rate and alerting delay. Revising or replacing the standard HLM may improve the performance of aberration detection for NNDSS standard weekly reports.

    • Substance Use and Abuse
      1. Changes in self-reported smokefree workplace policy coverage among employed adults-United States, 2003 and 2010-2011
        Babb S, Liu B, Kenemer B, Holmes CB, Hartman AM, Gibson JT, King BA.
        Nicotine Tob Res. 2017 Oct 12.
        Introduction: The workplace is a major source of exposure to secondhand smoke from combustible tobacco products. Smokefree workplace policies protect nonsmoking workers from secondhand smoke and help workers who smoke quit. This study examined changes in self-reported smokefree workplace policy coverage among U.S. workers from 2003 to 2010-2011. Methods: Data came from the 2003 (n = 74,728) and 2010-2011 (n = 70,749) waves of the Tobacco Use Supplement to the Current Population Survey. Among employed adults working indoors, a smokefree workplace policy was defined as a self-reported policy at the respondent’s workplace that did not allow smoking in work areas and public/common areas. Descriptive statistics were used to assess smokefree workplace policy coverage at two timepoints overall, by occupation, and by state. Results: The proportion of U.S. workers covered by smokefree workplace policies increased from 77.7% in 2003 to 82.8% in 2010-2011 (p < .00001). The proportion of workers reporting smokefree workplace policy coverage increased in 21 states (p < .001) and decreased in two states (p < .001) over this period. In 2010-2011, by occupation, this proportion ranged from 74.3% for blue collar workers to 84.9% for white collar workers; by state, it ranged from 63.3% in Nevada to 92.6% in Montana. Conclusions: From 2003 to 2010-2011, self-reported smokefree workplace policy coverage among indoor adult workers increased nationally, and occupational coverage disparities narrowed. However, coverage remained unchanged in half of states, and disparities persisted across occupations and states. Accelerated efforts are warranted to ensure that all workers are protected by smokefree workplace policies. Implications: This study assessed changes in the proportion of indoor workers reporting being covered by smokefree workplace policies from 2003 to 2010-2011 overall and by occupation and by state, using data from the Tobacco Use Supplement to the Current Population Survey. The findings indicate that smokefree workplace policy coverage among U.S. indoor workers has increased nationally, with occupational coverage disparities narrowing. However, coverage remained unchanged in half of states, and disparities persisted across occupations and states. Accelerated efforts are warranted to ensure that all workers are protected by smokefree workplace policies.

    • Zoonotic and Vectorborne Diseases
      1. Evaluation of immune responses in dogs to oral rabies vaccine under field conditions
        Smith TG, Millien M, Vos A, Fracciterne FA, Crowdis K, Chirodea C, Medley A, Chipman R, Qin Y, Blanton J, Wallace R.
        Vaccine. 2017 Oct 17.
        During the 20th century parenteral vaccination of dogs at central-point locations was the foundation of successful canine rabies elimination programs in numerous countries. However, countries that remain enzootic for canine rabies have lower infrastructural development compared to countries that have achieved elimination, which may make traditional vaccination methods less successful. Alternative vaccination methods for dogs must be considered, such as oral rabies vaccine (ORV). In 2016, a traditional mass dog vaccination campaign in Haiti was supplemented with ORV to improve vaccination coverage and to evaluate the use of ORV in dogs. Blisters containing live-attenuated, vaccine strain SPBNGAS-GAS were placed in intestine bait and distributed to dogs by hand. Serum was collected from 107 dogs, aged 3-12 months with no reported prior rabies vaccination, pre-vaccination and from 78/107 dogs (72.9%) 17 days post-vaccination. The rapid florescent focus inhibition test (RFFIT) was used to detect neutralizing antibodies and an ELISA to detect rabies binding antibodies. Post-vaccination, 38/41 (92.7%) dogs that received parenteral vaccine had detectable antibody (RFFIT >0.05IU/mL), compared to 16/27 (59.3%, p<0.01) dogs that received ORV or 21/27 (77.8%) as measured by ELISA (>40% blocking, p<0.05). The fate of 291 oral vaccines was recorded; 283 dogs (97.2%) consumed the bait; 272 dogs (93.4%) were observed to puncture the blister, and only 14 blisters (4.8%) could not be retrieved by vaccinators and were potentially left in the environment. Pre-vaccination antibodies (RFFIT >0.05IU/mL) were detected in 10/107 reportedly vaccine-naive dogs (9.3%). Parenteral vaccination remains the most reliable method for ensuring adequate immune response in dogs, however ORV represents a viable strategy to supplement existing parental vaccination campaigns in hard-to-reach dog populations. The hand-out model reduces the risk of unintended contact with ORV through minimizing vaccine blisters left in the community.

      2. Hidden dangers from the hunt
        Breedlove B, M’ikanatha NM.
        Emerging Infectious Diseases. 2017 ;23(9):1613-1614.

        [No abstract]

      3. Etymologia: Negri bodies
        Henry R, Murphy FA.
        Emerging Infectious Diseases. 2017 ;23(9):1461.

        [No abstract]

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