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Issue 49, December 12, 2017


CDC Science Clips: Volume 9, Issue 49, December 12, 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!

This week’s Top Ten articles show examples from programs funded by CDC’s National Center for Injury Prevention and Control. The program examples highlight the value of integrating systems thinking and traditional public health concepts to help move from “what works” as defined by research, to “how to make it work,” in practice. State health departments, universities, and local coalitions have applied the components of effective public health programs that value innovation, performance management, partnerships, communication, and political commitment in order to contribute to a robust public health system. Activities described include systems mapping, strategic planning, utilizing a shared risk and protective factor approach, creating diverse and engaged partnerships, utilizing data-to-action frameworks for synthesizing and applying data, surveillance, and evaluation.

  1. Top Articles of the Week

    Selected weekly by a senior CDC scientist from the standard sections listed below.
    The names of CDC authors are indicated in bold text.
    • Injury and Violence
      1. Programs geared toward preventing violence before it occurs at the community and societal levels of the social ecology are particularly challenging to evaluate. These programs are often focused on impacting the antecedents (or risk and protective factors) to violence, making it difficult to determine program success when solely relying on measures of violence reduction. The goal of this literature review is to identify indicators to measure risk and protective factors for violence that are accessible and measured at the community level. Indicators of community- and societal-level risk and protective factors from 116 articles are identified. These indicators strengthen violence prevention researchers’ and practitioners’ ability to detect proximal effects of violence prevention programs, practices, and policies, and provide timely feedback on the impact of their work. Thus, opportunities exist for violence prevention researchers to further study the associations between various indicators and different violent outcomes and to inform practitioner, evaluator, and funder developed logic models that include indicators of relevant risk and protective factors for crosscutting violence prevention measures and outcomes.

      2. The use of the Data-to-Action Framework in the evaluation of CDC’s DELTA FOCUS Program
        Armstead TL, Kearns M, Rambo K, Estefan LF, Dills J, Rivera MS, El-Beshti R.
        J Public Health Manag Pract. 2018 Jan/Feb;24 Suppl 1 :S51-s58.
        The Centers for Disease Control and Prevention’s (CDC’s) Domestic Violence Prevention Enhancements and Leadership Through Alliances, Focusing on Outcomes for Communities United with States (DELTA FOCUS) program is a 5-year cooperative agreement (2013-2018) funding 10 state domestic violence coalitions and local coordinated community response teams to engage in primary prevention of intimate partner violence. Grantees’ prevention strategies were often developmental and emergent; therefore, CDC’s approach to program oversight, administration, and support to grantees required a flexible approach. CDC staff adopted a Data-to-Action Framework for the DELTA FOCUS program evaluation that supported a culture of learning to meet dynamic and unexpected information needs. Briefly, a Data-to-Action Framework involves the collection and use of information in real time for program improvement. Utilizing this framework, the DELTA FOCUS data-to-action process yielded important insights into CDC’s ongoing technical assistance, improved program accountability by providing useful materials, and information for internal agency leadership, and helped build a learning community among grantees. CDC and other funders, as decision makers, can promote program improvements that are data-informed by incorporating internal processes supportive of ongoing data collection and review.

      3. State injury programs’ response to the opioid epidemic: The role of CDC’s Core Violence and Injury Prevention Program
        Deokar AJ, Dellapenna A, DeFiore-Hyrmer J, Laidler M, Millet L, Morman S, Myers L.
        J Public Health Manag Pract. 2018 Jan/Feb;24 Suppl 1 :S23-s31.
        The Centers for Disease Control and Prevention’s (CDC’s) Core Violence and Injury Prevention Program (Core) supports capacity of state violence and injury prevention programs to implement evidence-based interventions. Several Core-funded states prioritized prescription drug overdose (PDO) and leveraged their systems to identify and respond to the epidemic before specific PDO prevention funding was available through CDC. This article describes activities employed by Core-funded states early in the epidemic. Four case examples illustrate states’ approaches within the context of their systems and partners. While Core funding is not sufficient to support a comprehensive PDO prevention program, having Core in place at the beginning of the emerging epidemic had critical implications for identifying the problem and developing systems that were later expanded as additional resources became available. Important components included staffing support to bolster programmatic and epidemiological capacity; diverse and collaborative partnerships; and use of surveillance and evidence-informed best practices to prioritize decision-making.

      4. Introduction to the special issue: Catalyzing State Public Health Agency Actions to Prevent Injuries and Violence
        Hertz MF, Thigpen S.
        J Public Health Manag Pract. 2018 Jan/Feb;24 Suppl 1:S3-s5.

        [No abstract]

      5. Catalyzing state public health agency actions to prevent injuries and violence: Introductory remarks
        McClure R.
        J Public Health Manag Pract. 2018 Jan/Feb;24 Suppl 1:S1-s2.

        [No abstract]

      6. Innovative methods for designing actionable program evaluation
        Nesbit B, Hertz M, Thigpen S, Castellanos T, Brown M, Porter J, Williams A.
        J Public Health Manag Pract. 2018 Jan/Feb;24 Suppl 1:S12-s22.
        CONTEXT: For most programs, whether funded through governmental agencies or nongovernmental organizations, demonstrating the impact of implemented activities is vital to ensuring continued funding and support. OBJECTIVE: Program evaluation is a critical tool that serves the dual purpose of describing impact and identifying areas for program improvement. From a funder’s perspective, describing the individual and collective impact of state-based programs can be challenging due to variations in strategies being implemented and types of data being collected. DESIGN: A case study was used to describe the actionable, mixed-methods evaluation of the Core Violence and Injury Prevention Program (Core VIPP), including how the evaluation design and approach shifted to address evolving challenges faced by award recipients over time. Particular emphasis is given to innovative methods for collecting, analyzing, and disseminating data for key state and federal stakeholders. RESULTS: The results of the Core VIPP evaluation showed how this funding played a vital role in building injury and violence prevention capacity in state health departments, leading to a decrease in both intermediate and long-term outcomes. CONCLUSIONS: The lessons learned through the mixed-method evaluation of the Core VIPP informed the structure of the subsequent funding cycle (Core SVIPP) to include more prescriptive requirements for evidence-based implementation and a state support team structure for delivery of training and technical assistance.

      7. Mind the gap: Approaches to addressing the research-to-practice, practice-to-research chasm
        Smith LS, Wilkins N.
        J Public Health Manag Pract. 2018 Jan/Feb;24 Suppl 1:S6-s11.

        [No abstract]

      8. The power of academic-practitioner collaboration to enhance science and practice integration: Injury and violence prevention case studies
        Smith LS, Wilkins N, Marshall SW, Dellapenna A, Pressley JC, Bauer M, South EC, Green K.
        J Public Health Manag Pract. 2018 Jan/Feb;24 Suppl 1:S67-s74.
        One of the most substantial challenges facing the field of injury and violence prevention is bridging the gap between scientific knowledge and its real-world application to achieve population-level impact. Much synergy is gained when academic and practice communities collaborate; however, a number of barriers prevent better integration of science and practice. This article presents 3 examples of academic-practitioner collaborations, their approaches to working together to address injury and violence issues, and emerging indications of the impact on integrating research and practice. The examples fall along the spectrum of engagement with nonacademic partners as coinvestigators and knowledge producers. They also highlight the benefits of academic-community partnerships and the engaged scholarship model under which Centers for Disease Control and Prevention-funded Injury Control Research Centers operate to address the research-to-practice and practice-to-research gap.

      9. Connecting the dots: State health department approaches to addressing shared risk and protective factors across multiple forms of violence
        Wilkins N, Myers L, Kuehl T, Bauman A, Hertz M.
        J Public Health Manag Pract. 2018 Jan/Feb;24 Suppl 1:S32-s41.
        Violence takes many forms, including intimate partner violence, sexual violence, child abuse and neglect, bullying, suicidal behavior, and elder abuse and neglect. These forms of violence are interconnected and often share the same root causes. They can also co-occur together in families and communities and can happen at the same time or at different stages of life. Often, due to a variety of factors, separate, “siloed” approaches are used to address each form of violence. However, understanding and implementing approaches that prevent and address the overlapping root causes of violence (risk factors) and promote factors that increase the resilience of people and communities (protective factors) can help practitioners more effectively and efficiently use limited resources to prevent multiple forms of violence and save lives. This article presents approaches used by 2 state health departments, the Maryland Department of Health and Mental Hygiene and the Colorado Department of Public Health and Environment, to integrate a shared risk and protective factor approach into their violence prevention work and identifies key lessons learned that may serve to inform crosscutting violence prevention efforts in other states.

      10. Development of a comprehensive and interactive tool to inform state violence and injury prevention plans
        Wilson L, Deokar AJ, Zaesim A, Thomas K, Kresnow-Sedacca MJ.
        J Public Health Manag Pract. 2018 Jan/Feb;24 Suppl 1:S59-s66.
        CONTEXT: The Center of Disease Control and Prevention’s Core State Violence and Injury Prevention Program (Core SVIPP) provides an opportunity for states to engage with their partners to implement, evaluate, and disseminate strategies that lead to the reduction and prevention of injury and violence. Core SVIPP requires awardees to develop or update their state injury and violence plans. Currently, literature informing state planning efforts is limited, especially regarding materials related to injury and violence. Presumably, plans that are higher quality result in having a greater impact on preventing injury and violence, and literature to improve quality would benefit prevention programming. OBJECTIVE: (1) To create a comprehensive injury-specific index to aid in the development and revision of state injury and violence prevention plans, and (2) to assess the reliability and utility of this index. DESIGN: Through an iterative development process, a workgroup of subject matter experts created the Violence and Injury Prevention: Comprehensive Index Tool (VIP:CIT). The tool was pilot tested on 3 state injury and violence prevention plans and assessed for initial usability. Following revisions to the tool (ie, a rubric was developed to further delineate consistent criteria for rating; items were added and clarified), the same state plans were reassessed to test interrater reliability and tool utility. RESULTS: For the second assessment, reliability of the VIP:CIT improved, indicating that the rubric was a useful addition. Qualitative feedback from states suggested that the tool significantly helped guide plan development and communicate about planning processes. CONCLUSION: The final VIP:CIT is a tool that can help increase plan quality, decrease the research-to-practice gap, and increase connectivity to emerging public health paradigms. The tool provides an example of tailoring guidance materials to reflect academic literature, and it can be easily adapted to other topic areas to promote quality of strategic plans for numerous outcomes.

  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. AIMS: We hypothesized that height-corrected abdominal size (supine sagittal abdominal diameter/height ratio [SADHtR] or waist circumference/height ratio [WHtR]) would associate more strongly than body mass index (BMI, weight/height(2)) with levels of fasting insulin, triglycerides, and three derived biomarkers of insulin resistance. METHODS: Anthropometry, including SAD by caliper, was collected on 4398 adults in the 2011-2014 National Health and Nutrition Examination Survey. For comparison purposes, each adiposity indicator was scaled to its population-based, sex-specific, interquartile range (IQR). For each biomarker we created four outcome groups based on equal-sized populations with ascending values. Multivariable polytomous logistic regression modeled the relationships between the adiposity indicators and each biomarker. RESULTS: Highest-group insulin was associated with a one-IQR increment of BMI (RR 4.3 [95% CI 3.9-4.9]), but more strongly with a one-IQR increment of SADHtR (RR 5.7 [5.0-6.6]). For highest-group HOMA-IR the RR for BMI (4.2 [3.7-4.6]) was less than that of SADHtR (6.0 [5.1-7.0]). Similarly, RRs for BMI were smaller than those for SADHtR applying to highest-group triglycerides (RR 1.6 vs 2.1), triglycerides/HDL-cholesterol (RR 1.9 vs 2.4) and TyG index (RR 1.7 vs 2.2) (all p<0.001). The RRs for WHtR were consistently between those for SADHtR and BMI. The top 25% of insulin resistance among US adults was estimated to lie above adiposity thresholds of 0.140 for SADHtR, 0.606 for WHtR, or 29.6 kg/m(2) for BMI. CONCLUSIONS: Relative abdominal size rather than relative weight may better define adiposity associated with homeostatic insulin resistance. These population-based, cross-sectional findings could improve anthropometric prediction of cardiometabolic risk.

      2. Risk of cancer death by comorbidity severity and use of adjuvant chemotherapy among women with locoregional breast cancer
        Kimmick GG, Li X, Fleming ST, Sabatino SA, Wilson JF, Lipscomb J, Cress R, Bergom C, Anderson RT, Wu XC.
        J Geriatr Oncol. 2017 Nov 22.
        OBJECTIVES: To examine the associations of comorbidity and chemotherapy with breast cancer- and non-breast cancer-related death. MATERIALS AND METHODS: Included were women with invasive locoregional breast cancer diagnosed in 2004 from seven population-based cancer registries. Data were abstracted from medical records and verified with treating physicians when there were inconsistencies and missing information on cancer treatment. Comorbidity severity was quantified using the Adult Comorbidity Evaluation 27. Treatment guideline concordance was determined by comparing treatment received with the National Comprehensive Cancer Network guidelines. Kaplan-Meier method and multivariable Cox proportional hazards regressions were employed for statistical analyses. RESULTS: Of 5852 patients, 76% were under 70years old and 69% received guideline concordant adjuvant chemotherapy. Comorbidity was more prevalent in women age 70 and older (79% vs. 51%; p<0.001). After adjusting for tumor characteristics and treatment, severe comorbidity burden was associated with significantly higher cancer-related mortality in older patients (Hazard Ratio [HR]=2.38, 95% CI 1.08-5.24), but not in younger patients (HR=1.78, 95% CI 0.87-3.64). Among patients receiving guideline adjuvant chemotherapy, cancer-related mortality was significantly higher in older patients (HR=2.35, 95% CI 1.52-3.62), and those with severe comorbidity (HR=3.79, 95% CI 1.72-8.33). CONCLUSIONS: Findings suggest that, compared to women with no comorbidity, patients with breast cancer age 70 and older with severe comorbidity are at increased risk of dying from breast cancer, even after adjustment for adjuvant chemotherapy and other tumor and treatment differences. This information adds to risk-benefit discussions and emphasizes the need for further study of the role for adjuvant chemotherapy in these patient groups.

    • Communicable Diseases
      1. Time to first positive HIV-1 DNA PCR may differ with antiretroviral regimen in infants infected with non-B subtype HIV-1
        Balasubramanian R, Fowler MG, Dominguez K, Lockman S, Tookey PA, Huong NN, Nesheim S, Hughes MD, Lallemant M, Tosswill J, Shaffer N, Sherman G, Palumbo P, Shapiro DE.
        Aids. 2017 Nov 28;31(18):2465-2474.
        OBJECTIVE: To evaluate the association of type and timing of prophylactic maternal and infant antiretroviral regimen with time to first positive HIV-1 DNA PCR test, in nonbreastfed HIV-infected infants, from populations infected predominantly with HIV-1 non-B subtype virus. DESIGN: Analysis of combined data on nonbreastfed HIV-infected infants from prospective cohorts in Botswana, Thailand, and the United Kingdom (N = 405). METHODS: Parametric models appropriate for interval-censored outcomes estimated the time to first positive PCR according to maternal or infant antiretroviral regimen category and timing of maternal antiretroviral initiation, with adjustment for covariates. RESULTS: Maternal antiretroviral regimens included: no antiretrovirals (n = 138), single-nucleoside analog reverse transcriptase inhibitor (n = 165), single-dose nevirapine with zidovudine (n = 66), and combination prophylaxis with 3 or more antiretrovirals [combination antiretroviral therapy (cART), n = 36]. Type of maternal/infant antiretroviral regimen and timing of maternal antiretroviral initiation were each significantly associated with time to first positive PCR (multivariate P < 0.0001). The probability of a positive test with no antiretrovirals compared with the other regimen/timing groups was significantly lower at 1 day after birth, but did not differ significantly after age 14 days. In a subgroup of 143 infants testing negative at birth, infant cART was significantly associated with longer time to first positive test (multivariate P = 0.04). CONCLUSION: Time to first positive HIV-1 DNA PCR in HIV-1-infected nonbreastfed infants (non-B HIV subtype) may differ according to maternal/infant antiretroviral regimen and may be longer with infant cART, which may have implications for scheduling infant HIV PCR-diagnostic testing and confirming final infant HIV status.

      2. Changes in viral suppression status among US HIV-infected patients receiving care
        Crepaz N, Tang T, Marks G, Hall HI.
        Aids. 2017 Nov 13;31(17):2421-2425.
        OBJECTIVE: To examine changes in viral suppression status among HIV patients receiving care in 2014 and the extent of viral suppression among persons with infrequent care visits. METHODS: Using data reported to the National HIV Surveillance System from 33 jurisdictions with complete reporting of CD4 and viral load tests, we created four viral suppression status groups based on their first and last viral loads in 2014: both suppressed, first unsuppressed and last suppressed (improved), first suppressed and last unsuppressed (worsened), and both unsuppressed. We also calculated the number and percentage of persons whose sole viral load in 2014 was suppressed and had a suppressed viral load at their last test in 2013. RESULTS: Among 339 515 persons with at least two viral load tests in 2014, 72.6% had all viral loads suppressed (durably suppressed); 75.5% had the first and last tests suppressed, 10.5% improved, 4.2% worsened, and 9.9% had both unsuppressed. Among 92 309 persons who had only one viral load test in 2014, 69 960 (75.8%) were suppressed and, of those, 53 834 (76.9%) also had a suppressed viral load at their last test in 2013. CONCLUSION: National surveillance data show that the majority of patients in HIV care during 2014 were durably suppressed. More showed improved compared with worsened viral suppression status. Some patients who have less frequent care visits have sustained viral suppression. Yet one in 10 who was in regular care did not have a suppressed viral load in 2014, indicating missed opportunities for clinical interventions to help patients achieve and sustain viral suppression.

      3. Effects of concurrent exposure to antiretrovirals and cotrimoxazole prophylaxis among HIV-exposed, uninfected infants
        Ewing AC, King CC, Wiener JB, Chasela CS, Hudgens MG, Kamwendo D, Tegha G, Hosseinipour MC, Jamieson DJ, Van der Horst C, Kourtis AP.
        Aids. 2017 Nov 28;31(18):2455-2463.
        BACKGROUND: Given the potential of cotrimoxazole preventive therapy (CPT) to prevent bacterial and malarial infections in HIV-exposed, uninfected (HEU) infants, it is important to evaluate the effects of its concurrent use with antiretroviral agents that have overlapping toxicity profiles. METHODS: We used data from the Breastfeeding, Antiretrovirals, and Nutrition study (2004-2010) to evaluate the association of CPT and antiretrovirals with hematologic measures (hemoglobin, neutrophil, and alanine aminotransferase levels) from 6 to 48 weeks of age in 2006 HEU infants in Lilongwe, Malawi. Hazards of severe outcomes (anemia, neutropenia, and elevated alanine aminotransferase), as defined by the National Institutes of Health, were compared using Cox regression models, according to time-varying CPT (implemented June 2006), antiretroviral treatment arm (maternal triple antiretroviral, infant nevirapine, or none during 6 months of breastfeeding), and their interaction. The effects of these treatments on hemoglobin, neutrophil, and alanine aminotransferase levels were assessed using linear mixed models. RESULTS: In Cox models, CPT was associated with an increase in severe neutropenia [hazard ratio 1.97 (1.01, 3.86)] and a decrease in severe anemia (hazard ratio 0.65 (0.48, 0.88)]. Interactions between CPT and antiretroviral treatment were not significant. By 36 weeks, there was a significant association of CPT with increased hemoglobin levels regardless of antiretroviral drug exposure. CONCLUSIONS: In addition to expected associations with increased hazard of severe neutropenia and decreased neutrophil count, CPT was associated with reduced hazard of severe anemia and higher infant blood hemoglobin. This provides further support for CPT use in HEU infants in malaria-endemic resource-limited settings where anemia is prevalent.

      4. Combinations of interventions to achieve a national HIV incidence reduction goal: insights from an agent-based model
        Gopalappa C, Sansom SL, Farnham PG, Chen YH.
        Aids. 2017 Nov 28;31(18):2533-2539.
        OBJECTIVE: Analyzing HIV care service targets for achieving a national goal of a 25% reduction in annual HIV incidence and evaluating the use of annual HIV diagnoses to measure progress in incidence reduction. DESIGN: Because there are considerable interactions among HIV care services, we model the dynamics of ‘combinations’ of increases in HIV care continuum targets to identify those that would achieve 25% reductions in annual incidence and diagnoses. METHODS: We used Progression and Transmission of HIV/AIDS 2.0, an agent-based dynamic stochastic simulation of HIV in the United States. RESULTS: A 25% reduction in annual incidence could be achieved by multiple alternative combinations of percentages of persons with diagnosed infection and persons with viral suppression including 85 and 68%, respectively, and 90 and 59%, respectively. The first combination corresponded to an 18% reduction in annual diagnoses, and infections being diagnosed at a median CD4 cell count of 372 cells/mul or approximately 3.8 years from time of infection. The corresponding values on the second combination are 4%, 462 cells/mul, and 2.0 years, respectively. CONCLUSION: Our analysis provides policy makers with specific targets and alternative choices to achieve the goal of a 25% reduction in HIV incidence. Reducing annual diagnoses does not equate to reducing annual incidence. Instead, progress toward reducing incidence can be measured by monitoring HIV surveillance data trends in CD4 cell count at diagnosis along with the proportion who have achieved viral suppression to determine where to focus local programmatic efforts.

      5. When prevention of mother-to-child HIV transmission fails: preventing pretreatment drug resistance in African children
        Inzaule SC, Hamers RL, Calis J, Boerma R, Sigaloff K, Zeh C, Mugyenyi P, Akanmu S, Rinke de Wit TF.
        Aids. 2017 Nov 10.
        The scale-up of antiretroviral prophylaxis to prevent mother-to-child transmission of HIV has significantly reduced new pediatric infections in sub-Saharan Africa. However, among infants who become HIV-infected despite prevent mother-to-child transmission, more than 50% have drug-resistant HIV. Given high levels of resistance, WHO recommends the use of protease inhibitors as part of first-line pediatric antiretroviral therapy (ART) to optimize treatment response, but costs and logistic challenges restrict access. A great concern is the current lack of ART options for children who experience virological failure. In this opinion article, we argue that enhanced efforts are needed to help contain the emergence of pretreatment resistance in children and hence improve ART outcomes. The vertical transmission of (drug-resistant) HIV can be prevented through enhancing ART adherence and frequent viral-load testing during pregnancy and throughout breast-feeding. Pretreatment resistance, due to the use of subtherapeutic infant prophylaxis or exposure to suboptimal maternal ART through breast-feeding, can be prevented by the use of effective antiretroviral prophylaxis, based on either triple-drug combination or high genetic-barrier drugs, coupled with early infant diagnosis and prompt ART initiation. Further research is needed to assess programmatic barriers and cost-effectiveness of such strategies.

      6. Bisexual and bidirectional: Assessing the potential for HIV bridging in Mozambique
        Cummings B, Horth R, McFarland W, Lane T, Young PW, Nala R, Rutherford G, Raymond HF.
        AIDS Behav. 2017 Nov 29.
        African men who have sex with men (MSM) frequently, and often concurrently, have female partners, raising concerns about HIV sexual bridging. We explored potential HIV transmission in Mozambique from and to female partners of MSM focusing on preferred anal sex role and circumcision status. Data collected in a respondent-driven sampling study of MSM in 2011 in Maputo and Beira. Men who had oral or anal sex with other men 12 months prior completed a questionnaire and consented for HIV testing. Statistical analysis explored demographic/risk characteristics and associations among circumcision status, anal sex with men, sexual positions during anal sex with men and vaginal or anal sex with women. We identified 326 MSM in Maputo and 237 in Beira with both male and female partners 3 months before the study. Of these, 20.8% in Maputo and 36.0% in Beira had any receptive anal sex with men 12 months prior, including 895 unprotected sexual acts with males in Maputo and 692 in Beira. Uncircumcised and exclusively insertive males, 27.7% of the sample in Maputo and 33.6% in Beira, had the most unprotected sex with females: 1159 total acts in Maputo and 600 in Beira. Sexual bridging between MSM and women likely varies geographically and is probably bi-directional, occurring within a generalized epidemic where HIV prevalence is higher among reproductive-age women than MSM. Prevention strategies emphasizing correct and consistent condom use for all partners and circumcision for bisexual men should be considered.

      7. Sex practices by HIV awareness and engagement in the continuum of care among MSM: A National HIV Behavioral Surveillance Analysis in 21 U.S. cities
        Whitham HK, Sansom SL, Wejnert C, Finlayson T, Huang YA, An Q, Paz-Bailey G.
        AIDS Behav. 2017 Nov 23.
        Using National HIV Behavioral Surveillance (NHBS) cross-sectional survey and HIV testing data in 21 U.S. metropolitan areas, we identify sex practices among sexually active men who have sex with men (MSM) associated with: (1) awareness of HIV status, and (2) engagement in the HIV care continuum. Data from 2008, 2011, and 2014 were aggregated, yielding a sample of 5079 sexually active MSM living with HIV (MLWH). Participants were classified into HIV status categories: (1) unaware; (2) aware and out of care; (3) aware and in care without antiretroviral therapy (ART); and (4) aware and on ART. Analyses were conducted examining sex practices (e.g. condomless sex, discordant condomless sex, and number of sex partners) by HIV status. Approximately 30, 5, 10 and 55% of the sample was classified as unaware, aware and out of care, aware and in care without ART, and aware and on ART, respectively. Unaware MLWH were more likely to report condomless anal sex with a last male partner of discordant or unknown HIV status (25.9%) than aware MLWH (18.0%, p value < 0.0001). Unaware MLWH were 3 times as likely to report a female sex partner in the prior 12 months as aware MLWH (17.3 and 5.6%, p-value < 0.0001). When examining trends across the continuum of care, reports of any condomless anal sex with a male partner in the past year (ranging from 65.0 to 70.0%), condomless anal sex with a male partner of discordant or unknown HIV status (ranging from 17.7 to 21.3%), and median number of both male and female sex partners were similar. In conclusion, awareness of HIV and engagement in care was not consistently associated with protective sex practices, highlighting the need for continued prevention efforts.

      8. HIV and hepatitis B and C co-infection among people who inject drugs in Zanzibar
        Khatib A, Matiko E, Khalid F, Welty S, Ali A, Othman A, Haji S, Dahoma M, Rutherford G.
        BMC Public Health. 2017 Nov 28;17(1):917.
        BACKGROUND: People who inject drugs are at high risk of acquiring hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV) due to risky injection and sexual practices. The objective of this study is to investigate the epidemiology of HIV, hepatitis B, and hepatitis C, and co-infection of these viruses among people who inject drugs in Zanzibar, Tanzania. METHODS: We used respondent-driven sampling to identify 408 participants, from whom we collected demographic data, information on sexual behaviours and injection drug practices, and blood samples for biological testing. RESULTS: Prevalence of hepatitis B surface antigenaemia, HCV, and HIV infection were 5.9, 25.4, and 11.3%, respectively. Of the participants who were hepatitis B surface antigen (HBsAg) positive, 33.5% were infected with HCV and 18.8% were infected with HIV. Of the HCV-infected participants, 29.3% were infected with HIV. Of the participants who were infected with HIV, 9.0% were HBsAg positive, 66.6% had HCV and 8.5% had both. None of the potential risk factors we measured were associated with HBsAg positivity. In contrast, older age and longer duration of injection drug use were independently associated with HCV infection. HCV infection among people who inject drugs is lower in Zanzibar than in other countries, but could rise without proper interventions. CONCLUSIONS: These findings underscore the importance of screening people who inject drugs for HIV, HBsAg, and HCV; providing HBV vaccination to those who are eligible; initiating antiretroviral therapy for those who are co-infected with HIV/HBV and HIV/HCV; and introducing interventions that have high impact on reducing needle sharing.

      9. BACKGROUND: Although pneumonia is a leading cause of death in New York City (NYC), limited data exist about the settings in which pneumonia is acquired across NYC. Cases of pneumonia acquired in community settings are more likely to be preventable with vaccines and treatable with first-line antibiotics than those acquired in noncommunity settings. The objective of this study was to estimate the burden of hospitalizations associated with community-acquired (CAP), health-care-associated (HCAP), hospital-acquired (HAP), and ventilator-associated (VAP) pneumonia from 2010 to 2014. METHODS: This retrospective analysis was performed by using an all-payer reporting system of hospital discharges that included NYC residents aged >/= 18 years. Pneumonia-associated hospitalizations were defined as any hospitalization that included a diagnostic code for pneumonia among any of the discharge diagnoses. Using published clinical guidelines, we classified hospitalizations into mutually exclusive categories of CAP, HCAP, HAP, and VAP and defined pneumonia acquired in the community setting as the combination of CAP and HCAP. RESULTS: Of 4,614,108 hospitalizations during the reporting period, 283,927 (6.2%) involved pneumonia. Among pneumonia-associated hospitalizations, 154,158 (54.3%) were CAP, 85,656 (30.2%) were HCAP, 39,712 (14.0%) were HAP, and 4,401 (1.6%) were VAP. Death during hospitalization occurred in 7.9% of CAP-associated hospitalizations, compared with 15.6% of HCAP-associated hospitalizations, 20.7% of HAP-associated hospitalizations, and 21.6% of VAP-associated hospitalizations. CONCLUSIONS: Most pneumonia-associated hospitalizations in NYC involve pneumonias acquired in the community setting. Although 15.6% of pneumonia-associated hospitalizations were categorized as HAP or VAP, these pneumonias accounted for > 25% of deaths from pneumonia-associated hospitalizations. Public health pneumonia prevention efforts need to target both community and hospital settings.

      10. Expanding hospital HIV testing in the Bronx, New York and Washington, D.C.: Results from the HPTN 065 study
        Branson BM, Chavez PR, Hanscom B, Greene E, McKinstry L, Buchacz K, Beauchamp G, Gamble T, Zingman BS, Telzak E, Naab T, Fitzpatrick L, El-Sadr WM.
        Clin Infect Dis. 2017 Nov 27.
        Background: HIV testing is critical for both HIV treatment and prevention. Expanding testing in hospital settings can identify undiagnosed HIV infections. Methods: To evaluate the feasibility of universally offering HIV testing during emergency department (ED) visits and inpatient admissions, 9 hospitals in the Bronx, New York and 7 in Washington DC undertook various efforts to encourage staff to offer HIV testing routinely. Outcomes included the percentage of encounters with an HIV test, the change from year 1 to year 3, and the percentages of tests that were HIV-positive and new diagnoses. Results: From February 1, 2011 to January 31, 2014, HIV tests were conducted during 6.5% of 1,621,016 ED visits and 13.0% of 361,745 inpatient admissions in Bronx hospitals and 13.8% of 729,172 ED visits and 22.0% of 150,655 inpatient admissions in DC, with wide variation by hospital. From year 1 to year 3, testing was stable in the Bronx (6.6% to 6.9% of ED visits, 13.0% to 13.6% of inpatient admissions), but increased in DC (11.9% to 15.8% of ED visits, 19.0% to 23.9% of inpatient admissions). Overall, in the Bronx 0.4% (408) of ED HIV tests were positive, 0.3% (277) were new diagnoses; 1.8% (828) of inpatient tests were positive, 0.5% (244) were new diagnoses. In DC, 0.6% (618) of ED tests were positive, 0.4% (404) were new diagnoses; 4.9% (1349) of inpatient HIV tests were positive, 0.7% (189) were new diagnoses. Conclusion: Hospitals consistently identified previously undiagnosed HIV infections, but universal offer of HIV testing proved elusive.

      11. Severe respiratory illness associated with rhinovirus during the EV-D68 outbreak in the United States, August – November, 2014
        Prill MM, Dahl R, Midgley CM, Chern SW, Lu X, Feikin D, Sakthivel SK, Nix WA, Watson J, Gerber SI, Oberste MS.
        Clin Infect Dis. 2017 Nov 23.
        BACKGROUND: In 2014, a nationwide outbreak of severe respiratory illness occurred in the United States, primarily associated with enterovirus D-68 (EV-D68). A proportion of illness was associated with rhinoviruses and other enteroviruses, which we aimed to characterize further. METHODS: Respiratory specimens from pediatric and adult patients with respiratory illness were submitted to CDC during August – November 2014. While initial laboratory testing focused on identification of EV-D68, the negative specimens were typed by molecular sequencing to identify additional enterovirus (EV) and rhinovirus (RV) types. Testing for other pathogens was not conducted. We compared available clinical and epidemiologic characteristics among patients with EV-D68 and RV species A-C identified. RESULTS: Among 2629 typed specimens, 1012 were EV-D68 (39%) and 81 (3.1%) represented 24 other EV types; 968 were RVs (37%) covering 114 types and grouped into three human RV species (RV-A=446, RV-B=133, RV-C=389); and 568 (22%) had no RV or EV detected. EV-D68 was more frequently identified in patients presenting earlier in the investigation period. Among patients with EV-D68, RV-A, RV-B, or RV-C identified, the age distributions markedly differed. Clinical syndromes and ICU admissions by age were largely similar among those with EV-D68 and RV species. CONCLUSIONS: RVs were commonly associated with severe respiratory illness, alongside EV-D68, during the nationwide outbreak. Clinical characteristics were largely similar among those with EV-D68, RV-A, RV-B, or RV-C. A better understanding of the epidemiology of RVs and EVs is needed to help inform development and use of diagnostic tests, therapeutics, and preventive measures.

      12. Preventing respiratory viral transmission in long-term care: Knowledge, attitudes, and practices of healthcare personnel
        O’Neil CA, Kim L, Prill MM, Stone ND, Garg S, Talbot HK, Babcock HM.
        Infect Control Hosp Epidemiol. 2017 Nov 27:1-8.
        OBJECTIVE To examine knowledge and attitudes about influenza vaccination and infection prevention practices among healthcare personnel (HCP) in a long-term-care (LTC) setting. DESIGN Knowledge, attitudes, and practices (KAP) survey. SETTING An LTC facility in St Louis, Missouri. PARTICIPANTS All HCP working at the LTC facility were eligible to participate, regardless of department or position. Of 170 full- and part-time HCP working at the facility, 73 completed the survey, a 42.9% response rate. RESULTS Most HCP agreed that respiratory viral infections were serious and that hand hygiene and face mask use were protective. However, only 46% could describe the correct transmission-based precautions for an influenza patient. Correctly answering infection prevention knowledge questions did not vary by years of experience but did vary for HCP with more direct patient contact versus less patient contact. Furthermore, 42% of respondents reported working while sick, and 56% reported that their coworkers did. In addition, 54% reported that facility policies made staying home while ill difficult. Some respondents expressed concerns about the safety (22%) and effectiveness (27%) of the influenza vaccine, and 28% of respondents stated that they would not get the influenza vaccine if it was not required. CONCLUSIONS This survey of staff in an LTC facility identified several areas for policy improvement, particularly sick leave, as well as potential targets for interventions to improve infection prevention knowledge and to address HCP concerns about influenza vaccination to improve HCP vaccination rates in LTCs. Infect Control Hosp Epidemiol 2017;1-8.

      13. Programmatic evaluation of an algorithm for intensified tuberculosis case finding and isoniazid preventive therapy for people living with HIV in Thailand and Vietnam
        Cowger TL, Thai LH, Duong BD, Danyuttapolchai J, Kittimunkong S, Nhung NV, Nhan DT, Monkongdee P, Thoa CK, Khanh VT, Nateniyom S, Yen NT, Ngoc DV, Thinh T, Whitehead S, Pevzner ES.
        J Acquir Immune Defic Syndr. 2017 Dec 15;76(5):512-521.
        BACKGROUND: Tuberculosis (TB) screening affords clinicians the opportunity to diagnose or exclude TB disease and initiate isoniazid preventive therapy (IPT) for people living with HIV (PLHIV). METHODS: We implemented an algorithm to diagnose or rule out TB among PLHIV in 11 HIV clinics in Thailand and Vietnam. We assessed algorithm yield and uptake of IPT and factors associated with TB disease among PLHIV. RESULTS: A total of 1448 PLHIV not yet on antiretroviral therapy (ART) were enrolled and screened for TB. Overall, 634 (44%) screened positive and 119 (8%) were diagnosed with TB; of these, 40% (48/119) were diagnosed by a positive culture following a negative sputum smear microscopy. In total, 55% of those eligible (263/477) started on IPT and of those, 75% (196/263) completed therapy. The prevalence of TB disease we observed in this study was 8.2% (8218 per 100,000 persons): 46 and 25 times the prevalence of TB in the general population in Thailand and Vietnam, respectively. Several factors were independently associated with TB disease including being underweight [aOR (95% CI): 2.3 (1.2 to 2.6)] and using injection drugs [aOR (95% CI): 2.9 (1.3 to 6.3)]. CONCLUSIONS: The high yield of TB disease diagnosed among PLHIV screened with the algorithm, and higher burden among PLHIV who inject drugs, underscores the need for innovative, tailored approaches to TB screening and prevention. As countries adopt test-and-start for antiretroviral therapy, TB screening, sensitive TB diagnostics, and IPT should be included in differentiated-care models for HIV to improve diagnosis and prevention of TB among PLHIV.

      14. Brief report: Estimated incidence of perinatally acquired HIV infection in the United States, 1978-2013
        Nesheim SR, Wiener J, Fitz Harris LF, Lampe MA, Weidle PJ.
        J Acquir Immune Defic Syndr. 2017 Dec 15;76(5):461-464.
        BACKGROUND: An incidence of perinatally acquired HIV infection less than 1:100,000 live births is one of the Centers for Disease Control and Prevention (CDC) goals of the United States. Such an estimate has only been possible in recent years because regular nationwide data were lacking. METHOD: Using previously published CDC estimates of the number of infants born with HIV infection in the United States (interpolating for years for which there was no published estimate), and census data on the annual number of live-born infants, estimated incidence was calculated for 1978-2013. Exact 95% confidence intervals (CIs) were calculated using the Poisson distribution. RESULTS: Estimated incidence of perinatally acquired HIV infection peaked at 43.1 (95% CI: 41.1 to 45.1) in 1992 and declined rapidly after the use of zidovudine prophylaxis was recommended in 1994. In 2013, estimated incidence of perinatally acquired HIV infection in the United States was 1.8 (95% CI: 1.4 to 2.2), a 96% decline since the peak. CONCLUSION: Estimated incidence of perinatally acquired HIV infection in the United States in 2013 was 1.8/100,000 live births.

      15. Returning HIV-1 viral load results to participant-selected health facilities in national Population-based HIV Impact Assessment (PHIA) household surveys in three sub-Saharan African Countries, 2015 to 2016
        Saito S, Duong YT, Metz M, Lee K, Patel H, Sleeman K, Manjengwa J, Ogollah FM, Kasongo W, Mitchell R, Mugurungi O, Chimbwandira F, Moyo C, Maliwa V, Mtengo H, Nkumbula T, Ndongmo CB, Vere NS, Chipungu G, Parekh BS, Justman J, Voetsch AC.
        J Int AIDS Soc. 2017 Nov;20 Suppl 7:19-25.
        INTRODUCTION: Logistical complexities of returning laboratory test results to participants have precluded most population-based HIV surveys conducted in sub-Saharan Africa from doing so. For HIV positive participants, this presents a missed opportunity for engagement into clinical care and improvement in health outcomes. The Population-based HIV Impact Assessment (PHIA) surveys, which measure HIV incidence and the prevalence of viral load (VL) suppression in selected African countries, are returning VL results to health facilities specified by each HIV positive participant within eight weeks of collection. We describe the performance of the specimen and data management systems used to return VL results to PHIA participants in Zimbabwe, Malawi and Zambia. METHODS: Consenting participants underwent home-based counseling and HIV rapid testing as per national testing guidelines; all confirmed HIV positive participants had VL measured at a central laboratory on either the Roche CAP/CTM or Abbott m2000 platform. On a bi-weekly basis, a dedicated data management team produced logs linking the VL test result with the participants’ contact information and preferred health facility; project staff sent test results confidentially via project drivers, national courier systems, or electronically through an adapted short message service (SMS). Participants who provided cell phone numbers received SMS or phone call alerts regarding availability of VL results. RESULTS AND DISCUSSION: From 29,634 households across the three countries, 78,090 total participants 0 to 64 years in Zimbabwe and Malawi and 0 to 59 years in Zambia underwent blood draw and HIV testing. Of the 8391 total HIV positive participants identified, 8313 (99%) had VL tests performed and 8245 (99%) of these were returned to the selected health facilities. Of the 5979 VL results returned in Zimbabwe and Zambia, 85% were returned within the eight-week goal with a median turnaround time of 48 days (IQR: 33 to 61). In Malawi, where exact return dates were unavailable all 2266 returnable results reached the health facilities by 11 weeks. CONCLUSIONS: The first three PHIA surveys returned the vast majority of VL results to each HIV positive participant’s preferred health facility within the eight-week target. Even in the absence of national VL monitoring systems, a system to return VL results from a population-based survey is feasible, but it requires developing laboratory and data management systems and dedicated staff. These are likely important requirements to strengthen return of results systems in routine clinical care.

      16. Maternal but not infant anti-HIV-1 neutralizing antibody response associates with enhanced transmission and infant morbidity
        Ghulam-Smith M, Olson A, White LF, Chasela CS, Ellington SR, Kourtis AP, Jamieson DJ, Tegha G, van der Horst CM, Sagar M.
        MBio. 2017 Oct 24;8(5).
        A significant number of infants acquire HIV-1 through their infected mother’s breast milk, primarily due to limited access to antiretrovirals. Passive immunization with neutralizing antibodies (nAbs) may prevent this transmission. Previous studies, however, have generated conflicting results about the ability of nAbs to halt mother-to-child transmission (MTCT) and their impact on infant outcomes. This study compared plasma neutralizing activity in exposed infants and the infected mothers (n = 63) against heterologous HIV-1 variants and the quasispecies present in the mother. HIV-exposed uninfected infants (HEU) (n = 42), compared to those that eventually acquired infection (n = 21), did not possess higher nAb responses against heterologous envelopes (P = 0.46) or their mothers’ variants (P = 0.45). Transmitting compared to nontransmitting mothers, however, had significantly higher plasma neutralizing activity against heterologous envelopes (P = 0.03), although these two groups did not have significant differences in their ability to neutralize autologous strains (P = 0.39). Furthermore, infants born to mothers with greater neutralizing breadth and potency were significantly more likely to have a serious adverse event (P = 0.03). These results imply that preexisting anti-HIV-1 neutralizing activity does not prevent breast milk transmission. Additionally, high maternal neutralizing breadth and potency may adversely influence both the frequency of breast milk transmission and subsequent infant morbidity.IMPORTANCE Passive immunization trials are under way to understand if preexisting antibodies can decrease mother-to-child HIV-1 transmission and improve infant outcomes. We examined the influence of preexisting maternal and infant neutralizing activity on transmission and infant morbidity in a breastfeeding mother-infant cohort. Neutralization was examined against both the exposure strains circulating in the infected mothers and a standardized reference panel previously used to estimate breadth. HIV-exposed uninfected infants did not possess a broader and more potent response against both the exposure and heterologous strains compared to infants that acquired infection. Transmitting, compared to nontransmitting, mothers had significantly higher neutralization breadth and potency but similar responses against autologous variants. Infants born to mothers with higher neutralization responses were more likely to have a serious adverse event. Our results suggest that preexisting antibodies do not protect against breast milk HIV-1 acquisition and may have negative consequences for the baby.

      17. Vital Signs: Human immunodeficiency virus testing and diagnosis delays – United States
        Dailey AF, Hoots BE, Hall HI, Song R, Hayes D, Fulton P, Prejean J, Hernandez AL, Koenig LJ, Valleroy LA.
        MMWR Morb Mortal Wkly Rep. 2017 Dec 1;66(47):1300-1306.
        BACKGROUND: Persons unaware of their human immunodeficiency virus (HIV) infection account for approximately 40% of ongoing transmissions in the United States. Persons are unaware of their infection because of delayed HIV diagnoses that represent substantial missed opportunities to improve health outcomes and prevent HIV transmission. METHODS: Data from CDC’s National HIV Surveillance System were used to estimate, among persons with HIV infection diagnosed in 2015, the median interval (and range) from infection to diagnosis (diagnosis delay), based on the first CD4 test after HIV diagnosis and a CD4 depletion model indicating disease progression and, among persons living with HIV in 2015, the percentage with undiagnosed infection. Data from CDC’s National HIV Behavioral Surveillance were analyzed to determine the percentage of persons at increased risk for HIV infection who had tested in the past 12 months and who had missed opportunities for testing. RESULTS: An estimated 15% of persons living with HIV in 2015 were unaware of their infection. Among the 39,720 persons with HIV infection diagnosed in 2015, the estimated median diagnosis delay was 3.0 years (interquartile range = 0.7-7.8 years); diagnosis delay varied by race/ethnicity (from 2.2 years among whites to 4.2 years among Asians) and transmission category (from 2.0 years among females who inject drugs to 4.9 years among heterosexual males). Among persons interviewed through National HIV Behavioral Surveillance, 71% of men who have sex with men, 58% of persons who inject drugs, and 41% of heterosexual persons at increased risk for HIV infection reported testing in the past 12 months. In each risk group, at least two thirds of persons who did not have an HIV test had seen a health care provider in the past year. CONCLUSIONS: Delayed HIV diagnoses continue to be substantial for some population groups and prevent early entry to care to improve health outcomes and reduce HIV transmission to others. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Health care providers and others providing HIV testing can reduce HIV-related adverse health outcomes and risk for HIV transmission by implementing routine and targeted HIV testing to decrease diagnosis delays.

      18. Scale-up of voluntary medical male circumcision services for HIV prevention – 12 countries in southern and eastern Africa, 2013-2016
        Hines JZ, Ntsuape OC, Malaba K, Zegeye T, Serrem K, Odoyo-June E, Nyirenda RK, Msungama W, Nkanaunena K, Come J, Canda M, Nhaguiombe H, Shihepo EK, Zemburuka BL, Mutandi G, Yoboka E, Mbayiha AH, Maringa H, Bere A, Lawrence JJ, Lija GJ, Simbeye D, Kazaura K, Mwiru RS, Talisuna SA, Lubwama J, Kabuye G, Zulu JE, Chituwo O, Mumba M, Xaba S, Mandisarisa J, Baack BN, Hinkle L, Grund JM, Davis SM, Toledo C.
        MMWR Morb Mortal Wkly Rep. 2017 Dec 1;66(47):1285-1290.
        Countries in Southern and Eastern Africa have the highest prevalence of human immunodeficiency virus (HIV) infection in the world; in 2015, 52% (approximately 19 million) of all persons living with HIV infection resided in these two regions.* Voluntary medical male circumcision (VMMC) reduces the risk for heterosexually acquired HIV infection among males by approximately 60% (1). As such, it is an essential component of the Joint United Nations Programme on HIV/AIDS (UNAIDS) strategy for ending acquired immunodeficiency syndrome (AIDS) by 2030 (2). Substantial progress toward achieving VMMC targets has been made in the 10 years since the World Health Organization (WHO) and UNAIDS recommended scale-up of VMMC for HIV prevention in 14 Southern and Eastern African countries with generalized HIV epidemics and low male circumcision prevalence (3).(dagger) This has been enabled in part by nearly $2 billion in cumulative funding through the President’s Emergency Plan for AIDS Relief (PEPFAR), administered through multiple U.S. governmental agencies, including CDC, which has supported nearly half of all PEPFAR-supported VMMCs to date. Approximately 14.5 million VMMCs were performed globally during 2008-2016, which represented 70% of the original target of 20.8 million VMMCs in males aged 15-49 years through 2016 (4). Despite falling short of the target, these VMMCs are projected to avert 500,000 HIV infections by the end of 2030 (4). However, UNAIDS has estimated an additional 27 million VMMCs need to be performed by 2021 to meet the Fast Track targets (2). This report updates a previous report covering the period 2010-2012, when VMMC implementing partners supported by CDC performed approximately 1 million VMMCs in nine countries (5). During 2013-2016, these implementing partners performed nearly 5 million VMMCs in 12 countries. Meeting the global target will require redoubling current efforts and introducing novel strategies that increase demand among subgroups of males who have historically been reluctant to undergo VMMC.

      19. HIV prevention efforts and incidence of HIV in Uganda
        Grabowski MK, Serwadda DM, Gray RH, Nakigozi G, Kigozi G, Kagaayi J, Ssekubugu R, Nalugoda F, Lessler J, Lutalo T, Galiwango RM, Makumbi F, Kong X, Kabatesi D, Alamo ST, Wiersma S, Sewankambo NK, Tobian AA, Laeyendecker O, Quinn TC, Reynolds SJ, Wawer MJ, Chang LW.
        N Engl J Med. 2017 Nov 30;377(22):2154-2166.
        BACKGROUND: To assess the effect of a combination strategy for prevention of human immunodeficiency virus (HIV) on the incidence of HIV infection, we analyzed the association between the incidence of HIV and the scale-up of antiretroviral therapy (ART) and medical male circumcision in Rakai, Uganda. Changes in population-level viral-load suppression and sexual behaviors were also examined. METHODS: Between 1999 and 2016, data were collected from 30 communities with the use of 12 surveys in the Rakai Community Cohort Study, an open, population-based cohort of persons 15 to 49 years of age. We assessed trends in the incidence of HIV on the basis of observed seroconversion data, participant-reported use of ART, participant-reported male circumcision, viral-load suppression, and sexual behaviors. RESULTS: In total, 33,937 study participants contributed 103,011 person-visits. A total of 17,870 persons who were initially HIV-negative were followed for 94,427 person-years; among these persons, 931 seroconversions were observed. ART was introduced in 2004, and by 2016, ART coverage was 69% (72% among women vs. 61% among men, P<0.001). HIV viral-load suppression among all HIV-positive persons increased from 42% in 2009 to 75% by 2016 (P<0.001). Male circumcision coverage increased from 15% in 1999 to 59% by 2016 (P<0.001). The percentage of adolescents 15 to 19 years of age who reported never having initiated sex (i.e., delayed sexual debut) increased from 30% in 1999 to 55% in 2016 (P<0.001). By 2016, the mean incidence of HIV infection had declined by 42% relative to the period before 2006 (i.e., before the scale-up of the combination strategy for HIV prevention) – from 1.17 cases per 100 person-years to 0.66 cases per 100 person-years (adjusted incidence rate ratio, 0.58; 95% confidence interval [CI], 0.45 to 0.76); declines were greater among men (adjusted incidence rate ratio, 0.46; 95% CI, 0.29 to 0.73) than among women (adjusted incidence rate ratio, 0.68; 95% CI, 0.50 to 0.94). CONCLUSIONS: In this longitudinal study, the incidence of HIV infection declined significantly with the scale-up of a combination strategy for HIV prevention, which provides empirical evidence that interventions for HIV prevention can have a population-level effect. However, additional efforts are needed to overcome disparities according to sex and to achieve greater reductions in the incidence of HIV infection. (Funded by the National Institute of Allergy and Infectious Diseases and others.).

      20. Application of psychosocial models to Home-Based Testing and Counseling (HBTC) for increased uptake and household coverage in a large informal urban settlement in Kenya
        Oluoch P, Orwa J, Lugalia F, Mutinda D, Gichangi A, Oundo J, Karama M, Nganga Z, Galbraith J.
        Pan Afr Med J. 2017 ;27:285.
        Introduction: Home Based Testing and Counselling (HBTC) aims at reaching individuals who have low HIV risk perception and experience barriers which prevent them from seeking HIV testing and counseling (HTC) services. Saturating the community with HTC is needed to achieve the ambitious 90-90-90 targets of knowledge of HIV status, ARV treatment and viral suppression. This paper describes the use of health belief model and community participation principles in HBTC to achieve increased household coverage and HTC uptake. Methods: This cross sectional survey was done between August 2009 and April 2011 in Kibera slums, Nairobi city. Using three community participation principles; defining and mobilizing the community, involving the community, overcoming barriers and respect to cultural differences and four constructs of the health belief model; risk perception, perceived severity, perceived benefits of changed behavior and perceived barriers; we offered HTC services to the participants. Descriptive statistics were used to describe socio-demographic characteristics, calculate uptake and HIV prevalence. Results: There were 72,577 individuals enumerated at the start of the program; 75,141 residents were found during service delivery. Of those, 71,925 (95.7%) consented to participate, out of which 71,720 (99.7%) took the HIV test. First time testers were (39%). The HIV prevalence was higher (6.4%) among repeat testers than first time testers (4.0%) with more women (7.4%) testing positive than men (3.6%) and an overall 5.5% slum prevalence. Conclusion: This methodology demonstrates that the use of community participation principles combined with a psychosocial model achieved high HTC uptake, coverage and diagnosed HIV in individuals who believed they are HIV free. This novel approach provides baseline for measuring HTC coverage in a community.

      21. Invasive Haemophilus influenzae serotype A infection in children: Clinical description of an emerging pathogen – Alaska, 2002-2014
        Plumb ID, Lecy D, Singleton R, Engel MC, Hirschfeld M, Keck JW, Klejka J, Rudolph KM, Hennessy TW, Bruce MG.
        Pediatr Infect Dis J. 2017 Nov 17.
        BACKGROUND: Invasive infections from Haemophilus influenzae serotype a (Hia) have been reported with increasing frequency, especially among indigenous populations. However there are limited population-based-studies of clinical severity. We studied invasive Hia infections in Alaska to determine clinical characteristics, mortality, and sequelae. METHODS: We defined an invasive Hia infection as the first detection of Hia from a usually sterile site in a child <10 years of age from Alaska. We identified cases using the Alaska Invasive Bacterial Diseases Surveillance System and reviewed medical charts up to 2 years after reported illness. RESULTS: We identified invasive Hia infections in 36 children, 28 (78%) <1 year old, 34 (94%) living in an Alaskan village, and 25 (69%) without documented underlying illness. Overlapping clinical presentations included meningitis in 15 children (42%); bacteremia and pneumonia in 10 children (28%); and bone, joint or soft tissue infections in 10 children (22%). In four other children, no source of invasive infection was identified. Intensive care was provided for 11 children (31%); 12 children (33%) required surgical intervention. One year after infection, 4 children (11%) had died from Hia, and 5 children (14%) had ongoing neurologic sequelae. CONCLUSIONS: Invasive Hia infections in Alaska occurred predominantly in Alaska Native infants in rural communities. Although one-third of children had pre-existing conditions, most cases occurred without known comorbidity. Clinical syndromes were frequently severe. One year after infection, one in four children had either died or had neurologic sequelae. An effective vaccine would prevent significant morbidity and mortality in affected populations.

      22. Evaluating the evidence for more frequent than annual HIV screening of gay, bisexual, and other men who have sex with men in the United States: Results from a systematic review and CDC Expert Consultation
        DiNenno EA, Prejean J, Delaney KP, Bowles K, Martin T, Tailor A, Dumitru G, Mullins MM, Hutchinson A, Lansky A.
        Public Health Rep. 2017 Jan 1:33354917738769.
        The Centers for Disease Control and Prevention (CDC) recommended in 2006 that sexually active gay, bisexual, and other men who have sex with men (MSM) be screened for human immunodeficiency virus (HIV) at least annually. A workgroup comprising CDC and external experts conducted a systematic review of the literature, including benefits, harms, acceptability, and feasibility of annual versus more frequent screening among MSM, to determine whether evidence was sufficient to change the current recommendation. Four consultations with managers of public and nonprofit HIV testing programs, clinics, and mathematical modeling experts were conducted to provide input on the programmatic and scientific evidence. Mathematical models predicted that more frequent than annual screening of MSM could prevent some new HIV infections and would be more cost-effective than annual screening, but this evidence was considered insufficient due to study design. Evidence supports CDC’s current recommendation that sexually active MSM be screened at least annually. However, some MSM might benefit from more frequent screening. Future research should evaluate which MSM subpopulations would benefit most from more frequent HIV screening.

      23. Meningococcal carriage among a university student population – United States, 2015
        Breakwell L, Whaley M, Khan UI, Bandy U, Alexander-Scott N, Dupont L, Vanner C, Chang HY, Vuong JT, Martin S, MacNeil JR, Wang X, Meyer SA.
        Vaccine. 2017 Nov 25.
        OBJECTIVES: Several outbreaks of serogroup B meningococcal disease have occurred among university students in recent years. In the setting of high coverage of the quadrivalent meningococcal conjugate vaccine and prior to widespread use of serogroup B meningococcal vaccines among adolescents, we conducted surveys to characterize the prevalence and molecular characteristics of meningococcal carriage among university students. METHODS: Two cross-sectional oropharyngeal carriage surveys were conducted among undergraduates at a Rhode Island university. Isolates were characterized using slide agglutination, real-time polymerase chain reaction (rt-PCR), and whole genome sequencing. Adjusted prevalence ratios and 95% confidence intervals were calculated using Poisson regression to determine risk factors for carriage. RESULTS: A total of 1837 oropharyngeal specimens were obtained from 1478 unique participants. Overall carriage prevalence was 12.7-14.6% during the two survey rounds, with 1.8-2.6% for capsular genotype B, 0.9-1.0% for capsular genotypes C, W, or Y, and 9.9-10.8% for nongroupable strains by rt-PCR. Meningococcal carriage was associated with being male, smoking, party or club attendance, recent antibiotic use (inverse correlation), and recent respiratory infections. CONCLUSIONS: In this university setting, the majority of meningococcal carriage was due to nongroupable strains, followed by serogroup B. Further evaluation is needed to understand the dynamics of serogroup B carriage and disease among university students.

      24. Concern has grown that children vaccinated against rotavirus in developing countries may be vulnerable to rotavirus diarrhea in the second year of life due to waning immunity. Adding a booster dose of rotavirus vaccine at 9 or 12months of age with measles vaccine has been suggested as a strategy to address this. We evaluated the hypothetical potential benefits of a booster dose on reduction of rotavirus mortality. The projected number of deaths averted were calculated using national level full series vaccination coverage, estimated national rotavirus deaths by week of age, and VE at <12months of age and >/=12months of age derived from the published literature. We assumed three functional forms of waning based on the VE estimates: stepwise, linear, and logarithmic. We modeled three potential boosting scenarios: (a) reduced VE waning in the second year of life by 50%, (b) reestablished second year of life VE to the levels in the first year of life, and (c) boosted first year VE by 50% of the difference between VE in the first and second years. To express uncertainty resulting from the parameters, each of the nine models were run 1000 times using a random sample of input values. Across all WHO regions, with the stepwise models we estimated a median of 9800 (95%CI: 9400, 10,200), 19,600 (95%CI: 18,800, 20,400), and 29,400 (95%CI: 28,200, 30,700) additional rotavirus deaths averted in the reduced VE waning, reestablished VE, and boosted VE scenarios. These estimates were highly sensitive to the assumed functional form of waning with approximately 65-80% fewer deaths averted if immunity waned in a linear or logarithmic fashion compared to the stepwise model. While these projections will benefit from improved input data points, our resultsinform consideration of booster doses of rotavirus vaccine.

    • Disaster Control and Emergency Services
      1. Nuclear and radiological emergencies: Building capacity in medical physics to support response
        Berris T, Nusslin F, Meghzifene A, Ansari A, Herrera-Reyes E, Dainiak N, Akashi M, Gilley D, Ohtsuru A.
        Phys Med. 2017 Oct;42:93-98.
        Medical physicists represent a valuable asset at the disposal of a structured and planned response to nuclear or radiological emergencies (NREs), especially in the hospital environment. The recognition of this fact led the International Atomic Energy Agency (IAEA) and the International Organization for Medical Physics (IOMP) to start a fruitful collaboration aiming to improve education and training of medical physicists so that they may support response efforts in case of NREs. Existing shortcomings in specific technical areas were identified through international consultations supported by the IAEA and led to the development of a project aiming at preparing a specific and standardized training package for medical physicists in support to NREs. The Project was funded through extra-budgetary contribution from Japan within the IAEA Nuclear Safety Action Plan. This paper presents the work accomplished through that project and describes the current steps and future direction for enabling medical physicists to better support response to NREs.

    • Disease Reservoirs and Vectors
      1. Risk factors for tick exposure in suburban settings in the Northeastern United States
        Mead P, Hook S, Niesobecki S, Ray J, Meek J, Delorey M, Prue C, Hinckley A.
        Ticks Tick Borne Dis. 2017 Nov 21.
        Prevention of tick-borne diseases requires an understanding of when and where exposure to ticks is most likely. We used an epidemiologic approach to define these parameters for residents of a Lyme-endemic region. Two persons in each of 500 Connecticut households were asked to complete a log each night for one week during June, 2013. Participants recorded their whereabouts in 15min increments (indoors, outdoors in their yard, outdoors on others’ private property, or outdoors in public spaces) and noted each day whether they found a tick on themselves. Demographic and household information was also collected. Logs were completed for 934 participants in 471 households yielding 51,895 time-place observations. Median participant age was 49 years (range 2-91 years); 52% were female. Ninety-one participants (9.8%) reported finding a tick during the week, with slightly higher rates among females and minors. Household factors positively associated with finding a tick included having indoor/outdoor pets (odds ratio (OR)=1.7; 95% confidence interval (CI): 1.1-2.9), the presence of a bird feeder in the yard (OR=1.9; CI:1.2-3.2), and presence of an outdoor dining area (OR=2.2; CI:1.1-4.3). Individual factors associated with finding a tick on a given day were bathing or showering (OR=3.7; CI:1.3-10.3) and hours spent in one’s own yard (OR=1.2, CI:1.1-1.3). Nineteen participants found ticks on multiple days, more than expected assuming independence (p<0.001). Participants who found ticks on multiple days did not spend more time outdoors but were significantly more likely to be male than those finding ticks on a single day (p<0.03). Our findings suggest that most tick exposures in the study area occurred on private property controlled by the respective homeowner. Interventions that target private yards are a logical focus for prevention efforts.

    • Environmental Health
      1. Changes in extreme events and the potential impacts on human health
        Bell JE, Brown CL, Conlon K, Herring S, Kunkel KE, Lawrimore J, Luber G, Schreck C, Smith A, Uejio C.
        J Air Waste Manag Assoc. 2017 Nov 29.
        Extreme weather and climate-related events affect human health by causing death, injury, and illness, as well as having large socioeconomic impacts. Climate change has caused changes in extreme event frequency, intensity and geographic distribution, and will continue to be a driver for change in the future. Some of these events include heat waves, droughts, wildfires, dust storms, flooding rains, coastal flooding, storm surge, and hurricanes. The pathways connecting extreme events to health outcomes and economic losses can be diverse and complex. The difficulty in predicting these relationships comes from the local societal and environmental factors that affect disease burden. More information is needed about the impacts of climate change on public health and economies to effectively plan for and adapt to climate change. This article describes some of the ways extreme events are changing and provides examples of the potential impacts on human health and infrastructure. It also identifies key research gaps to be addressed to improve the resilience of public health to extreme events in the future. IMPLICATIONS: Extreme weather and climate events affect human health by causing death, injury, and illness, as well as having large socio-economic impacts. Climate change has caused changes in extreme event frequency, intensity and geographic distribution, and will continue to be a driver for change in the future. Some of these events include heat waves, droughts, wildfires, flooding rains, coastal flooding, storm surge, and hurricanes. The pathways connecting extreme events to health outcomes and economic losses can be diverse and complex. The difficulty in predicting these relationships comes from the local societal and environmental factors that affect disease burden.

    • Food Safety
      1. Use, overuse, and misuse of antimicrobials contributes to selection and dissemination of bacterial resistance determinants that may be transferred to humans and constitute a global public health concern. Because of the continued emergence and expansion of antimicrobial resistance, combined with the lack of novel antimicrobial agents, efforts are underway to preserve the efficacy of current available life-saving antimicrobials in humans. As a result, uses of medically important antimicrobials in food animal production have generated debate and led to calls to reduce both antimicrobial use and the need for use. This manuscript, commissioned by the World Health Organization (WHO) to help inform the development of the WHO guidelines on the use of medically important antimicrobials in food animals, includes three illustrations of antimicrobial use in food animal production that has contributed to the selection-and subsequent transfer-of resistance determinants from food animals to humans. Herein, antimicrobial use and the epidemiology of bacterial resistance are described for streptothricins, glycopeptides, and colistin. Taken together, these historical and current narratives reinforce the need for actions that will preserve the efficacy of antimicrobials.

    • Genetics and Genomics
      1. Motivation: Inferring population structure is important for both population genetics and genetic epidemiology. Principal components analysis (PCA) has been effective in ascertaining population structure with array genotype data but can be difficult to use with sequencing data, especially when low depth leads to uncertainty in called genotypes. Because PCA is sensitive to differences in variability, PCA using sequencing data can result in components that correspond to differences in sequencing quality (read depth and error rate), rather than differences in population structure. We demonstrate that even existing methods for PCA specifically designed for sequencing data can still yield biased conclusions when used with data having sequencing properties that are systematically different across different groups of samples (i.e., sequencing groups). This situation can arise in population genetics when combining sequencing data from different studies, or in genetic epidemiology when using historical controls such as samples from the 1000 Genomes Project. Results: To allow inference on population structure using PCA in these situations, we provide an approach that is based on using sequencing reads directly without calling genotypes. Our approach is to adjust the data from different sequencing groups to have the same read depth and error rate so that PCA does not generate spurious components representing sequencing quality. To accomplish this, we have developed a subsampling procedure to match the depth distributions in different sequencing groups, and a read-flipping procedure to match the error rates. We average over subsamples and read flips to minimize loss of information. We demonstrate the utility of our approach using two datasets from 1000 Genomes, and further evaluate it using simulation studies. Availability and Implementation: TASER-PC software is publicly available at http://web1.sph.emory.edu/users/yhu30/software.html. Contact: yijuan.hu@emory.edu. Supplementary information: Supplementary data are available at Bioinformatics online.

      2. The current state of funded NIH grants in implementation science in genomic medicine: a portfolio analysis
        Roberts MC, Clyne M, Kennedy AE, Chambers DA, Khoury MJ.
        Genet Med. 2017 Oct 26.
        PurposeImplementation science offers methods to evaluate the translation of genomic medicine research into practice. The extent to which the National Institutes of Health (NIH) human genomics grant portfolio includes implementation science is unknown. This brief report’s objective is to describe recently funded implementation science studies in genomic medicine in the NIH grant portfolio, and identify remaining gaps.MethodsWe identified investigator-initiated NIH research grants on implementation science in genomic medicine (funding initiated 2012-2016). A codebook was adapted from the literature, three authors coded grants, and descriptive statistics were calculated for each code.ResultsForty-two grants fit the inclusion criteria (~1.75% of investigator-initiated genomics grants). The majority of included grants proposed qualitative and/or quantitative methods with cross-sectional study designs, and described clinical settings and primarily white, non-Hispanic study populations. Most grants were in oncology and examined genetic testing for risk assessment. Finally, grants lacked the use of implementation science frameworks, and most examined uptake of genomic medicine and/or assessed patient-centeredness.ConclusionWe identified large gaps in implementation science studies in genomic medicine in the funded NIH portfolio over the past 5 years. To move the genomics field forward, investigator-initiated research grants should employ rigorous implementation science methods within diverse settings and populations.Genetics in Medicine advance online publication, 26 October 2017; doi:10.1038/gim.2017.180.

      3. Molecular characterization of a human G20P[28] rotavirus a strain with multiple genes related to bat rotaviruses
        Esona MD, Roy S, Rungsrisuriyachai K, Gautam R, Hermelijn S, Rey-Benito G, Bowen MD.
        Infect Genet Evol. 2017 Nov 26.
        Group A rotaviruses are the major cause of severe gastroenteritis in the young of mammals and birds. This report describes characterization of an unusual G20P[28] rotavirus strain detected in a 24month old child from Suriname. Genomic sequence analyses revealed that the genotype constellation of the Suriname strain RVA/Human-wt/SUR/2014735512/2013/G20P[28] was G20-P[28]-I13-R13-C13-M12-A23-N13-T15-E20-H15. Genes VP1, VP2, VP3, NSP1, NSP2, NSP3, NSP4 and NSP5 were recently assigned novel genotypes by the Rotavirus Classification Working Group (RCWG). Three of the 11 gene segments (VP7, VP4, VP6) were similar to cognate gene sequences of bat-like human rotavirus strain Ecu534 from Ecuador and the VP7, NSP3 and NSP5 gene segments of strain RVA/Human-wt/SUR/2014735512/2013/G20P[28] were found to be closely related to gene sequences of bat rotavirus strain 3081/BRA detected in Brazil. Although distantly related, the VP1 gene of the study strain and bat strain BatLi09 detected in Cameroon in 2014 are monophyletic. The NSP1 gene was found to be most closely related to human strain QUI-35-F5 from Brazil. These findings suggest that strain RVA/Human-wt/SUR/2014735512/2013/G20P[28] represents a zoonotic infection from a bat host.

    • Health Behavior and Risk
      1. PURPOSE: The objective of this study was to examine the relationship between school involvement and connectedness with measures of sexual risk, substance use, and experience of violence among students who had sexual contact with the same sex or with both sexes. METHODS: A sample of middle school and high school students who participated in a study conducted in a large urban school district were selected based on their reported experience of having initiated sexual activity with same-sex partners. In classroom-based surveys, we assessed self-reported involvement in school-based activities and feelings of school connectedness, as well as self-reported sexual risk, substance use, and experience of violence. RESULTS: Significant protective associations were found between school involvement and lifetime alcohol and marijuana use, and between school connectedness and ever having been in a fight, feeling safe at school, and drug use other than marijuana (all p < .05). CONCLUSIONS: Findings suggest that efforts to increase school involvement and connectedness provide a starting point for addressing significant health and safety concerns among students with same-sex sexual activity.

    • Health Economics
      1. Cost-effectiveness of public-health policy options in the presence of pretreatment NNRTI drug resistance in sub-Saharan Africa: a modelling study
        Phillips AN, Cambiano V, Nakagawa F, Revill P, Jordan MR, Hallett TB, Doherty M, De Luca A, Lundgren JD, Mhangara M, Apollo T, Mellors J, Nichols B, Parikh U, Pillay D, Rinke de Wit T, Sigaloff K, Havlir D, Kuritzkes DR, Pozniak A, van de Vijver D, Vitoria M, Wainberg MA, Raizes E, Bertagnolio S.
        Lancet HIV. 2017 Nov 22.
        BACKGROUND: There is concern over increasing prevalence of non-nucleoside reverse-transcriptase inhibitor (NNRTI) resistance in people initiating antiretroviral therapy (ART) in low-income and middle-income countries. We assessed the effectiveness and cost-effectiveness of alternative public health responses in countries in sub-Saharan Africa where the prevalence of pretreatment drug resistance to NNRTIs is high. METHODS: The HIV Synthesis Model is an individual-based simulation model of sexual HIV transmission, progression, and the effect of ART in adults, which is based on extensive published data sources and considers specific drugs and resistance mutations. We used this model to generate multiple setting scenarios mimicking those in sub-Saharan Africa and considered the prevalence of pretreatment NNRTI drug resistance in 2017. We then compared effectiveness and cost-effectiveness of alternative policy options. We took a 20 year time horizon, used a cost effectiveness threshold of US$500 per DALY averted, and discounted DALYs and costs at 3% per year. FINDINGS: A transition to use of a dolutegravir as a first-line regimen in all new ART initiators is the option predicted to produce the most health benefits, resulting in a reduction of about 1 death per year per 100 people on ART over the next 20 years in a situation in which more than 10% of ART initiators have NNRTI resistance. The negative effect on population health of postponing the transition to dolutegravir increases substantially with higher prevalence of HIV drug resistance to NNRTI in ART initiators. Because of the reduced risk of resistance acquisition with dolutegravir-based regimens and reduced use of expensive second-line boosted protease inhibitor regimens, this policy option is also predicted to lead to a reduction of overall programme cost. INTERPRETATION: A future transition from first-line regimens containing efavirenz to regimens containing dolutegravir formulations in adult ART initiators is predicted to be effective and cost-effective in low-income settings in sub-Saharan Africa at any prevalence of pre-ART NNRTI resistance. The urgency of the transition will depend largely on the country-specific prevalence of NNRTI resistance. FUNDING: Bill & Melinda Gates Foundation, World Health Organization.

    • Immunity and Immunization
      1. Tdap vaccination among healthcare personnel – 21 states, 2013
        O’Halloran AC, Lu PJ, Meyer SA, Williams WW, Schumacher PK, Sussell AL, Birdsey JE, Boal WL, Sweeney MH, Luckhaupt SE, Black CL, Santibanez TA.
        Am J Prev Med. 2017 Nov 16.
        INTRODUCTION: Outbreaks of pertussis can occur in healthcare settings. Vaccinating healthcare personnel may be helpful in protecting healthcare personnel from pertussis and potentially limiting spread to others in healthcare settings. METHODS: Data from 21 states using the 2013 Behavioral Risk Factor Surveillance System industry/occupation module were analyzed in 2016. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccination status was self-reported by healthcare personnel along with their occupation, healthcare setting/industry, demographics, and access to care factors. To compare groups, t-tests were used. The median state response rate was 44.0%. RESULTS: Among all healthcare personnel, 47.2% were vaccinated for Tdap. Physicians had higher Tdap coverage (66.8%) compared with all other healthcare personnel except nurse practitioners and registered nurses (59.5%), whose coverage did not statistically differ from that of physicians. Tdap vaccination coverage was higher among workers in hospitals (53.3%) than in long-term care facilities (33.3%) and other clinical settings, such as dentist, chiropractor, and optometrist offices (39.3%). Healthcare personnel who were younger, who had higher education, higher annual household income, a personal healthcare provider, and health insurance had higher Tdap vaccination coverage compared with reference groups. Tdap vaccination coverage among healthcare personnel in 21 states ranged from 30.6% in Mississippi to 65.9% in Washington. CONCLUSIONS: Improvement in Tdap vaccination among healthcare personnel is needed to potentially reduce opportunities for spread of pertussis in healthcare settings. On-site workplace vaccination, offering vaccines free of charge, and promoting vaccination may increase vaccination among healthcare personnel.

      2. BACKGROUND: Implementing rigorous epidemiologic studies in low-resource settings involves challenges in participant recruitment and follow-up (e.g., mobile populations, distrust), biological sample collection (e.g., cold-chain, laboratory equipment scarcity) and data collection (e.g., literacy, staff training, and infrastructure). This article describes the use of a monitoring and evaluation (M&E) framework to improve study efficiency and quality during participant engagement, and biological sample and data collection in a longitudinal cohort study of Bolivian infants. METHODS: The study occurred between 2013 and 2015 in El Alto, Bolivia, a high-altitude, urban, low-resource community. The study’s M&E framework included indicators for participant engagement (e.g., recruitment, retention, safety), biological sample (e.g., stool and blood), and data (e.g., anthropometry, questionnaires) collection and quality. Monitoring indicators were measured regularly throughout the study and used for course correction, communication, and staff retraining. RESULTS: Participant engagement indicators suggested that enrollment objectives were met (461 infants), but 15% loss-to-follow-up resulted in only 364 infants completing the study. Over the course of the study, there were four study-related adverse events (minor swelling and bruising related to a blood draw) and five severe adverse events (infant deaths) not related to study participation. Biological sample indicators demonstrated two blood samples collected from 95% (333 of 350 required) infants and stool collected for 61% of reported infant diarrhea episodes. Anthropometry data quality indicators were extremely high (median SDs for weight-for-length, length-for-age and weight-for-age z-scores 1.01, 0.98, and 1.03, respectively), likely due to extensive training, standardization, and monitoring efforts. CONCLUSIONS: Conducting human subjects research studies in low-resource settings often presents unique logistical difficulties, and collecting high-quality data is often a challenge. Investing in comprehensive M&E is important to improve participant recruitment, retention and safety, and sample and data quality. The M&E framework from this study can be applied to other longitudinal studies.

      3. OBJECTIVE: To examine the association between state Medicaid vaccine administration fees and children’s receipt of immunization services. METHODS: The study used the 2008-2012 Medicaid Analytic eXtract data and included children aged 0-17 years and continuously enrolled in a Medicaid fee-for-service plan in each study year. Analyses were restricted to 8 states with a Medicaid managed-care penetration rate <75%. Linear regressions were used to estimate the probability of children making >/=1 vaccination visit and the numbers of vaccination visits in the year as a function of state Medicaid vaccine administration fees, age group, sex, race/ethnicity, state unemployment rate, state managed-care penetration rate, and state and year-fixed effects. RESULTS: A total of 1,678,288 children were included. In 2008-2012, the average proportion of children making >/=1 vaccination visit per year was 31% and the mean number of vaccination visits was 0.9. State Medicaid reimbursements for vaccine administration was positively associated with immunization service utilization; for every $1 increase in the payment amount, the probability of children making >/=1 vaccination visit increased by 0.72 percentage point (95% confidence interval, 0.23-1.21; P=0.01), representing a 2% increase from the mean and the number of vaccination visits increased by 0.03 (95% confidence interval, -0.00 to 0.06; P<0.1). The estimated effect was greater among younger children. CONCLUSION: Higher Medicaid reimbursements for vaccine administration were associated with increased proportion of children receiving immunization services.

      4. Notes from the field: Absence of asymptomatic mumps virus shedding among vaccinated college students during a mumps outbreak – Washington, February-June 2017
        Bonwitt J, Kawakami V, Wharton A, Burke RM, Murthy N, Lee A, Dell B, Kay M, Duchin J, Hickman C, McNall RJ, Rota PA, Patel M, Lindquist S, DeBolt C, Routh J.
        MMWR Morb Mortal Wkly Rep. 2017 Dec 1;66(47):1307-1308.

        [No abstract]

      5. Fractional-dose inactivated poliovirus vaccine campaign – Sindh Province, Pakistan, 2016
        Pervaiz A, Mbaeyi C, Baig MA, Burman A, Ahmed JA, Akter S, Jatoi FA, Mahamud A, Asghar RJ, Azam N, Shah MN, Laghari MA, Soomro K, Wadood MZ, Ehrhardt D, Safdar RM, Farag N.
        MMWR Morb Mortal Wkly Rep. 2017 Dec 1;66(47):1295-1299.
        Following the declaration of eradication of wild poliovirus (WPV) type 2 in September 2015, trivalent oral poliovirus vaccine (tOPV) was withdrawn globally to reduce the risk for type 2 vaccine-derived poliovirus (VDPV2) transmission; all countries implemented a synchronized switch to bivalent OPV (type 1 and 3) in April 2016 (1,2). Any isolation of VDPV2 after the switch is to be treated as a potential public health emergency and might indicate the need for supplementary immunization activities (3,4). On August 9, 2016, VDPV2 was isolated from a sewage sample taken from an environmental surveillance site in Hyderabad, Sindh province, Pakistan. Possible vaccination activities in response to VDPV2 isolation include the use of injectable inactivated polio vaccine (IPV), which poses no risk for vaccine-derived poliovirus transmission. Fractional-dose, intradermal IPV (fIPV), one fifth of the standard intramuscular dose, has been developed to more efficiently manage limited IPV supplies. fIPV has been shown in some studies to be noninferior to full-dose IPV (5,6) and was used successfully in response to a similar detection of a single VDPV2 isolate from sewage in India (7). Injectable fIPV was used for response activities in Hyderabad and three neighboring districts. This report describes the findings of an assessment of preparatory activities and subsequent implementation of the fIPV campaign. Despite achieving high coverage (>80%), several operational challenges were noted. The lessons learned from this campaign could help to guide the planning and implementation of future fIPV vaccination activities.

      6. Predictors of seasonal influenza vaccination among older adults in Thailand
        Praphasiri P, Ditsungnoen D, Sirilak S, Rattanayot J, Areerat P, Dawood FS, Lindblade KA.
        PLoS One. 2017 ;12(11):e0188422.
        BACKGROUND: In advance of a large influenza vaccine effectiveness (VE) cohort study among older adults in Thailand, we conducted a population-based, cross-sectional survey to measure vaccine coverage and identify factors associated with influenza vaccination among older Thai adults that could bias measures of vaccine effectiveness. METHOD: We selected adults >/=65 years using a two-stage, stratified, cluster sampling design. Functional status was assessed using the 10-point Vulnerable Elders Survey (VES); scores >/=3 indicated vulnerability. Questions about attitudes towards vaccination were based on the Health Belief Model. The distance between participants’ households and the nearest vaccination clinic was calculated. Vaccination status was determined using national influenza vaccination registry. Prevalence ratios (PR) and 95% confidence intervals (CIs) were calculated using log-binomial multivariable models accounting for the sampling design. RESULT: We enrolled 581 participants, of whom 60% were female, median age was 72 years, 41% had at least one chronic underlying illness, 24% met the criteria for vulnerable, and 23% did not leave the house on a daily basis. Influenza vaccination rate was 34%. In multivariable models, no variable related to functional status was associated with vaccination. The strongest predictors of vaccination were distance to the nearest vaccination center (PR 3.0, 95% CI 1.7-5.1 for participants in the closest quartile compared to the furthest), and high levels of a perception of benefits of influenza vaccination (PR 2.8, 95% CI 1.4-5.6) and cues to action (PR 2.7, 95% CI 1.5-5.1). CONCLUSION: Distance to vaccination clinics should be considered in analyses of influenza VE studies in Thailand. Strategies that emphasize benefits of vaccination and encourage physicians to recommend annual influenza vaccination could improve influenza vaccine uptake among older Thai adults. Outreach to more distant and less mobile older adults may also be required to improve influenza vaccination coverage.

      7. In 2016, the Immunization Technical Advisory Group of the South-East Asia Region (SEAR) endorsed a regional goal to achieve </=1% prevalence of hepatitis B surface antigen (HBsAg) among 5-year-old children by 2020. Chronic hepatitis B virus (HBV) infection is largely preventable with a birth dose of hepatitis B vaccine (HepB-BD) followed by two to three additional doses. We reviewed the progress towards hepatitis B control through vaccination in SEAR during 1992-2015. We summarized hepatitis B vaccination data and reviewed the literature to determine the prevalence of chronic HBV infection pre- and post-vaccine introduction. We used a mathematical model to determine post-vaccine prevalence of HBsAg among 5year olds in countries lacking national serosurvey data and estimated the impact of vaccination on disease burden. Regional coverage with three doses of hepatitis B vaccine (HepB3) increased from 56% in 2011 to 87% in 2015. By 2016, 7 of 11 countries had introduced universal HepB-BD. Regional HepB-BD coverage increased from 9% in 2011 to 34% in 2015. In 2015, estimated HBsAg among 5year olds was 1.1% with variability among countries. Myanmar (3.8%), Timor-Leste (2.7%), Indonesia (1.8%), and India (1%) had the highest prevalence of HBsAg. During 1992-2015, vaccination prevented approximately 16 million chronic HBV infections and 2.6 million related deaths. In 2015, around 197,640 perinatal HBV infections occurred in SEAR with majority occurring in India (62%), Bangladesh (24%), and Myanmar (8%). Myanmar had the highest rate of perinatal chronic HBV infections at 16 per 1000 live births. Despite significant progress in the control of HBV, SEAR needs to secure political commitment for elimination and consider additional strategies, such as promoting health facility births, universal birth dose administration, developing strong coordination between health sectors, and using alternative vaccine delivery methods, to improve HepB-BD coverage and subsequently achieve HBV control and elimination.

      8. Knowledge, attitudes, and practices of private sector immunization service providers in Gujarat, India
        Hagan JE, Gaonkar N, Doshi V, Patni A, Vyas S, Mazumdar V, Kosambiya JK, Gupta S, Watkins M.
        Vaccine. 2017 Nov 22.
        BACKGROUND: India is responsible for 30% of the annual global cohort of unvaccinated children worldwide. Private practitioners provide an estimated 21% of vaccinations in urban centers of India, and are important partners in achieving high vaccination coverage. METHODS: We used an in-person questionnaire and on-site observation to assess knowledge, attitudes, and practices of private immunization service providers regarding delivery of immunization services in the urban settings of Surat and Baroda, in Gujarat, India. We constructed a comprehensive sampling frame of all private physician providers of immunization services in Surat and Baroda cities, by consulting vaccine distributors, local branches of physician associations, and published lists of private medical practitioners. All providers were contacted and asked to participate in the study if they provided immunization services. Data were collected using an in-person structured questionnaire and directly observing practices; one provider in each practice setting was interviewed. RESULTS: The response rate was 82% (121/147) in Surat, and 91% (137/151) in Baroda. Of 258 participants 195 (76%) were pediatricians, and 63 (24%) were general practitioners. Practices that were potential missed opportunities for vaccination (MOV) included not strictly following vaccination schedules if there were concerns about ability to pay (45% of practitioners), and not administering more than two injections in the same visit (60%). Only 22% of respondents used a vaccination register to record vaccine doses, and 31% reported vaccine doses administered to the government. Of 237 randomly selected vaccine vials, 18% had expired vaccine vial monitors. CONCLUSIONS: Quality of immunization services in Gujarat can be strengthened by providing training and support to private immunization service providers to reduce MOVs and improve quality and safety; other more context specific strategies that should be evaluated may involve giving feedback to providers on quality of services delivered and working through professional societies to adopt standards of practice.

      9. BACKGROUND: The safety of hepatitis B vaccination during pregnancy has not been well studied. OBJECTIVE: We characterized adverse events (AEs) after hepatitis B vaccination of pregnant women reported to the Vaccine Adverse Event Reporting System (VAERS), a spontaneous reporting surveillance system. METHODS: We searched VAERS for AEs reports involving pregnant women who received hepatitis B vaccine from January 1, 1990-June 30, 2016. All reports and available medical records were reviewed by physicians. Observed AEs were compared to expected AEs and known rates of pregnancy outcomes to assess for any unexpected safety concern. RESULTS: We found 192 reports involving pregnant women following hepatitis B vaccination of which 110 (57.3%) described AEs; 12 (6.3%) were classified as serious; one newborn death was identified in a severely premature delivery, and there were no maternal deaths. Eighty-two (42.7%) reports did not describe any AEs. Among pregnancies for which gestational age was reported, most women were vaccinated during the first trimester, 86/115 (74.7%). Among reports describing an AE, the most common pregnancy-specific outcomes included spontaneous abortion in 23 reports, preterm delivery in 7 reports, and elective termination in 5 reports. The most common non-pregnancy specific outcomes were general disorders and administration site conditions, such as injection site and systemic reactions, in 21 reports. Among 22 reports describing an AE among infants born to women vaccinated during pregnancy, 5 described major birth defects each affecting different organ systems. CONCLUSION: Our analysis of VAERS reports involving hepatitis B vaccination during pregnancy did not identify any new or unexpected safety concerns.

      10. BACKGROUND: Rotavirus is the most common cause of severe diarrhea in Nepali children, accounting for 25-33% of childhood diarrhea hospitalizations. Two rotavirus vaccines recommended for inclusion in national immunization programs have been associated with a low risk of intussusception in post-marketing studies conducted in several countries. Data on the epidemiology of intussusception hospitalizations are lacking in Nepal. Thus, we aimed to describe the epidemiology of intussusception-associated hospitalizations among Nepali children in preparation for rotavirus vaccine introduction. METHODS: A retrospective review of intussusception hospitalizations for a three year period was conducted at two major pediatric hospitals in Kathmandu, Nepal. Possible intussusception cases were identified through admission, discharge, and operation theater logs and ultrasound registers. Cases with a diagnosis of possible intussusception were selected for medical record review and classified as confirmed if they met the Brighton Collaboration level 1 criteria of diagnostic certainty and the child was aged<24months. Data on demographics, clinical course, and outcome were abstracted and analyzed. RESULTS: Eight-five confirmed intussusception cases were identified; most (96%) were confirmed at surgery. The number of intussusception cases peaked between ages 4-7 months; no cases occurred in children 0-2 months. Fifty-nine (64%) case-patients were male. The median duration of symptoms before admission was 2days (range: 0-14). Abdominal pain, bloody stool, and vomiting were the most common clinical features. All cases underwent surgical treatment; there was only one death. CONCLUSIONS: This is the first study to evaluate the epidemiology of intussusception hospitalizations among children aged<24months in Nepal. Because the public health impact of rotavirus vaccination could be substantial in Nepal, where childhood diarrhea-related morbidity and mortality are high, this baseline knowledge of intussusception prior to introduction of rotavirus vaccine in the national immunization schedule will provide useful information for post-vaccine introduction safety monitoring.

      11. Vaccine wastage in Nigeria: An assessment of wastage rates and related vaccinator knowledge, attitudes and practices
        Wallace AS, Willis F, Nwaze E, Dieng B, Sipilanyambe N, Daniels D, Abanida E, Gasasira A, Mahmud M, Ryman TK.
        Vaccine. 2017 Dec 4;35(48 Pt B):6751-6758.
        INTRODUCTION: The introduction of new vaccines highlights concerns about high vaccine wastage, knowledge of wastage policies and quality of stock management. However, an emphasis on minimizing wastage rates may cause confusion when recommendations are also being made to reduce missed opportunities to routinely vaccinate children. This concern is most relevant for lyophilized vaccines without preservatives [e.g. measles-containing vaccine (MCV)], which can be used for a limited time once reconstituted. METHODS: We sampled 54 health facilities within 11 local government areas (LGAs) in Nigeria and surveyed health sector personnel regarding routine vaccine usage and wastage-related knowledge and practices, conducted facility exit interviews with caregivers of children about missed opportunities for routine vaccination, and abstracted vaccine stock records and vaccination session data over a 6-month period to calculate wastage rates and vaccine vial usage patterns. RESULTS: Nearly half of facilities had incomplete vaccine stock data for calculating wastage rates. Among facilities with sufficient data, mean monthly facility-level wastage rates were between 18 and 35% across all reviewed vaccines, with little difference between lyophilized and liquid vaccines. Most (98%) vaccinators believed high wastage led to recent vaccine stockouts, yet only 55% were familiar with the multi-dose vial policy for minimizing wastage. On average, vaccinators reported that a minimum of six children must be present prior to opening a 10-dose MCV vial. Third dose of diphtheria-tetanus-pertussis vaccine (DTP3) was administered in 84% of sessions and MCV in 63%; however, the number of MCV and DTP3 doses administered were similar indicating the number of children vaccinated with DTP3 and MCV were similar despite less frequent MCV vaccination opportunities. Among caregivers, 30% reported being turned away for vaccination at least once; 53% of these children had not yet received the missed dose. DISCUSSION: Our findings show inadequate implementation of vaccine management guidelines, missed opportunities to vaccinate, and lyophilized vaccine wastage rates below expected rates. Missed opportunities for vaccination may occur due to how the health system’s contradicting policies may force health workers to prioritize reduced wastage rates over vaccine administration, particularly for multi-dose vials.

    • Injury and Violence
      1. A cross-national exploration of societal-level factors associated with child physical abuse and neglect
        Klevens J, Ports KA, Austin C, Ludlow IJ, Hurd J.
        Glob Public Health. 2017 Nov 28:1-12.
        Children around the world experience violence at the hands of their caregivers at alarming rates. A recent review estimates that a minimum of 50% of children in Asia, Africa, and North America experienced severe physical violence by caregivers in the past year, with large variations between countries. Identifying modifiable country-level factors driving these geographic variations has great potential for achieving population-level reductions in rates of child maltreatment. This study builds on previous research by focusing on caregiver-reported physical abuse and neglect victimisation, examining 22 societal factors representing 11 different constructs among 42 countries from 5 continents at different stages of development. Our findings suggest that gender inequity may be important for both child physical abuse and neglect. Indicators of literacy and development may also be important for child neglect. Given the limitations of the correlational findings and measurement issues, it is critical to continue to investigate societal-level factors of child maltreatment so that interventions and prevention efforts can incorporate strategies that have the greatest potential for population-level impact.

      2. Evaluation of an integrated multisector campaign to increase child helmet use in Vietnam
        Nhan LD, Parker L, Son MT, Parker EM, Moore MR, Sidik M, Draisin N.
        Inj Prev. 2017 Nov 25.
        OBJECTIVE: This study presents child helmet use before, during and after implementing the Vietnamese National Child Helmet Action Plan (NCHAP) and evaluates its effect on child helmet use. The NCHAP, an integrated multisector campaign, incorporated a wide-scale public awareness campaign, school-based interventions, increased police patrolling and enforcement, and capacity building and support to relevant government departments in target provinces. METHODS: In Vietnam’s three largest cities, 100 schools in 20 districts were selected to monitor motorcycle helmet use behaviour. The effectiveness of the NCHAP was measured by unannounced, filmed observations of student motorcycle passengers and their adult drivers as they arrived or left their schools at four points. Baseline observations at each school were conducted in March 2014, with subsequent observations in April 2015, December 2015 and May 2016. RESULTS: Across the 84 218 observed students, student helmet prevalence increased from 36.1% in March 2014 to 69.3% immediately after the initiation in April 2015. Subsequent observations in December 2015 and May 2016 showed a reduction and stabilisation of helmet use, with 49.8% and 56.9% of students wearing helmets, respectively. Helmet use in students was higher when adult drivers were also wearing helmets. CONCLUSIONS: Integrated multisectoral interventions between governments, civil society and the corporate sector that incorporate communications, school-based education, incentives for change and police enforcement have the potential to increase helmet use among children. Future integrated campaigns may be more effective with an increased focus on parents and other adult drivers given their potential influence on child helmet use.

      3. A comprehensive approach to motorcycle-related head injury prevention: Experiences from the field in Vietnam, Cambodia, and Uganda
        Craft G, Van Bui T, Sidik M, Moore D, Ederer DJ, Parker EM, Ballesteros MF, Sleet DA.
        Int J Environ Res Public Health. 2017 Nov 30;14(12).
        Motorcyclists account for 23% of global road traffic deaths and over half of fatalities in countries where motorcycles are the dominant means of transport. Wearing a helmet can reduce the risk of head injury by as much as 69% and death by 42%; however, both child and adult helmet use are low in many countries where motorcycles are a primary mode of transportation. In response to the need to increase helmet use by all drivers and their passengers, the Global Helmet Vaccine Initiative (GHVI) was established to increase helmet use in three countries where a substantial portion of road users are motorcyclists and where helmet use is low. The GHVI approach includes five strategies to increase helmet use: targeted programs, helmet access, public awareness, institutional policies, and monitoring and evaluation. The application of GHVI to Vietnam, Cambodia, and Uganda resulted in four key lessons learned. First, motorcyclists are more likely to wear helmets when helmet use is mandated and enforced. Second, programs targeted to at-risk motorcyclists, such as child passengers, combined with improved awareness among the broader population, can result in greater public support needed to encourage action by decision-makers. Third, for broad population-level change, using multiple strategies in tandem can be more effective than using a single strategy alone. Lastly, the successful expansion of GHVI into Cambodia and Uganda has been hindered by the lack of helmet accessibility and affordability, a core component contributing to its success in Vietnam. This paper will review the development of the GHVI five-pillar approach in Vietnam, subsequent efforts to implement the model in Cambodia and Uganda, and lessons learned from these applications to protect motorcycle drivers and their adult and child passengers from injury.

    • Laboratory Sciences
      1. Background: Specimen labeling errors have long plagued the laboratory industry putting patients at risk of transfusion-related death, medication errors, misdiagnosis, and patient mismanagement. Many interventions have been implemented and deemed to be effective in reducing sample error rates. The objective of this review was to identify and evaluate the effectiveness of laboratory practices/ interventions to develop evidence based recommendations for the best laboratory practices to reduce labeling errors. Content: The standardized LMBP A-6 methods were used to conduct this systematic review. Total evidence included 12 studies published during the time periods of 1980 to September 2015. Combined data from seven studies found that the interventions developed as a result of improved communication and collaboration between the laboratory and clinical staff resulted in substantial decrease in specimen labeling errors (Median relative percent change in labeling errors: -75.86; IQI: -84.77, -58.00). Further data from subset of four studies showed a significant decrease in specimen labeling errors after the institution of the standardized specimen labeling protocols (Median relative percent decrease in specimen labeling errors: -72.45; IQI: -83.25, -46.50). Summary: Based on the evidence included in this review, the interventions that enhance the communication and collaboration between laboratory and healthcare professionals can decrease the specimen identification errors in healthcare settings. However, more research is needed to make the conclusion on the effectiveness of other evaluated practices in this review including training and education of the specimen collection staff, audit and feedback of labeling errors, and implementation of new technology (other than barcoding).

      2. Differences in staining intensities affect reported occurrences and concentrations of Giardia spp. in surface drinking water sources
        Alderisio KA, Villegas LF, Ware MW, McDonald LA, Xiao L, Villegas EN.
        J Appl Microbiol. 2017 Dec;123(6):1607-1613.
        AIM: USEPA Method 1623, or its equivalent, is currently used to monitor for protozoan contamination of surface drinking water sources worldwide. At least three approved staining kits used for detecting Cryptosporidium and Giardia are commercially available. This study focuses on understanding the differences among staining kits used for Method 1623. METHODS AND RESULTS: Merifluor and EasyStain labelling kits were used to monitor Cryptosporidium oocyst and Giardia cyst densities in New York City’s raw surface water sources. In the year following a change to the approved staining kits for use with Method 1623, an anomaly was noted in the occurrence of Giardia cysts in New York City’s raw surface water. Specifically, Merifluor-stained samples had higher Giardia cyst densities as compared with those stained with EasyStain. Side by side comparison revealed significantly lower fluorescence intensities of Giardia muris as compared with Giardia duodenalis cysts when labelled with EasyStain. CONCLUSIONS: This study showed very poor fluorescence intensity signals by EasyStain on G. muris cysts resulting in lower cyst counts, while Merifluor, with its broader Giardia cyst staining specificity, resulted in higher cyst counts, when using Methods 1623. SIGNIFICANCE AND IMPACT OF THE STUDY: These results suggest that detected Giardia cyst concentrations are dependent on the staining kits used, which can result in a more or less conservative estimation of occurrences and densities of zoonotic Giardia cysts by detecting a broader range of Giardia species/Assemblages.

      3. Repetitive exposure to hand-transmitted vibration is associated with development of peripheral vascular and sensorineural dysfunctions. These disorders and symptoms associated with it are referred to as hand-arm vibration syndrome (HAVS). Although the symptoms of the disorder have been well characterized, the etiology and contribution of various exposure factors to development of the dysfunctions are not well understood. Previous studies performed using a rat-tail model of vibration demonstrated that vascular and peripheral nervous system adverse effects of vibration are frequency-dependent, with vibration frequencies at or near the resonant frequency producing the most severe injury. However, in these investigations, the amplitude of the exposed tissue was greater than amplitude typically noted in human fingers. To determine how contact with vibrating source and amplitude of the biodynamic response of the tissue affects the risk of injury occurring, this study compared the influence of frequency using different levels of restraint to assess how maintaining contact of the tail with vibrating source affects the transmission of vibration. Data demonstrated that for the most part, increasing the contact of the tail with the platform by restraining it with additional straps resulted in an enhancement in transmission of vibration signal and elevation in factors associated with vascular and peripheral nerve injury. In addition, there were also frequency-dependent effects, with exposure at 250 Hz generating greater effects than vibration at 62.5 Hz. These observations are consistent with studies in humans demonstrating that greater contact and exposure to frequencies near the resonant frequency pose the highest risk for generating peripheral vascular and sensorineural dysfunction.

      4. Operational evaluation of rapid diagnostic testing for Ebola Virus Disease in Guinean laboratories
        VanSteelandt A, Aho J, Franklin K, Likofata J, Kamgang JB, Keita S, Koivogui L, Magassouba N, Martel LD, Dahourou AG.
        PLoS One. 2017 ;12(11):e0188047.
        BACKGROUND: Rapid Diagnostic Tests (RDTs) for Ebola Virus Disease (EVD) at the point of care have the potential to increase access and acceptability of EVD testing and the speed of patient isolation and secure burials for suspect cases. A pilot program for EVD RDTs in high risk areas of Guinea was introduced in October 2015. This paper presents concordance data between EVD RDTs and PCR testing in the field as well as an assessment of the acceptability, feasibility, and quality assurance of the RDT program. METHODS AND FINDINGS: Concordance data were compiled from laboratory surveillance databases. The operational measures of the laboratory-based EVD RDT program were evaluated at all 34 sentinel sites in Guinea through: (1) a technical questionnaire filled by the lab technicians who performed the RDTs, (2) a checklist filled by the evaluator during the site visits, and (3) direct observation of the lab technicians performing the quality control test. Acceptability of the EVD RDT was good for technicians, patients, and families although many technicians (69.8%) expressed concern for their safety while performing the test. The feasibility of the program was good based on average technician knowledge scores (6.6 out of 8) but basic infrastructure, equipment, and supplies were lacking. There was much room for improvement in quality assurance of the program. CONCLUSIONS: The implementation of new diagnostics in weak laboratory systems requires general training in quality assurance, biosafety and communication with patients in addition to specific training for the new test. Corresponding capacity building in terms of basic equipment and a long-term commitment to transfer supervision and quality improvement to national public health staff are necessary for successful implementation.

    • Maternal and Child Health
      1. State of newborn care in South Sudan’s displacement camps: a descriptive study of facility-based deliveries
        Sami S, Kerber K, Kenyi S, Amsalu R, Tomczyk B, Jackson D, Dimiti A, Scudder E, Meyers J, Umurungi JP, Kenneth K, Mullany LC.
        Reprod Health. 2017 Nov 29;14(1):161.
        BACKGROUND: Approximately 2.7 million neonatal deaths occur annually, with highest rates of neonatal mortality in countries that have recently experienced conflict. Constant instability in South Sudan further strains a weakened health system and poses public health challenges during the neonatal period. We aimed to describe the state of newborn facility-level care in displaced person camps across Juba, Malakal, and Maban. METHODS: We conducted clinical observations of the labor and delivery period, exit interviews with recently delivered mothers, health facility assessments, and direct observations of midwife time-use. Study participants were mother-newborn pairs who sought services and birth attendants who provided delivery services between April and June 2016 in five health facilities. RESULTS: Facilities were found to be lacking the recommended medical supplies for essential newborn care. Two of the five facilities had skilled midwives working during all operating hours, with 6.2% of their time spent on postnatal care. Selected components of thermal care (62.5%), infection prevention (74.8%), and feeding support (63.6%) were commonly practiced, but postnatal monitoring (27.7%) was less consistently observed. Differences were found when comparing the primary care level to the hospital (thermal: relative risk [RR] 0.48 [95% CI] 0.40-0.58; infection: RR 1.28 [1.11-1.47]; feeding: RR 0.49 [0.40-0.58]; postnatal: RR 3.17 [2.01-5.00]). In the primary care level, relative to newborns delivered by traditional birth attendants, those delivered by skilled attendants were more likely to receive postnatal monitoring (RR 1.59 [1.09-2.32]), but other practices were not statistically different. Mothers’ knowledge of danger signs was poor, with fever as the highest reported (44.8%) followed by not feeding well (41.0%), difficulty breathing (28.9%), reduced activity (27.7%), feeling cold (18.0%) and convulsions (11.2%). CONCLUSIONS: Addressing health service delivery in contexts affected by conflict is vital to reducing the global newborn mortality rate and reaching the Sustainable Development Goals. Gaps in intrapartum and postnatal care, particularly skilled care at birth, suggest a critical need to build the capacity of the existing health workforce while increasing access to skilled deliveries.

      2. The burden of congenital rubella syndrome in the Philippines: results from a retrospective assessment
        Lopez AL, Raguindin PF, Jonas Del Rosario J, Najarro RV, Du E, Aldaba J, Salonga AM, Monzon-Pajarillo AK, Santiago AP, Ou AC, Ducusin MJ.
        Western Pac Surveill Response J. 2017 Apr-Jun;8(2):17-24.
        Introduction: In line with the regional aim of eliminating rubella and congenital rubella syndrome (CRS), phased introduction of rubella-containing vaccines (RCV) in the Philippines’ routine immunization programme began in 2010. We estimated the burden of CRS in the country before widespread nationwide programmatic RCV use. Methods: We performed a retrospective chart review in four tertiary hospitals. Children born between 1 January 2009 and 31 December 2014 and identified as possible CRS cases based on the presence of one or more potential manifestations of CRS documented in hospital or clinic charts were reviewed. Cases that met the clinical case definition of CRS were classified as either confirmed (with laboratory confirmation) or probable (without laboratory confirmation). Cases that did not fulfil the criteria for either confirmed or probable CRS were excluded from the analysis. Results: We identified 18 confirmed and 201 probable cases in this review. Depending on the hospital, the estimated incidence of CRS ranged from 30 to 233 cases per 100 000 live births. The estimated national burden of CRS was 20 to 31 cases per 100 000 annually. Discussion: This is the first attempt to assess the national CRS burden using in-country hospital data in the Philippines. Prospective surveillance for CRS and further strengthening of the ongoing measles-rubella surveillance are necessary to establish accurate estimates of the burden of CRS and the impact of programmatic RCV use in the future.

    • Occupational Safety and Health
      1. Characterization of exposure to byproducts from firing lead-free frangible ammunition in an enclosed, ventilated firing range
        Grabinski CM, Methner MM, Jackson JM, Moore AL, Flory LE, Tilly T, Hussain SM, Ott DK.
        J Occup Environ Hyg. 2017 Jun;14(6):461-472.
        U.S. Air Force small arms firing ranges began using copper-based, lead-free frangible ammunition in the early 2000s due to environmental and health concerns related to the use of lead-based ammunition. Exposure assessments at these firing ranges have routinely detected chemicals and metals in amounts much lower than their mass-based occupational exposure limits, yet, instructors report work-related health concerns including respiratory distress, nausea, and headache. The objective of this study at one firing range was to characterize the aerosol emissions produced by weapons during firing events and evaluate the ventilation system’s effectiveness in controlling instructor exposure to these emissions. The ventilation system was assessed by measuring the range static air pressure differential and the air velocity at the firing line. Air flow patterns were near the firing line. Instructor exposure was sampled using a filter-based air sampling method for metals and a wearable, real-time ultrafine particle counter. Area air sampling was simultaneously performed to characterize the particle size distribution, morphology, and composition. In the instructor’s breathing zone, the airborne mass concentration of copper was low (range = <1 microg/m(3) to 16 microg/m(3)), yet the ultrafine (nanoscale) particle number concentration increased substantially during each firing event. Ultrafine particles contained some copper and were complex in morphology and composition. The ventilation assessment found that the average velocity across all shooting lanes was acceptable compared to the recommended guideline (20% of the ideal 0.38 m/s (75 ft/min). However, uniform, downrange airflow pattern requirements were not met. These results suggest that the mass-based occupational exposure limits, as applied to this environment, may not be protective enough to eliminate health complaints reported by instructors whose full-time job involves training personnel on weapons that fire lead-free frangible ammunition. Using an ultrafine particle counter appears to be an alternative method of assessing ventilation effectiveness in removing ultrafine particulate produced during firing events.

      2. Synthetic cannabinoid and mitragynine exposure of law enforcement agents during the raid of an illegal laboratory – Nevada, 2014
        Tapp L, Ramsey JG, Wen A, Gerona R.
        MMWR Morb Mortal Wkly Rep. 2017 Dec 1;66(47):1291-1294.
        Synthetic cannabinoids (SCs), commonly known by the street name “Spice,” are designer drugs of abuse that mimic the psychoactive effects of marijuana. Intentional SC use has resulted in multiple toxicities (1,2), but little is known about occupational SC exposure. After a federal agency’s law enforcement personnel in Nevada reported irritability and feeling “high” after raiding illegal SC laboratories and processing seized SCs, a request for a health hazard evaluation was made by the agency to CDC’s National Institute for Occupational Safety and Health (NIOSH) in 2014 to evaluate agents’ occupational SC exposures. After making the request for a health hazard evaluation, federal agents conducted a raid of an illegal SC laboratory, with assistance from local law enforcement and Drug Enforcement Administration (DEA) personnel and with NIOSH investigators observing from a distance. After the raid, agents collected and processed material evidence. NIOSH investigators tested agents’ urine for SC levels before and after the raid and measured SCs in the air and on surfaces after the raid. DEA determined that AB-PINACA (an SC compound) and mitragynine (a plant material with opium-like effects, also known as “kratom”) were present in the illegal laboratory. AB-PINACA, its metabolites, and mitragynine were not detected in agents’ urine before the raid; however, one or more of these substances was found in the urine of six of nine agents after the raid and processing of the SC evidence. AB-PINACA was detected in one surface wipe sample from the SC laboratory; none was detected in the air in the laboratory or in the offices of the law enforcement agency where the materials were processed after the raid. No policies were in place regarding work practices and use of personal protective equipment (PPE) during raids and evidence processing. To protect agents from SC exposures, NIOSH recommended that the agency require agents to wear a minimum level of PPE (e.g., protective gloves and disposable clothing) and undergo training in PPE and in handling and storing of contaminated evidence from SC laboratory raids. Showers and locker rooms also need to be provided so that agents can reduce contamination and prevent take-home exposure.

    • Physical Activity
      1. Achieving equity in physical activity participation: ACSM experience and next steps
        Hasson RE, Brown DR, Dorn J, Barkley L, Torgan C, Whitt-Glover M, Ainsworth B, Keith N.
        Med Sci Sports Exerc. 2017 Apr;49(4):848-858.
        There is clear and consistent evidence that regular physical activity is an important component of healthy lifestyles and fundamental to promoting health and preventing disease. Despite the known benefits of physical activity participation, many people in the United States remain inactive. More specifically, physical activity behavior is socially patterned with lower participation rates among women; racial/ethnic minorities; sexual minority youth; individuals with less education; persons with physical, mental, and cognitive disabilities; individuals >65 yr of age; and those living in the southeast region of the United States. Many health-related outcomes follow a pattern that is similar to physical activity participation. In response to the problem of inequities in physical activity and overall health in the United States, the American College of Sports Medicine (ACSM) has developed a national roadmap that supports achieving health equity through a physically active lifestyle. The actionable, integrated pathways that provide the foundation of ACSM’s roadmap include the following: 1) communication-raising awareness of the issue and magnitude of health inequities and conveying the power of physical activity in promoting health equity; 2) education-developing educational resources to improve cultural competency for health care providers and fitness professionals as well as developing new community-based programs for lay health workers; 3) collaboration-building partnerships and programs that integrate existing infrastructures and leverage institutional knowledge, reach, and voices of public, private, and community organizations; and 4) evaluation-ensuring that ACSM attains measurable progress in reducing physical activity disparities to promote health equity. This article provides a conceptual overview of these four pathways of ACSM’s roadmap, an understanding of the challenges and advantages of implementing these components, and the organizational and economic benefits of achieving health equity.

    • Public Health Leadership and Management
      1. PURPOSE: This report describes Centers for Disease Control and Prevention programs that expose students to epidemiology and public health sciences (EPHS). METHODS: The Science Ambassador workshop targets middle and high school teachers and promotes teaching EPHS in the classroom. The National Science Olympiad Disease Detectives event is an extracurricular science competition for middle and high school students based on investigations of outbreaks and other public health problems. The Epidemiology Elective Program provides experiential learning activities for veterinary and medical students. RESULTS: As of 2016, 234 teachers from 37 states and territories and three other countries participated in SA workshops. Several are teaching units or entire courses in EPHS. The National Science Olympiad Disease Detectives event exposed approximately 15,000 middle and high school students to EPHS during the 2015-2016 school year. The Epidemiology Elective Program has exposed 1,795 veterinary and medical students to EPHS. CONCLUSIONS: Students can master fundamental concepts of EPHS as early as middle school and educators are finding ways to introduce this material into their classrooms. Programs to introduce veterinary and medical students to EPHS can help fill the gap in exposing older students to the field. Professional organizations can assist by making their members aware of these programs.

    • Zoonotic and Vectorborne Diseases
      1. Chikungunya virus disease among travelers – United States, 2014-2016
        Lindsey NP, Staples JE, Fischer M.
        Am J Trop Med Hyg. 2017 Nov 27.
        Chikungunya virus is a mosquito-borne alphavirus that causes an acute febrile illness with severe polyarthralgia. The first local transmission of chikungunya virus in the Western Hemisphere was reported in December 2013. In the following year, the virus spread throughout much of the Americas and the number of cases among travelers increased substantially. We reviewed the epidemiology of chikungunya virus disease cases reported among U.S. travelers from 2014 to 2016. A total of 3,941 travel-acquired cases were reported from 49 states and the District of Columbia; 3,616 (92%) reported travel to other countries or territories in the Americas; the remaining 8% reported travel to Asia, Africa, or the Western Pacific. The most commonly reported travel destinations were the Dominican Republic, Puerto Rico, and Haiti. The largest number of cases (N = 2,780, 71%) had illness onset in 2014, followed by 2015 (N = 913, 23%) and 2016 (N = 248, 6%). Cases occurred in every month, but 70% of case-patients had illness onset from April to September, the months when mosquitoes are most likely to be active in the continental United States. Travel-acquired chikungunya cases will likely continue to occur and present a risk of introduction of the virus to locations in the continental United States. Clinicians and public health officials should be educated about the recognition, diagnosis, management, and timely reporting of chikungunya cases.

      2. Zika virus as a sexually transmitted pathogen
        Mead PS, Hills SL, Brooks JT.
        Curr Opin Infect Dis. 2017 Nov 14.
        PURPOSE OF REVIEW: Zika virus has recently emerged from an obscure mosquito-borne pathogen to an international public health concern. It is the first viral agent newly demonstrated to cause birth defects in several decades, and it is the only arbovirus now known to be transmitted sexually. The purpose of this review is to provide an overview of current understanding of sexual transmission of Zika virus and its possible clinical and public health consequences. RECENT FINDINGS: Sexual transmission of Zika virus has been reported from at least 13 countries without simultaneous mosquito-borne transmission; it is undoubtedly also occurring in countries with active arthropod transmission. Most published cases involve transmission from symptomatically infected men to women partners. Nevertheless, transmission from a symptomatic man to another man, from a symptomatic woman to a man, and from an asymptomatic man to a woman has also been reported. Sexual transmission has occurred before symptom onset, during illness, and after resolution of the source partner’s symptoms. With the exception of a woman who developed symptomatic infection 44 days after onset of her husband’s illness, nearly all instances reported to date have occurred within 20 days of the source partner’s illness. Zika virus RNA has been detected in semen, saliva, blood, urine, and vaginal and cervical secretions; the length of time during which RNA can be detected varies widely across different body fluids but is especially lengthy in semen. Although semen has been found to contain ZIKV RNA for more than 180 days after illness onset, only a small proportion of samples with detectable RNA yield replicative virus whenever cultured. SUMMARY: Public health agencies have promulgated interim recommendations to prevent sexual transmission of Zika virus; however, much remains unknown regarding the duration of contagiousness and risk factors for transmission. Given the risk for birth defects, the greatest concern is for transmission of the virus to women who are pregnant or attempting to become pregnant. To prevent sexual transmission in general, couples are advised to use condoms or not have sex for at least 6 months from the start of the male partner’s symptoms or the date he was diagnosed with Zika or after he has returned from an area with risk of ZIKV infection. Women who have symptomatic ZIKV infection or have traveled to an area of risk are advised to use condoms or avoid sex for 8 weeks from the start of the woman’s symptoms or the date she was diagnosed with Zika or after the woman returns from the area of risk.

      3. Response to correction of refractive errors and hypoaccommodation in children with congenital Zika syndrome
        Ventura LO, Lawrence L, Ventura CV, Dutton GN, Marinho P, Ferro PF, Gois AL, Dias NC, Ventura L, Moore CA, Hyvarinen L.
        J AAPOS. 2017 Oct 21.
        PURPOSE: To describe the immediate response to correction of refractive errors and hypoaccommodation in children with congenital Zika syndrome (CZS). METHODS: Children born between May and December 2015 with a confirmed diagnosis of CZS and enrolled in a multidisciplinary early intervention program were included in this study. All children received a comprehensive ophthalmic examination, including dynamic retinoscopy and cycloplegic refraction. Children were prescribed their full correction if they met the criteria for refractive error, and additional plus 3.00 overcorrection for strabismus, accommodative dysfunction, and/or low vision. Monocular and binocular visual responses to Lea Grating Test at 30 cm, with and without eyeglasses, were measured on day 1 of glasses wear. RESULTS: A total of 60 children were evaluated (mean age at evaluation, 11.5 +/- 1.1 months; range, 9.0-16.0 months). Lea Grating Test responses were abnormal in all children prior to spectacle correction. Hypoaccommodation was present in 17 of 21 children (81%). Overcorrection was prescribed for all children. Visual responses were subnormal even with glasses use; however, immediate improvement in binocular vision was found in 37 children (62%) and in 74 of 119 eyes (62.2%). For the monocular visual improvement, 27 of 115 eyes (23.5%) had structural abnormalities, and 44 of 115 eyes (38.3%) were structurally normal. There was a statistical difference between the cycloplegic refraction of the children in August and in November, including emmetropia (P = 0.001), hyperopia (P = 0.000), myopia (P = 0.007), and astigmatism (P = 0.004). CONCLUSIONS: Eyeglasses can improve visual acuity in children with CZS. Significant changes in their refractive status over time requires periodic updates.

      4. Most Zika disease cases diagnosed in the continental US have been associated with travel to areas with risk of Zika transmission, mainly the Caribbean and Latin America. Limited information has been published about the demographic and travel characteristics of Zika case-patients in the United States, besides their age and gender. During 2016-2017 the County of San Diego Health and Human Services Agency, California, expanded the scope and completeness of demographic and travel information collected from Zika case-patients for public health surveillance purposes. The majority (53.8%) of travel-related Zika virus infection case-patients (n = 78) in the county were Hispanic, significantly higher (p </= 0.05) than the 33.0% of Hispanics in the county. Foreign-born residents, mainly from Mexico, were also overrepresented among cases compared to their share in the county population (33.3 vs. 23.0%; p </= 0.05). Seventeen (21.8%) patients reported a primary language other than English (14 Spanish). Most case-patients traveled for tourism (54%) or to visit friends and relatives (36%). This surveillance information helps identify higher-risk populations and implement culturally targeted interventions for Zika prevention and control.

      5. Fetal Zika virus infection in Vietnam
        Lan PT, Quang LC, Huong VT, Thuong NV, Hung PC, Huong T, Thao HP, Thao NT, Mounts AW, Nolen LD.
        PLoS Curr. 2017 Sep 5;9.
        As of 13 July 2016, 13 countries have reported fetal Zika virus (ZIKV) infection. Here we report a case of fetal ZIKV infection that resulted from an infection originating in Vietnam.

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