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Issue 50, December 19, 2017


CDC Science Clips: Volume 9, Issue 50, December 19, 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, Science Clips is pleased to feature articles from the December 15, 2017 CDC-led supplement of CANCER, Population-based Cancer Survival in the United States (2001-2009): findings from the CONCORD-2 study.

The Centers for Disease Control and Prevention (CDC) helps support a nationwide network of population-based cancer registries. The registries provide ongoing, systematic collection of incidence and survival information on all patients diagnosed with cancer. These data tell a compelling story about the disproportionate burden of lower cancer survival experienced by vulnerable populations.

Articles in the supplement use data from 37 statewide cancer registries, covering 80% of the U.S. population. These data constitute the largest study of population-based cancer survival to date in the United States. Survival up to five years following diagnosis are presented for 10 leading cancers (female breast, colon, rectum, liver, lung, cervix, ovary, prostate, stomach and acute lymphoblastic leukemia in children) by race (black and white), state at diagnosis and stage at diagnosis (where applicable).  Each of the 10 cancer-specific papers includes clinical and cancer control perspectives highlighting how clinical practice may have had an impact on population-based cancer survival trends, and how public health agencies can use this information to help target early diagnosis and treatment services.

  1. Key Scientific Articles in Featured Topic Areas
    Subject matter experts decide what topic to feature, and articles are selected from the last 3 to 6 months of published literature. Key topic coincides monthly with other CDC products (e.g. Vital Signs).

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions – Cancer Registries
      1. Population-based cancer survival in the United States: Data, quality control, and statistical methods
        Allemani C, Harewood R, Johnson CJ, Carreira H, Spika D, Bonaventure A, Ward K, Weir HK, Coleman MP.
        Cancer. 2017 Dec 15;123 Suppl 24:4982-4993.
        BACKGROUND: Robust comparisons of population-based cancer survival estimates require tight adherence to the study protocol, standardized quality control, appropriate life tables of background mortality, and centralized analysis. The CONCORD program established worldwide surveillance of population-based cancer survival in 2015, analyzing individual data on 26 million patients (including 10 million US patients) diagnosed between 1995 and 2009 with 1 of 10 common malignancies. METHODS: In this Cancer supplement, we analyzed data from 37 state cancer registries that participated in the second cycle of the CONCORD program (CONCORD-2), covering approximately 80% of the US population. Data quality checks were performed in 3 consecutive phases: protocol adherence, exclusions, and editorial checks. One-, 3-, and 5-year age-standardized net survival was estimated using the Pohar Perme estimator and state- and race-specific life tables of all-cause mortality for each year. The cohort approach was adopted for patients diagnosed between 2001 and 2003, and the complete approach for patients diagnosed between 2004 and 2009. RESULTS: Articles in this supplement report population coverage, data quality indicators, and age-standardized 5-year net survival by state, race, and stage at diagnosis. Examples of tables, bar charts, and funnel plots are provided in this article. CONCLUSIONS: Population-based cancer survival is a key measure of the overall effectiveness of services in providing equitable health care. The high quality of US cancer registry data, 80% population coverage, and use of an unbiased net survival estimator ensure that the survival trends reported in this supplement are robustly comparable by race and state. The results can be used by policymakers to identify and address inequities in cancer survival in each state and for the United States nationally. Cancer 2017;123:4982-93. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

      2. Cervical cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study
        Benard VB, Watson M, Saraiya M, Harewood R, Townsend JS, Stroup AM, Weir HK, Allemani C.
        Cancer. 2017 Dec 15;123 Suppl 24:5119-5137.
        BACKGROUND: Overall, cervical cancer survival in the United States has been reported to be among the highest in the world, despite slight decreases over the last decade. Objective of the current study was to describe cervical cancer survival trends among US women and examine differences by race and stage. METHODS: This study used data from the CONCORD-2 study to compare survival among women (aged 15-99 years) diagnosed in 37 states covering 80% of the US population. Survival was adjusted for background mortality (net survival) with state- and race-specific life tables and was age-standardized with the International Cancer Survival Standard weights. Five-year survival was compared by race (all races, blacks, and whites). Two time periods, 2001-2003 and 2004-2009, were considered because of changes in how the staging variable was collected. RESULTS: From 2001 to 2009, 90,620 women were diagnosed with invasive cervical cancer. The proportion of cancers diagnosed at a regional or distant stage increased over time in most states. Overall, the 5-year survival was 63.5% in 2001-2003 and 62.8% in 2004-2009. The survival was lower for black women versus white women in both calendar periods and in most states; black women had a higher proportion of distant-stage cancers. CONCLUSIONS: The stability of the overall survival over time and the persistent differences in survival between white and black women in all US states suggest that there is a need for targeted interventions and improved access to screening, timely treatment, and follow-up care, especially among black women. Cancer 2017;123:5119-37. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

      3. Stomach cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study
        Jim MA, Pinheiro PS, Carreira H, Espey DK, Wiggins CL, Weir HK.
        Cancer. 2017 Dec 15;123 Suppl 24:4994-5013.
        BACKGROUND: Stomach cancer was a leading cause of cancer-related deaths early in the 20th century and has steadily declined over the last century in the United States. Although incidence and death rates are now low, stomach cancer remains an important cause of morbidity and mortality in black, Asian and Pacific Islander, and American Indian/Alaska Native populations. METHODS: Data from the CONCORD-2 study were used to analyze stomach cancer survival among males and females aged 15 to 99 years who were diagnosed in 37 states covering 80% of the US population. Survival analyses were corrected for background mortality using state-specific and race-specific (white and black) life tables and age-standardized using the International Cancer Survival Standard weights. Net survival is presented up to 5 years after diagnosis by race (all, black, and white) for 2001 through 2003 and 2004 through 2009 to account for changes in collecting Surveillance, Epidemiology, and End Results Summary Stage 2000 data from 2004. RESULTS: Almost one-third of stomach cancers were diagnosed at a distant stage among both whites and blacks. Age-standardized 5-year net survival increased between 2001 to 2003 and 2004 to 2009 (26.1% and 29%, respectively), and no differences were observed by race. The 1-year, 3-year, and 5-year survival estimates were 53.1%, 33.8%, and 29%, respectively. Survival improved in most states. Survival by stage was 64% (local), 28.2% (regional), and 5.3% (distant). CONCLUSIONS: The current results indicate high fatality for stomach cancer, especially soon after diagnosis. Although improvements in stomach cancer survival were observed, survival remained relatively low for both blacks and whites. Primary prevention through the control of well-established risk factors would be expected to have the greatest impact on further reducing deaths from stomach cancer. Cancer 2017;123:4994-5013. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

      4. Rectal cancer survival in the United States by race and stage, 2001 to 2009: Findings from the CONCORD-2 study
        Joseph DA, Johnson CJ, White A, Wu M, Coleman MP.
        Cancer. 2017 Dec 15;123 Suppl 24:5037-5058.
        BACKGROUND: In the first CONCORD study, 5-year survival for patients with diagnosed with rectal cancer between 1990 and 1994 was <60%, with large racial disparities noted in the majority of participating states. We have updated these findings to 2009 by examining population-based survival by stage of disease at the time of diagnosis, race, and calendar period. METHODS: Data from the CONCORD-2 study were used to compare survival among individuals aged 15 to 99 years who were diagnosed in 37 states encompassing up to 80% of the US population. We estimated net survival up to 5 years after diagnosis correcting for background mortality with state-specific and race-specific life table. Survival estimates were age-standardized with the International Cancer Survival Standard weights. We present survival estimates by race (all, black, and white) for 2001 through 2003 and 2004 through 2009 to account for changes in collecting the data for Surveillance, Epidemiology, and End Results Summary Stage 2000. RESULTS: There was a small increase in 1-year, 3-year, and 5-year net survival between 2001-2003 (84.6%, 70.7%, and 63.2%, respectively), and 2004-2009 (85.1%, 71.5%, and 64.1%, respectively). Black individuals were found to have lower 1-year, 3-year, and 5-year survival than white individuals in both periods; the absolute difference in survival between black and white individuals declined only for 5-year survival. Black patients had lower 5-year survival than whites at each stage at the time of diagnosis in both time periods. CONCLUSIONS: There was little improvement noted in net survival for patients with rectal cancer, with persistent disparities noted between black and white individuals. Additional investigation is needed to identify and implement effective interventions to ensure the consistent and equitable use of high-quality screening, diagnosis, and treatment to improve survival for patients with rectal cancer. Cancer 2017;123:5037-58. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

      5. Disparities in breast cancer survival in the United States (2001-2009): Findings from the CONCORD-2 study
        Miller JW, Smith JL, Ryerson AB, Tucker TC, Allemani C.
        Cancer. 2017 Dec 15;123 Suppl 24:5100-5118.
        BACKGROUND: Reducing breast cancer incidence and achieving equity in breast cancer outcomes remains a priority for public health practitioners, health care providers, policy makers, and health advocates. Monitoring breast cancer survival can help evaluate the effectiveness of health services, quantify inequities in outcomes between states or population subgroups, and inform efforts to improve the effectiveness of cancer management and treatment. METHODS: We analyzed breast cancer survival using individual patient records from 37 statewide registries that participated in the CONCORD-2 study, covering approximately 80% of the US population. Females were diagnosed between 2001 and 2009 and were followed through December 31, 2009. Age-standardized net survival at 1 year, 3 years, and 5 years after diagnosis was estimated by state, race (white, black), stage at diagnosis, and calendar period (2001-2003 and 2004-2009). RESULTS: Overall, 5-year breast cancer net survival was very high (88.2%). Survival remained remarkably high from 2001 through 2009. Between 2001 and 2003, survival was 89.1% for white females and 76.9% for black females. Between 2004 and 2009, survival was 89.6% for white females and 78.4% for black females. CONCLUSIONS: Breast cancer survival was more than 10 percentage points lower for black females than for white females, and this difference persisted over time. Reducing racial disparities in survival remains a challenge that requires broad, coordinated efforts at the federal, state, and local levels. Monitoring trends in breast cancer survival can highlight populations in need of improved cancer management and treatment. Cancer 2017;123:5100-18. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

      6. Liver cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study
        Momin BR, Pinheiro PS, Carreira H, Li C, Weir HK.
        Cancer. 2017 Dec 15;123 Suppl 24:5059-5078.
        BACKGROUND: Worldwide, liver cancer is a leading cause of death for both men and women. The number of Americans who are diagnosed with and die of liver cancer has been rising slowly each year. Using data from the CONCORD-2 study, this study examined population-based survival by state, race, and stage at diagnosis. METHODS: Data from 37 statewide registries, which covered 81% of the US population, for patients diagnosed during 2001-2009 were analyzed. Survival up to 5 years was adjusted for background mortality (net survival) with state- and race-specific life tables, and it was age-standardized with the International Cancer Survival Standard weights. RESULTS: Liver cancer was diagnosed overall more often at the localized stage, with blacks being more often diagnosed at distant and regional stages than whites. 5-year net survival was 12.2% in 2001-2003 and 14.8% in 2004-2009. Whites had higher survival than blacks in both calendar periods (11.7% vs 9.1% and 14.3% vs 11.4%, respectively). During 2004-2009, 5-year survival was 25.7% for localized-stage disease, 9.5% for regional-stage disease, and 3.5% for distant-stage disease. CONCLUSIONS: Some progress has occurred in survival for patients with liver cancer, but 5-year survival remains low, even for those diagnosed at the localized stage. Efforts directed at controlling well-established risk factors such as hepatitis B may have the greatest impact on reducing the burden of liver cancer in the United States. Cancer 2017;123:5059-78. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

      7. Lung cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study
        Richards TB, Henley SJ, Puckett MC, Weir HK, Huang B, Tucker TC, Allemani C.
        Cancer. 2017 Dec 15;123 Suppl 24:5079-5099.
        BACKGROUND: Results from the second CONCORD study (CONCORD-2) indicated that 5-year net survival for lung cancer was low (range, 10%-20%) between 1995 and 2009 in most countries, including the United States, which was at the higher end of this range. METHODS: Data from CONCORD-2 were used to analyze net survival among patients with lung cancer (aged 15-99 years) who were diagnosed in 37 states covering 80% of the US population. Survival was corrected for background mortality using state-specific and race-specific life tables and age-standardized using International Cancer Survival Standard weights. Net survival was estimated for patients diagnosed between 2001 and 2003 and between 2004 and 2009 at 1, 3, and 5 years after diagnosis by race (all races, black, and white); Surveillance, Epidemiology, and End Results Summary Stage 2000; and US state. RESULTS: Five-year net survival increased from 16.4% (95% confidence interval, 16.3%-16.5%) for patients diagnosed 2001-2003 to 19.0% (18.8%-19.1%) for those diagnosed 2004-2009, with increases in most states and among both blacks and whites. Between 2004 and 2009, 5-year survival was lower among blacks (14.9%) than among whites (19.4%) and ranged by state from 14.5% to 25.2%. CONCLUSIONS: Lung cancer survival improved slightly between the periods 2001-2003 and 2004-2009 but was still low, with variation between states, and persistently lower survival among blacks than whites. Efforts to control well established risk factors would be expected to have the greatest impact on reducing the burden of lung cancer, and efforts to ensure that all patients receive timely and appropriate treatment should reduce the differences in survival by race and state. Cancer 2017;123:5079-99. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

      8. Prostate cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study
        Steele CB, Li J, Huang B, Weir HK.
        Cancer. 2017 Dec 15;123 Suppl 24:5160-5177.
        BACKGROUND: The 5-year relative survival for prostate cancers diagnosed between 1990 and 1994 in the United States was very high (92%); however, survival in black males was 7% lower compared with white males. The authors updated these findings and examined survival by stage and race. METHODS: The authors used data from the CONCORD-2 study for males (ages 15-99 years) who were diagnosed with prostate cancer in 37 states, covering 80% of the US population. Survival was adjusted for background mortality (net survival) using state-specific and race-specific life tables and was age-standardized. Data were presented for 2001 through 2003 and 2004 through 2009 to account for changes in collecting SEER Summary Stage 2000. RESULTS: Among the 1,527,602 prostate cancers diagnosed between 2001 and 2009, the proportion of localized cases increased from 73% to 77% in black males and from 77% to 79% in white males. Although the proportion of distant-stage cases was higher among black males than among white males, they represented less than 6% of cases in both groups between 2004 and 2009. Net survival exceeded 99% for localized stage between 2004 and 2009 in both racial groups. Overall, and in most states, 5-year net survival exceeded 95%. CONCLUSIONS: Prostate cancer survival has increased since the first CONCORD study, and the racial gap has narrowed. Earlier detection of localized cancers likely contributed to this finding. However, racial disparities also were observed in overall survival. To help understand which factors might contribute to the persistence of this disparity, states could use local data to explore sociodemographic characteristics, such as survivors’ health insurance status, health literacy, treatment decision-making processes, and treatment preferences. Cancer 2017;123:5160-77. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

      9. Disparities in ovarian cancer survival in the United States (2001-2009): Findings from the CONCORD-2 study
        Stewart SL, Harewood R, Matz M, Rim SH, Sabatino SA, Ward KC, Weir HK.
        Cancer. 2017 Dec 15;123 Suppl 24:5138-5159.
        BACKGROUND: Ovarian cancer is the fifth leading cause of cancer death among women in the United States. This study reports ovarian cancer survival by state, race, and stage at diagnosis using data from the CONCORD-2 study, the largest and most geographically comprehensive, population-based survival study to date. METHODS: Data from women diagnosed with ovarian cancer between 2001 and 2009 from 37 states, covering 80% of the US population, were used in all analyses. Survival was estimated up to 5 years and was age standardized and adjusted for background mortality (net survival) using state-specific and race-specific life tables. RESULTS: Among the 172,849 ovarian cancers diagnosed between 2001 and 2009, more than one-half were diagnosed at distant stage. Five-year net survival was 39.6% between 2001 and 2003 and 41% between 2004 and 2009. Black women had consistently worse survival compared with white women (29.6% from 2001-2003 and 31.1% from 2004-2009), despite similar stage distributions. Stage-specific survival for all races combined between 2004 and 2009 was 86.4% for localized stage, 60.9% for regional stage, and 27.4% for distant stage. CONCLUSIONS: The current data demonstrate a large and persistent disparity in ovarian cancer survival among black women compared with white women in most states. Clinical and public health efforts that ensure all women who are diagnosed with ovarian cancer receive appropriate, guidelines-based treatment may help to decrease these disparities. Future research that focuses on the development of new methods or modalities to detect ovarian cancer at early stages, when survival is relatively high, will likely improve overall US ovarian cancer survival. Cancer 2017;123:5138-59. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

      10. BACKGROUND: Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy. This report describes the survival of children with ALL in the United States using the most comprehensive and up-to-date cancer registry data. METHODS: Data from 37 state cancer registries that cover approximately 80% of the US population were used. Age-standardized survival up to 5 years was estimated for children aged 0-14 years who were diagnosed with ALL during 2 periods (2001-2003 and 2004-2009). RESULTS: In total, 17,500 children with ALL were included. The pooled age-standardized net survival estimates for all US registries combined were 95% at 1 year, 90% at 3 years, and 86% at 5 years for children diagnosed during 2001-2003, and 96%, 91%, and 88%, respectively, for those diagnosed during 2004-2009. Black children who were diagnosed during 2001-2003 had lower 5-year survival (84%) than white children (87%) and had less improvement in survival by 2004-2009. For those diagnosed during 2004-2009, the 1-year and 5-year survival estimates were 96% and 89%, respectively, for white children and 96% and 84%, respectively, for black children. During 2004-2009, survival was highest among children aged 1 to 4 years (95%) and lowest among children aged <1 year (60%). CONCLUSIONS: The current results indicate that overall net survival from childhood ALL in the United States is high, but disparities by race still exist, especially beyond the first year after diagnosis. Clinical and public health strategies are needed to improve health care access, clinical trial enrollment, treatment, and survivorship care for children with ALL. Cancer 2017;123:5178-89. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

      11. The essential role of population-based cancer survival in cancer control in the United States
        Weir HK, Richardson LC.
        Cancer. 2017 Dec 15;123 Suppl 24:4961-4962.

        [No abstract]

      12. Population-based cancer survival (2001 to 2009) in the United States: Findings from the CONCORD-2 study
        Weir HK, Stewart SL, Allemani C, White MC, Thomas CC, White A, Coleman MP.
        Cancer. 2017 Dec 15;123 Suppl 24:4963-4968.

        [No abstract]

      13. Colon cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study
        White A, Joseph D, Rim SH, Johnson CJ, Coleman MP, Allemani C.
        Cancer. 2017 Dec 15;123 Suppl 24:5014-5036.
        BACKGROUND: In the first CONCORD study (2008), 5-year survival for patients diagnosed with colon cancer between 1990 and 1994 in the United States was among the highest in the world (60%), but there were large racial disparities in most participating states. The CONCORD-2 study (2015) enabled the examination of survival trends between 1995 and 2009 for US states by race and stage. METHODS: The authors analyzed data from 37 state population-based cancer registries, covering approximately 80% of the US population, for patients who were diagnosed with colon cancer between 2001 and 2009 and were followed through 2009. Survival up to 5 years was corrected for background mortality (net survival) using state-specific and race-specific life tables and age-standardized using the International Cancer Survival Standard weights. Survival is presented by race (all, black, white), stage, state, and calendar period (2001-2003 and 2004-2009) to account for changes in methods used to collect stage. RESULTS: Five-year net survival increased by 0.9%, from 63.7% between 2001 and 2003 to 64.6% between 2004 and 2009. More black than white patients were diagnosed with distant-stage disease between 2001 and 2003 (21.5% vs 17.2%) and between 2004 and 2009 (23.3% vs 18.8%). Survival improved for both blacks and whites, but 5-year net survival was 9-10% lower for blacks than for whites both between 2001 and 2003 (54.7% vs 64.5%) and between 2004 and 2009 (56.6% vs 65.4%). The absolute difference between blacks and whites decreased by only 1% during the decade. CONCLUSIONS: Five-year net survival from colon cancer increased slightly over time. Survival among blacks diagnosed between 2004 and 2009 had still not reached the level of that among whites diagnosed between 1990 and 1994, some 15 to 20 years earlier. These findings suggest a need for more targeted efforts to improve screening and to ensure timely, appropriate treatment, especially for blacks, to reduce this large and persistent disparity in survival. Cancer 2017;123:5014-36. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

      14. The history and use of cancer registry data by public health cancer control programs in the United States
        White MC, Babcock F, Hayes NS, Mariotto AB, Wong FL, Kohler BA, Weir HK.
        Cancer. 2017 Dec 15;123 Suppl 24:4969-4976.
        Because cancer registry data provide a census of cancer cases, registry data can be used to: 1) define and monitor cancer incidence at the local, state, and national levels; 2) investigate patterns of cancer treatment; and 3) evaluate the effectiveness of public health efforts to prevent cancer cases and improve cancer survival. The purpose of this article is to provide a broad overview of the history of cancer surveillance programs in the United States, and illustrate the expanding ways in which cancer surveillance data are being made available and contributing to cancer control programs. The article describes the building of the cancer registry infrastructure and the successful coordination of efforts among the 2 federal agencies that support cancer registry programs, the Centers for Disease Control and Prevention and the National Cancer Institute, and the North American Association of Central Cancer Registries. The major US cancer control programs also are described, including the National Comprehensive Cancer Control Program, the National Breast and Cervical Cancer Early Detection Program, and the Colorectal Cancer Control Program. This overview illustrates how cancer registry data can inform public health actions to reduce disparities in cancer outcomes and may be instructional for a variety of cancer control professionals in the United States and in other countries. Cancer 2017;123:4969-76. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

  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. Low level of the plasma sphingolipid, glucosylceramide, is associated with thrombotic diseases
        Deguchi H, Navarro S, Payne AB, Elias DJ, Dowling NF, Austin HD, Espana F, Medina P, Hooper WC, Griffin JH.
        Res Pract Thromb Haemost. 2017 Jul;1(1):33-40.
        Background: One previous pilot study suggested the association of low plasma glucosylceramide (GlcCer) levels with venous thrombosis (VTE) risk. Objective: We aimed to confirm and evaluate the association of low plasma GlcCer levels with VTE and myocardial infarction (MI) occurrence, respectively. Patients and Methods: We evaluated the association of GlcCer in two independent case-control studies of Caucasian VTE populations (N = 210 and 636) and one case-control study of Caucasian MI patients (N = 345). Result: Plasma GlcCer levels in VTE patients were lower compared to controls in two independent VTE populations (5.0 vs 5.8 mug/mL, p = 0.003 for the Scripps registry, and 5.6 vs 6.0 mug/mL, p = 0.001 for the Valencia registry, respectively). A low plasma GlcCer level (below 10th percentile of controls) was associated with increased VTE occurrence [odds ratio (OR) = 3.7 (95%CI, 1.8-7.9) for Scripps registry and OR = 2.1 (95%CI, 1.3-3.3) for Valencia registry, respectively). For the MI study, the median GlcCer plasma level was lower in MI patients than in controls (4.3 vs 5.6 mug/mL, p<0.001), and a low level of GlcCer (below 10th percentile of control) was associated with higher MI occurrence [OR = 7.7, (95%CI, 4.3-13.8)]. Conclusion: Lower concentration of GlcCer was associated with VTE occurrence in two independent studies and also with MI occurrence in one study.

      2. INTRODUCTION: A quality rating and improvement system (QRIS) is a fundamental component of most states’ early care and education infrastructures. States can use a QRIS to set standards that define high-quality care and award child care providers with a quality rating designation based on how well they meet these standards. The objective of this review was to describe the extent to which states’ QRIS standards include obesity prevention content. METHODS: We collected publicly available data on states’ QRIS standards. We compared states’ QRIS standards with 47 high-impact obesity prevention components in Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 3rd Edition, and 6 additional topics based on the Centers for Disease Control and Prevention’s Spectrum of Opportunities for Obesity Prevention in the Early Care and Education Setting. RESULTS: Thirty-eight states operated a state-wide QRIS in early 2015. Of those, 27 states’ QRIS included obesity prevention standards; 20 states had at least one QRIS standard that aligned with the high-impact obesity prevention components, and 21 states had at least one QRIS standard that aligned with at least one of the 6 additional topics. QRIS standards related to the physical activity high-impact obesity prevention components were the most common, followed by components for screen time, nutrition, and infant feeding. CONCLUSION: The high proportion of states operating a QRIS that included obesity prevention standards, combined with the widespread use of QRISs among states, suggests that a QRIS is a viable way to embed obesity prevention standards into state early care and education systems.

      3. Early results of states’ efforts to support, scale, and sustain the National Diabetes Prevention Program
        Mensa-Wilmot Y, Bowen SA, Rutledge S, Morgan JM, Bonner T, Farris K, Blacher R, Rutledge G.
        Prev Chronic Dis. 2017 Dec 7;14:E130.
        The Centers for Disease Control and Prevention (CDC) developed a cooperative agreement with health departments in all 50 states and the District of Columbia to strengthen chronic disease prevention and management efforts through the implementation of evidence-based strategies, such as CDC’s National Diabetes Prevention Program. The National Diabetes Prevention Program supports organizations to deliver the year-long lifestyle change program that has been proven to prevent or delay the onset of type 2 diabetes among those at high risk. This article describes activities, barriers, and facilitators reported by funded states during the first 3 years (2013-2015) of a 5-year funding cycle.

      4. State public health actions to prevent and control diabetes, heart disease, obesity and associated risk factors, and promote school health
        Park BZ, Cantrell L, Hunt H, Farris RP, Schumacher P, Bauer UE.
        Prev Chronic Dis. 2017 Dec 7;14:E127.
        The National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention funds a program to boost progress in reducing the prevalence and incidence of multiple chronic diseases and their associated risk factors. This article describes the program, State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors, and Promote School Health, and the program’s action model, design, and administration and management structure. This program is based on 4 domains of public health action: 1) epidemiology and surveillance, 2) environmental approaches, 3) health care system interventions, and 4) community programs linked to clinical services. The 4 domains of public health action leverage data to inform action, support healthy choices and behaviors, strengthen delivery of clinical preventive services, and help Americans better manage their health.

      5. Overweight and obesity in local media: An analysis of media coverage in CDC-funded communities
        Thomas CN, Inokuchi D, Lehman T, Ledsky R, Weldy A.
        Prev Chronic Dis. 2017 Dec 7;14:E126.
        We conducted a content analysis of newspaper and television news coverage in Centers for Disease Control and Prevention (CDC) grantee locations from June 2011 through May 2013. After searching 2 databases for news stories related to overweight or obesity, we coded and analyzed stories for valence (how the author/reporter framed overweight and obesity control strategies), descriptors, causes and solutions, and populations mentioned. Of almost 3,000 stories analyzed, most had a neutral or positive valence, depicted overweight and obesity as epidemic, discussed individual causes and environmental solutions most frequently, and mentioned children most often. Earned media can be part of addressing overweight and obesity by emphasizing prevention and by emphasizing both environmental and individual causes and solutions.

      6. Evaluating cross-cutting approaches to chronic disease prevention and management: Developing a comprehensive evaluation
        Vaughan M, Jernigan J, Barnes SP, Shea P, Davis R, Rutledge S.
        Prev Chronic Dis. 2017 Dec 7;14:E131.
        We provide an overview of the comprehensive evaluation of State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health (State Public Health Actions). State Public Health Actions is a program funded by the Centers for Disease Control and Prevention to support the statewide implementation of cross-cutting approaches to promote health and prevent and control chronic diseases. The evaluation addresses the relevance, quality, and impact of the program by using 4 components: a national evaluation, performance measures, state evaluations, and evaluation technical assistance to states. Challenges of the evaluation included assessing the extent to which the program contributed to changes in the outcomes of interest and the variability in the states’ capacity to conduct evaluations and track performance measures. Given the investment in implementing collaborative approaches at both the state and national level, achieving meaningful findings from the evaluation is critical.

    • Communicable Diseases
      1. Estimates of seasonal influenza-associated mortality in Bangladesh, 2010-2012
        Ahmed M, Aleem MA, Roguski K, Abedin J, Islam A, Alam KF, Gurley ES, Rahman M, Azziz-Baumgartner E, Homaira N, Sturm-Ramirez K, Danielle Iuliano A.
        Influenza Other Respir Viruses. 2017 Dec 2.
        BACKGROUND: Seasonal influenza-associated mortality estimates help identify the burden of disease and assess the value of public health interventions such as annual influenza immunization. Vital registration is limited in Bangladesh making it difficult to estimate seasonal influenza mortality. OBJECTIVES: Our study aimed to estimate seasonal influenza-associated mortality rates for 2010-2012 in Bangladesh. METHODS: We conducted surveillance among hospitalized patients with severe acute respiratory illness (SARI) for persons aged >/=5 years and severe pneumonia for children <5 years in 11 sites across Bangladesh. We defined the catchment areas of these sites and conducted a community survey in 22 randomly selected unions (administrative units) within the catchment areas to identify respiratory deaths. We multiplied the proportion of influenza-positive patients at our surveillance sites by the age-specific number of respiratory deaths identified to estimate seasonal influenza-associated mortality. RESULTS: Among 4221 surveillance case-patients, 553 (13%) were positive for influenza viruses. Concurrently, we identified 1191 persons who died within 2 weeks of developing an acute respiratory illness within the catchment areas of the surveillance hospitals. In 2010-2011, the estimated influenza-associated mortality rate was 6 (95% CI 4-9) per 100 000 for children <5 years and 41 (95% CI 35-47) per 100 000 for persons >60 years. During 2011-2012, the estimated influenza-associated mortality rate was 13 (95% CI 10-16) per 100 000 among children <5 years and 88 (95% CI 79-98) per 100 000 among persons aged >60 years. CONCLUSIONS: We identified a substantial burden of influenza-associated deaths in Bangladesh suggesting that the introduction of prevention and control measures including seasonal vaccination should be considered by local public health decision-makers.

      2. Purpose of Review: Noroviruses are the most common cause of gastroenteritis outbreaks in long-term care facility (LTCFs). This review summarizes the most up-to-date knowledge on norovirus infection in LTCFs with the aim of identifying potential strategies for management. Recent Findings: LTCF residents are at greater risk of norovirus infection. Early identification of norovirus infection and prompt initiation of appropriate supportive therapy are required to reduce morbidity and mortality. Measures to prevent outbreaks and reduce the risk of norovirus infection in LTCFs include timely diagnosis and implementation of infection control interventions to limit virus transmission. Summary: Current guidelines for prevention and control are based on generic principles of infection control. Real-time reverse transcription-quantitative polymerase chain reaction assays have been the gold standard for the rapid and sensitive detection of noroviruses. With the recent breakthroughs of human norovirus in vitro culture, doors are now opened to evaluate the efficacy of environmental disinfectants and hand hygiene options. Additionally, development of licensed vaccines against noroviruses may provide another important tool for infection prevention among high-risk individuals.

      3. HIV surveillance among pregnant women attending antenatal clinics: Evolution and current direction
        Dee J, Garcia Calleja JM, Marsh K, Zaidi I, Murrill C, Swaminathan M.
        JMIR Public Health Surveill. 2017 Dec 5;3(4):e85.
        Since the late 1980s, human immunodeficiency virus (HIV) sentinel serosurveillance among pregnant women attending select antenatal clinics (ANCs) based on unlinked anonymous testing (UAT) has provided invaluable information for tracking HIV prevalence and trends and informing global and national HIV models in most countries with generalized HIV epidemics. However, increased coverage of HIV testing, prevention of mother-to-child transmission (PMTCT), and antiretroviral therapy has heightened ethical concerns about UAT. PMTCT programs now routinely collect demographic and HIV testing information from the same pregnant women as serosurveillance and therefore present an alternative to UAT-based ANC serosurveillance. This paper reports on the evolution and current direction of the global approach to HIV surveillance among pregnant women attending ANCs, including the transition away from traditional UAT-based serosurveillance and toward new guidance from the World Health Organization and the Joint United Nations Programme on HIV/AIDS on the implementation of surveillance among pregnant women attending ANCs based on routine PMTCT program data.

      4. Update: Influenza activity – United States, October 1-November 25, 2017
        Dugan VG, Blanton L, Elal AI, Alabi N, Barnes J, Brammer L, Burns E, Cummings CN, Davis T, Flannery B, Fry AM, Garg S, Garten R, Gubareva L, Jang Y, Kniss K, Kramer N, Lindstrom S, Mustaquim D, O’Halloran A, Olsen SJ, Sessions W, Taylor C, Trock S, Xu X, Wentworth DE, Katz J, Jernigan D.
        MMWR Morb Mortal Wkly Rep. 2017 Dec 8;66(48):1318-1326.
        Influenza activity in the United States was low during October 2017, but has been increasing since the beginning of November. Influenza A viruses have been most commonly identified, with influenza A(H3N2) viruses predominating. Several influenza activity indicators were higher than is typically seen for this time of year. The majority of influenza viruses characterized during this period were genetically or antigenically similar to the 2017-18 Northern Hemisphere cell-grown vaccine reference viruses. These data indicate that currently circulating viruses have not undergone significant antigenic drift; however, circulating A(H3N2) viruses are antigenically less similar to egg-grown A(H3N2) viruses used for producing the majority of influenza vaccines in the United States. It is difficult to predict which influenza viruses will predominate in the 2017-18 influenza season; however, in recent past seasons in which A(H3N2) viruses predominated, hospitalizations and deaths were more common, and the effectiveness of the vaccine was lower. Annual influenza vaccination is recommended for all persons aged >/=6 months who do not have contraindications. Multiple influenza vaccines are approved and recommended for use during the 2017-18 season, and vaccination should continue to be offered as long as influenza viruses are circulating and unexpired vaccine is available. This report summarizes U.S. influenza activity* during October 1-November 25, 2017 (surveillance weeks 40-47).(dagger).

      5. Elizabethkingia in children: A comprehensive review of symptomatic cases reported from 1944-2017
        Dziuban EJ, Franks J, So M, Peacock G, Blaney DD.
        Clin Infect Dis. 2017 Dec 2.
        Elizabethkingia species often exhibit extensive antibiotic resistance and result in high morbidity and mortality, yet no systematic reviews exist that thoroughly characterize and quantify concerns for infected infants and children. We performed a review of literature and identified an initial 902 articles; 96 articles reporting 283 pediatric cases met our inclusion criteria and were subsequently reviewed. Case reports spanned 28 countries and ranged from 1944 to 2017. Neonatal meningitis remains the most common presentation of this organism in children, along with a range of other clinical manifestations. The majority of reported cases occurred as isolated cases, rather than within outbreaks. Mortality was high but has decreased in recent years, although neurologic sequelae among survivors remains concerning. Child outcomes can be improved through effective prevention measures and early identification and treatment of infected patients.

      6. Tuberculosis among migrants in Bishkek, the capital of the Kyrgyz Republic
        Goncharova O, Denisiuk O, Zachariah R, Davtyan K, Nabirova D, Acosta C, Kadyrov A.
        Public Health Action. 2017 Sep 21;7(3):218-223.
        Setting: Twenty-two first-line, two second-line and one tertiary health facility in Bishkek, the capital of Kyrgyzstan. Objectives: Among migrants, a marginalised population at risk for acquiring and transmitting tuberculosis (TB), we determined the proportion with TB among all registered TB cases. For those registered at primary-level facilities, we then reported on their demographic and clinical profiles and TB treatment outcomes. Design: This was a retrospective cohort analysis of 2012-2013 programme data. Results: Of 2153 TB patients registered in all health facilities, 969 (45%) were migrants, of whom 454 were registered in first-line facilities. Of these, 27% were cross-border migrants, 50% had infectious TB and 12% had drug-resistant TB. Treatment success was 74% for new cases and 44% for retreatment TB (the World Health Organization target is 85%). Failure in new and retreatment TB patients was respectively 8% and 25%. Twenty-six individuals started on a first-line anti-tuberculosis regimen failed due to multidrug-resistant TB. Eight (25%) of 32 individuals on a retreatment TB regimen also failed. Loss to follow-up was 10% for new and 19% for retreatment TB. Conclusion: Migrants constituted almost half of all TB patients, drug resistance is prevalent and treatment outcomes unsatisfactory. Fostering inter-country collaboration and prioritising rapid TB diagnostics (Xpert((R)) MTB/RIF) and innovative ways forward for improving treatment outcomes is urgent.

      7. Bayesian hierarchical model of ceftriaxone resistance proportions among Salmonella serotype Heidelberg infections
        Gu W, Medalla F, Hoekstra RM.
        Spat Spatiotemporal Epidemiol. 2018 February;24:19-26.
        The National Antimicrobial Resistance Monitoring System (NARMS) at the Centers for Disease Control and Prevention tracks resistance among Salmonella infections. The annual number of Salmonella isolates of a particular serotype from states may be small, making direct estimation of resistance proportions unreliable. We developed a Bayesian hierarchical model to improve estimation by borrowing strength from relevant sampling units. We illustrate the models with different specifications of spatio-temporal interaction using 2004-2013 NARMS data for ceftriaxone-resistant Salmonella serotype Heidelberg. Our results show that Bayesian estimates of resistance proportions were smoother than observed values, and the difference between predicted and observed proportions was inversely related to the number of submitted isolates. The model with interaction allowed for tracking of annual changes in resistance proportions at the state level. We demonstrated that Bayesian hierarchical models provide a useful tool to examine spatio-temporal patterns of small sample size such as those found in NARMS.

      8. Influenza-associated mortality in South Africa, 2009-2013: The importance of choices related to influenza infection proxies
        Gul D, Cohen C, Tempia S, Newall AT, Muscatello DJ.
        Influenza Other Respir Viruses. 2017 Dec 2.
        BACKGROUND: Regression modeling methods are commonly used to estimate influenza-associated mortality using covariates such as laboratory-confirmed influenza activity in the population as a proxy of influenza incidence. OBJECTIVE: We examined the choices of influenza proxies that can be used from influenza laboratory surveillance data and their impact on influenza-associated mortality estimates. METHOD: Semiparametric generalized additive models with a smoothing spline were applied on national mortality data from South Africa and influenza surveillance data as covariates to obtain influenza-associated mortality estimates from respiratory causes from 2009 to 2013. Proxies examined included alternative ways of expressing influenza laboratory surveillance data such as weekly or yearly proportion or rate of positive samples, using influenza subtypes, or total influenza data and expressing the data as influenza season-specific or across all seasons. RESULT: Based on model fit, weekly proportion and influenza subtype-specific proxy formulation provided the best fit. The choice of proxies used gave large differences to mortality estimates, but the 95% confidence interval of these estimates overlaps. CONCLUSION: Regardless of proxy chosen, mortality estimates produced may be broadly consistent and not statistically significant for public health practice.

      9. Evaluation of data sources and approaches for estimation of influenza-associated mortality in India
        Narayan VV, Iuliano AD, Roguski K, Haldar P, Saha S, Sreenivas V, Kant S, Zodpey S, Pandav CS, Jain S, Krishnan A.
        Influenza Other Respir Viruses. 2017 Dec 2.
        BACKGROUND: No estimates of influenza-associated mortality exist for India. OBJECTIVE: To evaluate national mortality and viral surveillance data from India for assessing their appropriateness in estimating influenza-associated mortality using varied analytic approaches. METHODS: We reviewed influenza virus surveillance data from a national influenza surveillance network. We also reviewed national mortality data from Civil Registration System (CRS), Medical Certification of Cause of Death (MCCD) and the Sample Registration System (SRS). We compared and scored the different sources of mortality data using specific criteria, including the process of cause of death assignment, sample size, proportion of ill-defined deaths, representativeness and availability of time series data. Each of these 5 parameters was scored on a scale from 1 to 5. To evaluate how to generate an influenza-associated mortality estimate for India, we also reviewed 4 methodologic approaches to assess the appropriateness of their assumptions and requirements for these data sets. RESULTS: The influenza virus surveillance data included year-round sample testing for influenza virus and was found to be suitable for influenza mortality estimation modelling. Based on scoring for the 5 mortality data criteria, the SRS data had the highest score with 20 of 25 possible score, whereas MCCD and CRS scored 16 and 12, respectively. The SRS which used verbal autopsy survey methods was determined to be nationally representative and thus adequate for estimating influenza-associated mortality. Evaluation of the modelling methods demonstrated that Poisson regression, risk difference and mortality multiplier methods could be applied to the Indian setting. CONCLUSION: Despite significant challenges, it is possible to estimate influenza-associated mortality in India.

      10. Improving linkage, retention, and reengagement in HIV care in 12 metropolitan areas
        Neumann MS, Carey JW, Flores SA, Fisher HH, Hoyte T, Pitts N, Carry M, Freeman A.
        Health Promot Pract. 2017 Nov 1:1524839917741310.
        The Centers for Disease Control and Prevention developed the Enhanced Comprehensive HIV Prevention Planning (ECHPP) project to support 12 health departments’ improvement of their HIV prevention and care portfolios in response to new national guidelines. We systematically analyzed 3 years of progress reports to learn how grantees put into practice local intervention strategies intended to link people to, and keep them in, HIV care. All grantees initiated seven activities to support these strategies: (1) improve surveillance data systems, (2) revise staffing duties and infrastructures, (3) update policies and procedures, (4) establish or strengthen partnerships, (5) identify persons not in care, (6) train personnel, and (7) create ways to overcome obstacles to receiving care. Factors supporting ECHPP grantee successes were thorough planning, attention to detail, and strong collaboration among health department units, and between the health department and external stakeholders. Other jurisdictions may consider adopting similar strategies when planning and enhancing HIV linkage, retention, and reengagement efforts in their areas. ECHPP experiences, lessons learned, and best practices may be relevant when applying new public health policies that affect community and health care practices jurisdiction-wide.

      11. High HIV-1 RNA among newly diagnosed people in Botswana
        Novitsky V, Prague M, Moyo S, Gaolathe T, Mmalane M, Kadima Yankinda E, Chakalisa U, Lebelonyane R, Khan N, Powis KM, Widenfelt E, Gaseitsiwe S, Dryden-Peterson SL, Pretorius Holme M, De Gruttola V, Bachanas P, Makhema J, Lockman S, Essex M.
        AIDS Res Hum Retroviruses. 2017 Dec 7.
        OBJECTIVE: HIV-1 RNA level is strongly associated with HIV transmission risk. We sought to determine whether HIV-1 RNA level was associated with prior knowledge of HIV status among treatment-naive HIV-infected individuals in Botswana, a country with high rates of antiretroviral treatment (ART) coverage. This information may be helpful in targeting HIV diagnosis and treatment efforts in similar high-HIV-prevalence settings. DESIGN: Population-based survey. METHODS: HIV-infected individuals were identified during a household survey performed in 30 communities across Botswana. ART-naive persons with detectable HIV-1 RNA (>400 copies/mL) were divided into two groups, newly diagnosed and individuals tested in the past who knew about their HIV infection at the time of household visit but had not taken ART. Levels of HIV-1 RNA were compared between groups, overall and by age and gender. RESULTS: Among 815 HIV-infected ART-naive persons with detectable virus, newly diagnosed individuals had higher levels of HIV-1 RNA (n=490, median HIV-1 RNA 4.35, IQR 3.79-4.91 log10 copies/mL) than those who knew about their HIV-positive status (n=325, median HIV-1 RNA 4.10, IQR 3.55-4.68 log10 copies/mL; p-values <0.001, but p-value =0.011 after adjusting for age and gender). A non-significant trend for higher HIV-1 RNA was found among newly diagnosed men aged 30 years or older (median HIV-1 RNA 4.58, IQR 4.07-5.02 log10 copies/mL vs. 4.17, 3.61-4.71 log10 copies/mL). CONCLUSIONS: Newly diagnosed individuals have elevated levels of HIV-1 RNA. This study highlights the need for early diagnosis and treatment of HIV infection for purposes of HIV epidemic control, even in a setting with high ART coverage.

      12. The national burden of influenza-associated severe acute respiratory illness hospitalization in Rwanda, 2012-2014
        Nyamusore J, Rukelibuga J, Mutagoma M, Muhire A, Kabanda A, Williams T, Mutoni A, Kamwesiga J, Nyatanyi T, Omolo J, Kabeja A, Koama JB, Mukarurangwa A, Umuringa JD, Granados C, Gasana M, Moen A, Tempia S.
        Influenza Other Respir Viruses. 2017 Dec 2.
        BACKGROUND: Estimates of influenza-associated hospitalization are severely limited in low- and middle-income countries, especially in Africa. OBJECTIVES: To estimate the national number of influenza-associated severe acute respiratory illness (SARI) hospitalization in Rwanda. METHODS: We multiplied the influenza virus detection rate from influenza surveillance conducted at 6 sentinel hospitals by the national number of respiratory hospitalization obtained from passive surveillance after adjusting for underreporting and reclassification of any respiratory hospitalizations as SARI during 2012-2014. The population at risk was obtained from projections of the 2012 census. Bootstrapping was used for the calculation of confidence intervals (CI) to account for the uncertainty associated with all levels of adjustment. Rates were expressed per 100 000 population. A sensitivity analysis using a different estimation approach was also conducted. RESULTS: SARI cases accounted for 70.6% (9759/13 813) of respiratory admissions at selected hospitals: 77.2% (6783/8786) and 59.2% (2976/5028) among individuals aged <5 and >/=5 years, respectively. Overall, among SARI cases tested, the influenza virus detection rate was 6.3% (190/3022): 5.7% (127/2220) and 7.8% (63/802) among individuals aged <5 and >/=5 years, respectively. The estimated mean annual national number of influenza-associated SARI hospitalizations was 3663 (95% CI: 2930-4395-rate: 34.7; 95% CI: 25.4-47.7): 2637 (95% CI: 2110-3164-rate: 168.7; 95% CI: 135.0-202.4) among children aged <5 years and 1026 (95% CI: 821-1231-rate: 11.3; 95% CI: 9.0-13.6) among individuals aged >/=5 years. The estimates obtained from both approaches were not statistically different (overlapping CIs). CONCLUSIONS: The burden of influenza-associated SARI hospitalizations was substantial and was highest among children aged <5 years.

      13. Prevalence, incidence, and clearance of anal high-risk human papillomavirus (HPV) infection among HIV-infected men in the SUN Study
        Patel P, Bush T, Kojic EM, Conley L, Unger ER, Darragh TM, Henry K, Hammer J, Escota G, Palefsky JM, Brooks JT.
        J Infect Dis. 2017 Dec 4.
        Background: The natural history of anal HPV infection among HIV-infected men is unknown. Methods: We collected anal swabs for cytology, HPV detection, and genotyping at annual visits from 2004-2012. We examined baseline prevalence, incidence and clearance of anal HPV infection at 48 months, and associated factors among HIV-infected men. Results: We examined 403 men who have sex with men (MSM) and 96 men who have sex with women (MSW) (median age 42 years for both, 87 vs. 91% were prescribed cART, median CD4 cell count was 454 vs. 379 cells/mm3, and 74 vs. 75% had undetectable viral load, respectively). For type 16, prevalence among MSM and MSW was 38% vs. 14% (p<0.001), and incidence was 24% vs. 6% (p=0.001), respectively. For type 18, prevalence was 24% vs. 8% (p<0.001), and incidence was 14% vs. 3% (p=0.009), respectively. Among MSM and MSW, clearance of prevalent HPV 16 and HPV 18 was 51% and 66% (p=0.682), and 69% and 60% (p=0.538), respectively. Condomless receptive anal sex was associated with persistent HPV 16 among all men (OR 2.37, p=0.014). Conclusions: MSM had higher prevalence and incidence of HPV than MSW, but similar clearance. Condomless anal sex may predict cancer risk among HIV-infected men.

      14. Screening for Chlamydia trachomatis and Neisseria gonorrhoeae infection among asymptomatic men who have sex with men in Bangkok, Thailand
        Pattanasin S, Dunne EF, Wasinrapee P, Tongtoyai J, Chonwattana W, Sriporn A, Luechai P, Mock PA, Chitwarakorn A, Holtz TH, Curlin ME.
        Int J STD AIDS. 2017 Jan 1:956462417744904.
        We report positivity rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection at each anatomic site among asymptomatic men who have sex with men (MSM). We calculated the number needed to screen (NNS) to detect CT and NG infection at each anatomic site. From 2006 to 2010, we enrolled Thai MSM, age >/= 18 years into the Bangkok MSM Cohort Study. Participants underwent physical examination and had rectal, urethral, and pharyngeal screening for CT and NG infection using nucleic acid amplification tests (NAATs). Of 1744 enrollees, 1696 (97.2%) had no symptoms of CT and NG infection. The positivity rates of CT and NG infection at any site were 14.3% (rectum, urethra, pharynx) and 6.4% (rectum, urethra), respectively. The NNS to detect rectal CT and rectal NG infections was 10 and 16, respectively (p < 0.05). For urethral infection, the NNS of CT was lower than the NNS of NG (22, 121: p < 0.05). The lowest NNS found for rectal CT infection was in HIV-infected MSM (6, 5-8). Asymptomatic CT and NG infection were common among MSM in Bangkok, Thailand and frequently detected in the rectum. In setting where screening in all specimens using NAAT is not feasible, rectal screening should be a priority.

      15. Test and treat for TB-HIV
        Ridzon R.
        Int J Tuberc Lung Dis. 2017 ;21(12):1208.

        [No abstract]

      16. Massive iatrogenic outbreak of human immunodeficiency virus type 1 in rural Cambodia, 2014-2015
        Rouet F, Nouhin J, Zheng DP, Roche B, Black A, Prak S, Leoz M, Gaudy-Graffin C, Ferradini L, Mom C, Mam S, Gautier C, Lesage G, Ken S, Phon K, Kerleguer A, Yang C, Killam W, Fujita M, Mean C, Fontenille D, Barin F, Plantier JC, Bedford T, Ramos A, Saphonn V.
        Clin Infect Dis. 2017 Dec 4.
        Background: In 2014-2015, 242 individuals aged 2-89 were newly HIV-1 diagnosed in Roka, a rural commune in Cambodia. A case-control study attributed the outbreak to unsafe injections. We aimed to reconstruct the likely transmission history of the outbreak. Methods: We assessed in 209 (86.4%) HIV-infected cases the presence of hepatitis C and B viruses (HCV, HBV). We identified recent infections using antibody (Ab) avidity testing for HIV and HCV, and HBcIgM Ab for HBV. We performed evolutionary phylogenetic analyses of viral strains. Geographical coordinates and parenteral exposure through medical services provided by an unlicensed health care practitioner were obtained from 193 cases and 1499 controls during interviews. Results: Cases were co-infected with HCV (78.5%) and HBV (12.9%). We identified 79 (37.8%) recent (<130 days) HIV infections. Phylogeny of 202 HIV env C2V3 sequences showed a 198-sample CRF01_AE strains cluster, with time to most recent common ancestor (tMRCA) in September 2013 (95% highest posterior density, August 2012-July 2014), and a peak of 15 infections/day in September 2014. Three geospatial HIV hotspots were discernible in Roka and correlated with high exposure to the practitioner (P=0.04). Fifty-nine (38.6%) of 153 tested cases showed recent (<180 days) HCV infections. Ninety HCV NS5B sequences formed three main clades, one containing 34 subtypes 1b with tMRCA in 2012, and two with 51 subtypes 6e and tMRCAs in 2002-2003. Conclusions: Unsafe injections in Cambodia most likely led to an explosive iatrogenic spreading of HIV, associated with a long-standing and more genetically-diverse HCV propagation.

      17. Estimated incidence of influenza-associated severe acute respiratory infections in Indonesia, 2013-2016
        Susilarini NK, Haryanto E, Praptiningsih CY, Mangiri A, Kipuw N, Tarya I, Rusli R, Sumardi G, Widuri E, Sembiring MM, Noviyanti W, Widaningrum C, Lafond KE, Samaan G, Setiawaty V.
        Influenza Other Respir Viruses. 2017 Dec 5.
        BACKGROUND: Indonesia’s hospital-based Severe Acute Respiratory Infection (SARI) surveillance system, Surveilans Infeksi Saluran Pernafasan Akut Berat Indonesia (SIBI), was established in 2013. While respiratory illnesses such as SARI pose a significant problem, there are limited incidence-based data on influenza disease burden in Indonesia. This study aimed to estimate the incidence of influenza-associated SARI in Indonesia during 2013-2016 at three existing SIBI surveillance sites. METHODS: From May 2013 to April 2016, inpatients from sentinel hospitals in three districts of Indonesia (Gunung Kidul, Balikpapan, Deli Serdang) were screened for SARI. Respiratory specimens were collected from eligible inpatients and screened for influenza viruses. Annual incidence rates were calculated using these SIBI-enrolled influenza-positive SARI cases as a numerator, with a denominator catchment population defined through hospital admission survey (HAS) to identify respiratory-coded admissions by age to hospitals in the sentinel site districts. RESULTS: From May 2013 to April 2016, there were 1527 SARI cases enrolled, of whom 1392 (91%) had specimens tested and 199 (14%) were influenza-positive. The overall estimated annual incidence of influenza-associated SARI ranged from 13 to 19 per 100 000 population. Incidence was highest in children aged 0-4 years (82-114 per 100 000 population), followed by children 5-14 years (22-36 per 100 000 population). CONCLUSIONS: Incidence rates of influenza-associated SARI in these districts indicate a substantial burden of influenza hospitalizations in young children in Indonesia. Further studies are needed to examine the influenza burden in other potential risk groups such as pregnant women and the elderly.

      18. Epidemiology of influenza in West Africa after the 2009 influenza A(H1N1) pandemic, 2010-2012
        Talla Nzussouo N, Duque J, Adedeji AA, Coulibaly D, Sow S, Tarnagda Z, Maman I, Lagare A, Makaya S, Elkory MB, Kadjo Adje H, Shilo PA, Tamboura B, Cisse A, Badziklou K, Mainassara HB, Bara AO, Keita AM, Williams T, Moen A, Widdowson MA, McMorrow M.
        BMC Infect Dis. 2017 Dec 4;17(1):745.
        BACKGROUND: Over the last decade, capacity for influenza surveillance and research in West Africa has strengthened. Data from these surveillance systems showed influenza A(H1N1)pdm09 circulated in West Africa later than in other regions of the continent. METHODS: We contacted 11 West African countries to collect information about their influenza surveillance systems (number of sites, type of surveillance, sampling strategy, populations sampled, case definitions used, number of specimens collected and number of specimens positive for influenza viruses) for the time period January 2010 through December 2012. RESULTS: Of the 11 countries contacted, 8 responded: Burkina Faso, Cote d’Ivoire, Mali, Mauritania, Niger, Nigeria, Sierra Leone and Togo. Countries used standard World Health Organization (WHO) case definitions for influenza-like illness (ILI) and severe acute respiratory illness (SARI) or slight variations thereof. There were 70 surveillance sites: 26 SARI and 44 ILI. Seven countries conducted SARI surveillance and collected 3114 specimens of which 209 (7%) were positive for influenza viruses. Among influenza-positive SARI patients, 132 (63%) were influenza A [68 influenza A(H1N1)pdm09, 64 influenza A(H3N2)] and 77 (37%) were influenza B. All eight countries conducted ILI surveillance and collected 20,375 specimens, of which 2278 (11%) were positive for influenza viruses. Among influenza-positive ILI patients, 1431 (63%) were influenza A [820 influenza A(H1N1)pdm09, 611 influenza A(H3N2)] and 847 (37%) were influenza B. A majority of SARI and ILI case-patients who tested positive for influenza (72% SARI and 59% ILI) were children aged 0-4 years, as were a majority of those enrolled in surveillance. The seasonality of influenza and the predominant influenza type or subtype varied by country and year. CONCLUSIONS: Influenza A(H1N1)pdm09 continued to circulate in West Africa along with influenza A(H3N2) and influenza B during 2010-2012. Although ILI surveillance systems produced a robust number of samples during the study period, more could be done to strengthen surveillance among hospitalized SARI case-patients. Surveillance systems captured young children but lacked data on adults and the elderly. More data on risk groups for severe influenza in West Africa are needed to help shape influenza prevention and clinical management policies and guidelines.

      19. The effects of the attributable fraction and the duration of symptoms on burden estimates of influenza-associated respiratory illnesses in a high HIV-prevalence setting, South Africa, 2013-2015
        Tempia S, Walaza S, Moyes J, Cohen AL, von Mollendorf C, McMorrow ML, Mhlanga S, Treurnicht FK, Venter M, Pretorius M, Hellferscee O, Wolter N, von Gottberg A, Nguweneza A, McAnerney JM, Dawood H, Variava E, Madhi SA, Cohen C.
        Influenza Other Respir Viruses. 2017 Dec 6.
        BACKGROUND: The attributable fraction of influenza virus detection to illness (INF-AF) and the duration of symptoms as a surveillance inclusion criterion could potentially have substantial effects on influenza disease burden estimates. METHODS: We estimated rates of influenza-associated influenza-like illness (ILI) and severe acute (SARI-10) or chronic (SCRI-10) respiratory illness (using a symptom duration cut-off of </=10 days) among HIV-infected and HIV-uninfected patients attending 3 hospitals and 2 affiliated clinics in South Africa during 2013-2015. We calculated the unadjusted and INF-AF adjusted rates and relative risk (RR) due to HIV infection. Rates were expressed per 100 000 population. RESULTS: The estimated mean annual unadjusted rates of influenza-associated illness were 1467.7, 50.3 and 27.4 among patients with ILI, SARI-10 and SCRI-10, respectively. After adjusting for the INF-AF the percent reduction of the estimated rates was 8.9% (rate: 1336.9), 11.0% (rate: 44.8) and 16.3% (rate: 22.9) among patients with ILI, SARI-10 and SCRI-10, respectively. HIV-infected compared to HIV-uninfected individuals experienced a 2.3 (95% CI: 2.2-2.4), 9.7 (95% CI: 8.0-11.8) and 10.0 (95% CI: 7.9-12.7) fold increased risk of influenza-associated illness among patients with ILI, SARI-10 and SCRI-10, respectively. Overall 34% of the estimated influenza-associated hospitalizations had symptom duration of >10 days; 8% and 44% among individuals aged <5 and >/=5 years, respectively. CONCLUSION: The marginal differences between unadjusted and INF-AF adjusted rates are unlikely to affect policies on prioritization of interventions. HIV-infected individuals experienced an increased risk of influenza-associated illness and may benefit more from annual influenza immunization. The use of a symptom duration cut-off of </=10 days may underestimate influenza-associated disease burden, especially in older individuals. This article is protected by copyright. All rights reserved.

      20. The seasonal incidence of symptomatic influenza in the United States
        Tokars JI, Olsen SJ, Reed C.
        Clin Infect Dis. 2017 Dec 1.
        Background: The seasonal incidence of influenza is often approximated as “5% to 20%”. Methods: We used two methods to estimate the seasonal incidence of symptomatic influenza in the United States. First, we made a statistical estimate extrapolated from influenza-associated hospitalization rates for 2010-11 to 2015-16, collected as part of national surveillance, covering approximately 9% of the United States, and including the existing mix of vaccinated and unvaccinated persons. Second, we performed a literature search and meta-analysis of published manuscripts that followed cohorts of subjects during 1996-2016 to detect laboratory-confirmed symptomatic influenza among unvaccinated persons; we adjusted this result to the United States median vaccination coverage and effectiveness during 2010-2016. Results: The statistical estimate of influenza incidence among all ages ranged from 3.0-11.3% among seasons, with median values of 8.3 (95% confidence interval [CI] 7.3%, 9.7%) for all ages, 9.3% (CI 8.2%, 11.1%) for children <18 years and 8.9% (CI 8.2%, 9.9%) for adults 18-64 years. Corresponding values for the meta-analysis were 7.1% (CI 6.1, 8.1) for all ages, 8.7% (6.6, 10.5) for children, and 5.1% (3.6, 6.6) for adults. Conclusions: The two approaches produced comparable results for children and persons of all ages. The statistical estimates are more versatile and permit estimation of season-to-season variation. During 2010-2016, the incidence of symptomatic influenza among vaccinated and unvaccinated United States residents, including both medically attended and non-attended infections, was approximately 8% and varied from 3% to 11% among seasons.

      21. BACKGROUND: The 2014-2016 Ebola crisis in West Africa had approximately eight times as many reported deaths as the sum of all previous Ebola outbreaks. The outbreak magnitude and occurrence of multiple Ebola cases in at least seven countries beyond Liberia, Sierra Leone, and Guinea, hinted at the possibility of broad-scale transmission of Ebola. MAIN TEXT: Using a modeling tool developed by the US Centers for Disease Control and Prevention during the Ebola outbreak, we estimated the number of Ebola cases that might have occurred had the disease spread beyond the three countries in West Africa to cities in other countries at high risk for disease transmission (based on late 2014 air travel patterns). We estimated Ebola cases in three scenarios: a delayed response, a Liberia-like response, and a fast response scenario. Based on our estimates of the number of Ebola cases that could have occurred had Ebola spread to other countries beyond the West African foci, we emphasize the need for improved levels of preparedness and response to public health threats, which is the goal of the Global Health Security Agenda. Our estimates suggest that Ebola could have potentially spread widely beyond the West Africa foci, had local and international health workers and organizations not committed to a major response effort. Our results underscore the importance of rapid detection and initiation of an effective, organized response, and the challenges faced by countries with limited public health systems. Actionable lessons for strengthening local public health systems in countries at high risk of disease transmission include increasing health personnel, bolstering primary and critical healthcare facilities, developing public health infrastructure (e.g. laboratory capacity), and improving disease surveillance. With stronger local public health systems infectious disease outbreaks would still occur, but their rapid escalation would be considerably less likely, minimizing the impact of public health threats such as Ebola. CONCLUSIONS: The Ebola outbreak could have potentially spread to other countries, where limited public health surveillance and response capabilities may have resulted in additional foci. Health security requires robust local health systems that can rapidly detect and effectively respond to an infectious disease outbreak.

    • Disaster Control and Emergency Services
      1. Public health implications of complex emergencies and natural disasters
        Culver A, Rochat R, Cookson ST.
        Confl Health. 2017 ;11:32.
        Background: During the last decade, conflict or natural disasters have displaced unprecedented numbers of persons. This leads to conditions prone to outbreaks that imperil the health of displaced persons and threaten global health security. Past literature has minimally examined the association of communicable disease outbreaks with complex emergencies (CEs) and natural disasters (NDs). Methods: To examine this association, we identified CEs and NDs using publicly available datasets from the Center for Research on the Epidemiology of Disasters and United Nations Flash and Consolidated Appeals archive for 2005-2014. We identified outbreaks from World Health Organization archives. We compared findings to identify overlap of outbreaks, including their types (whether or not of a vaccine-preventable disease), and emergency event types (CE, ND, or Both) by country and year using descriptive statistics and measure of association. Results: There were 167 CEs, 912 NDs, 118 events linked to ‘Both’ types of emergencies, and 384 outbreaks. Of CEs, 43% were associated with an outbreak; 24% NDs were associated with an outbreak; and 36% of ‘Both’ types of emergencies were associated with an outbreak. Africa was disproportionately affected, where 67% of total CEs, 67% of ‘Both’ events (CE and ND), and 46% of all outbreaks occurred for the study period. The odds ratio of a vaccine-preventable outbreak occurring in a CE versus an ND was 4.14 (95% confidence limits 1.9, 9.4). Conclusions: CEs had greater odds of being associated with outbreaks compared with NDs. Moreover, CEs had high odds of a vaccine-preventable disease causing that outbreak. Focusing on better vaccine coverage could reduce CE-associated morbidity and mortality by preventing outbreaks from spreading.

      2. Acute malnutrition among children, mortality, and humanitarian interventions in conflict-affected regions – Nigeria, October 2016-March 2017
        Leidman E, Tromble E, Yermina A, Johnston R, Isokpunwu C, Adeniran A, Bulti A.
        MMWR Morb Mortal Wkly Rep. 2017 Dec 8;66(48):1332-1335.
        A public health emergency was declared by the Nigerian Federal Ministry of Health in northeastern Nigeria in June 2016 and escalated by the United Nations to a Level 3 Emergency in August 2016, after confirmation of wild poliovirus and measles outbreaks and evidence that prevalence of acute malnutrition exceeded emergency thresholds in areas newly liberated from Boko Haram control (1,2). To monitor rates of mortality, acute malnutrition among children, infectious disease morbidity, and humanitarian interventions after the emergency declaration, a series of cross-sectional household surveys were conducted in fall 2016 and winter 2017 in the northeastern states of Borno and Yobe using a cluster methodology. All-cause mortality among all age groups (crude mortality) and among children aged <5 years (under-five mortality) were above emergency thresholds in 2017 and significantly increased from 2016, despite evidence of increased preventive public health interventions, including measles vaccination. Access to treatment for common childhood illnesses remained very low, as evidenced by reports of fewer than one in six children in areas outside Borno’s capital receiving any care for diarrhea. The data from these surveys provide evidence of excessively high mortality (particularly among children), highlight the impact of ongoing violence, and underscore the need for humanitarian efforts to scale up access to treatment services in conflict-affected areas.

    • Disease Reservoirs and Vectors
      1. Evaluating acarological risk for exposure to Ixodes scapularis and Ixodes scapularis-borne pathogens in recreational and residential settings in Washington County, Minnesota
        Hahn MB, Bjork JK, Neitzel DF, Dorr FM, Whitemarsh T, Boegler KA, Graham CB, Johnson TL, Maes SE, Eisen RJ.
        Ticks Tick Borne Dis. 2017 Nov 22.
        The distribution of I. scapularis, the tick vector of the bacteria that cause Lyme disease, has been expanding over the last two decades in the north-central United States in parallel with increasing incidence of human cases of Lyme disease in that region. However, assessments of residential risk for exposure to ticks are lacking from this region. Here, we measured the density of host-seeking I. scapularis nymphs in two suburban and two rural public recreational sites located in Washington County, Minnesota as well as in nearby residential properties. We sought to compare tick densities across land use types and to identify environmental factors that might impact nymphal density. We also assessed the prevalence of infection in the collected ticks with Lyme disease spirochetes (Borrelia burgdorferi sensu stricto, B. mayonii), and other I. scapularis-borne pathogens including B. miyamotoi, Babesia microti and Anaplasma phagocytophilum. Similar to studies from the eastern United States, on residential properties, I. scapularis nymphal densities were highest in the ecotonal areas between the forest edge and the lawn. Residences with the highest densities of nymphs were more likely to have a higher percentage of forest cover, log piles, and signs of deer on their property. In recreational areas, we found the highest nymphal densities both in the wooded areas next to trails as well as on mowed trails. Among the 303 host-seeking I. scapularis nymphs tested for pathogens, B. burgdorferi sensu stricto, A. phagocytophilum and B. miyamotoi were detected in 42 (13.8%), 14 (4.6%), and 2 (0.6%) nymphs, respectively.

      2. Minimizing mosquito larval habitat within roadside stormwater treatment best management practices in southern California through incremental improvements to structure
        Metzger ME, Harbison JE, Burns JE, Kramer VL, Newton JH, Drews J, Hu R.
        Ecological Engineering. 2018 ;110:185-191.
        A five-year study was conducted in Orange County, California to document the presence of standing water and the presence or absence of larval mosquitoes within 23 stormwater treatment Best Management Practices (BMPs) installed along State Route 73 by the California Department of Transportation. Findings were used to guide incremental improvements to BMP design and function with the aim of reducing the occurrence of standing water that persisted more than 96 h after precipitation. During the first year of monitoring, a number of structural and non-structural factors were identified as causes for standing water within BMPs suitable for mosquitoes. Uneven grades, inlet design and construction, and novel structural features were most frequently responsible for standing water, often exacerbated by sediment and debris accumulations and periodic or perennial non-stormwater flows. Subsequent modifications to BMPs eliminated or reduced the size of persistent standing water pools. The study demonstrated that mosquito larval habitat can be mitigated in BMPs designed to remain dry between precipitation events by collecting field data that identifies where post-construction structural and managerial changes are needed to eliminate or reduce unintended sources of standing water.

      3. Bourbon virus in field-collected ticks, Missouri, USA
        Savage HM, Burkhalter KL, Godsey MS, Panella NA, Ashley DC, Nicholson WL, Lambert AJ.
        Emerg Infect Dis. 2017 Dec;23(12):2017-2022.
        Bourbon virus (BRBV) was first isolated in 2014 from a resident of Bourbon County, Kansas, USA, who died of the infection. In 2015, an ill Payne County, Oklahoma, resident tested positive for antibodies to BRBV, before fully recovering. We retrospectively tested for BRBV in 39,096 ticks from northwestern Missouri, located 240 km from Bourbon County, Kansas. We detected BRBV in 3 pools of Amblyomma americanum (L.) ticks: 1 pool of male adults and 2 pools of nymphs. Detection of BRBV in A. americanum, a species that is aggressive, feeds on humans, and is abundant in Kansas and Oklahoma, supports the premise that A. americanum is a vector of BRBV to humans. BRBV has not been detected in nonhuman vertebrates, and its natural history remains largely unknown.

      4. Increases in the competitive fitness of West Nile virus isolates after introduction into California
        Worwa G, Hutton AA, Frey M, Duggal NK, Brault AC, Reisen WK.
        Virology. 2017 Nov 28;514:170-181.
        To investigate the phenotypic evolution of West Nile virus (WNV) in California, we competed sixteen isolates made during 2007-08 against COAV997-5nt, a genetically marked clone from the founding 2003 California isolate COAV997-2003. Using in vivo fitness competitions in House Finches (HOFI) and Culex tarsalis mosquitoes, we found that the majority of WNV WN02 and SW03 genotype isolates exhibited elevated replicative fitness in both hosts compared to COAV997-5nt. Increased replicative capacity in HOFIs was not associated with increased mortality, indicating that these isolates had not gained avian virulence. One WN02 isolate from Coachella Valley, a region geographically close to the isolation of COAV997, showed neutral fitness in HOFIs and reduced fitness in Cx. tarsalis. Two isolates from Kern County and Sacramento/Yolo County out-competed COAV997-nt in HOFIs, but were transmitted less efficiently by Cx. tarsalis. Competition demonstrated neutral or increased fitness that appeared independent of both WN02 and SW03 genotypes.

    • Environmental Health
      1. Prenatal and early-life triclosan and paraben exposure and allergic outcomes
        Lee-Sarwar K, Hauser R, Calafat AM, Ye X, O’Connor GT, Sandel M, Bacharier LB, Zeiger RS, Laranjo N, Gold DR, Weiss ST, Litonjua AA, Savage JH.
        J Allergy Clin Immunol. 2017 Oct 27.
        BACKGROUND: In cross-sectional studies triclosan and parabens, ubiquitous ingredients in personal care and other products, are associated with allergic disease. OBJECTIVES: We investigated the association between prenatal and early-life triclosan and paraben exposure and childhood allergic disease in a prospective longitudinal study. METHODS: Subjects were enrollees in the Vitamin D Antenatal Asthma Reduction Trial. Triclosan, methyl paraben, and propyl paraben concentrations were quantified in maternal plasma samples pooled from the first and third trimesters and urine samples from children at age 3 or 4 years. Outcomes were parental report of physician-diagnosed asthma or recurrent wheezing and allergic sensitization to food or environmental antigens based on serum specific IgE levels at age 3 years in high-risk children. RESULTS: The analysis included 467 mother-child pairs. Overall, there were no statistically significant associations of maternal plasma or child urine triclosan or paraben concentrations with asthma or recurrent wheeze or food or environmental sensitization at age 3 years. A trend toward an inverse association between triclosan and paraben exposure and allergic sensitization was observed. There was evidence of effect measure modification by sex, with higher odds of environmental sensitization associated with increasing paraben concentrations in male compared with female subjects. CONCLUSIONS: We did not identify a consistent association between prenatal and early-life triclosan or paraben concentrations and childhood asthma, recurrent wheeze, or allergic sensitization in the overall study population. The differential effects of triclosan or paraben exposure on allergic sensitization by sex observed in this study warrant further exploration.

    • Food Safety
      1. Genetic susceptibility to hemolytic-uremic syndrome after shiga toxin-producing Escherichia coli (STEC) infection: a Centers for Disease Control and Prevention (CDC) FoodNet Study
        Kallianpur AR, Bradford Y, Mody RK, Garman KN, Comstock N, Lathrop SL, Lyons C, Saupe A, Wymore K, Canter JA, Olson LM, Palmer A, Jones TF.
        J Infect Dis. 2017 Dec 6.
        Background: Post-diarrheal hemolytic-uremic syndrome (D+HUS) following Shiga toxin-producing Escherichia coli (STEC) infection is a serious condition lacking specific treatment. Host immune dysregulation and genetic susceptibility to complement hyperactivation are implicated in non-STEC-related HUS. However, genetic susceptibility to D+HUS remains largely uncharacterized. Methods: Patients with culture-confirmed STEC diarrhea, identified through the CDC FoodNet surveillance system (2007-2012), were serotyped and classified by laboratory and/or clinical criteria as suspected, probable, or confirmed D+HUS, or as controls and genotyped at 200 loci linked to non-diarrheal HUS or similar pathologies. Genetic associations with D+HUS were explored by multivariable regression, adjusting for known risk factors. Results: Of 641 enrollees with STEC O157:H7, 80 had suspected D+HUS (41 probable and 32 confirmed D+HUS). Twelve genes related to cytokine signaling, complement pathways, platelet function, pathogen recognition, iron transport, and endothelial function were associated with D+HUS in multivariable-adjusted analyses (p</=0.05). Of 12 significant SNPs, 5 were associated with all levels of D+HUS (intergenic SNP rs10874639, TFRC rs3804141, EDN1 rs5370, GP1BA rs121908064, and B2M rs16966334), and 7 SNPs (6 non-complement-related) were associated with confirmed D+HUS (all p<0.05). Conclusions: Polymorphisms in many non-complement-related genes may contribute to D+HUS susceptibility. These results require replication, but they suggest novel therapeutic targets in D+HUS.

      2. Unusually high illness severity and short incubation periods in two foodborne outbreaks of Salmonella Heidelberg infections with potential coincident Staphylococcus aureus intoxication
        Nakao JH, Talkington D, Bopp CA, Besser J, Sanchez ML, Guarisco J, Davidson SL, Warner C, Mc I, Group JP, Comstock N, Xavier K, Pinsent TS, Brown J, Douglas JM, Gomez GA, Garrett NM, Carleton HA, Tolar B, Wise ME.
        Epidemiol Infect. 2017 Dec 6:1-9.
        We describe the investigation of two temporally coincident illness clusters involving salmonella and Staphylococcus aureus in two states. Cases were defined as gastrointestinal illness following two meal events. Investigators interviewed ill persons. Stool, food and environmental samples underwent pathogen testing. Alabama: Eighty cases were identified. Median time from meal to illness was 5.8 h. Salmonella Heidelberg was identified from 27 of 28 stool specimens tested, and coagulase-positive S. aureus was isolated from three of 16 ill persons. Environmental investigation indicated that food handling deficiencies occurred. Colorado: Seven cases were identified. Median time from meal to illness was 4.5 h. Five persons were hospitalised, four of whom were admitted to the intensive care unit. Salmonella Heidelberg was identified in six of seven stool specimens and coagulase-positive S. aureus in three of six tested. No single food item was implicated in either outbreak. These two outbreaks were linked to infection with Salmonella Heidelberg, but additional factors, such as dual aetiology that included S. aureus or the dose of salmonella ingested may have contributed to the short incubation periods and high illness severity. The outbreaks underscore the importance of measures to prevent foodborne illness through appropriate washing, handling, preparation and storage of food.

    • Genetics and Genomics
      1. Evolutionary analysis of mumps viruses of genotype F collected in mainland China in 2001-2015
        Cui A, Rivailler P, Zhu Z, Deng X, Hu Y, Wang Y, Li F, Sun Z, He J, Si Y, Tian X, Zhou S, Lei Y, Zheng H, Rota PA, Xu W.
        Sci Rep. 2017 Dec 7;7(1):17144.
        Mumps incidence in mainland China remains at a high level. Genotype F has been the predominant genotype of mumps virus (MuV) in the last 20 years in mainland China. To better understand the genetic characteristics of MuV in China, the sequences of the Small Hydrophobic (SH), Hemagglutinin-Neuraminidase (HN) and Fusion (F) genes of MuVs of genotype F collected during 2001-2015 were determined. The evolutionary rates of the HN and F genes were similar (0.5 x 10(-3) substitutions/site/year) whereas the SH gene evolutionary rate was three times faster. The most recent common ancestor of genotype F was traced back to 1980. Four lineages were identified within HN and F MuV sequences. A phylogeographic analysis indicated that the genotype F viruses originally spread from the Liaoning and Shandong provinces followed by a spread to the South and East of China. This study provides important genetic baseline data for the development of prevention and control measures of mumps.

      2. The accuracy of hospital ICD-9-CM codes for determining Sickle Cell Disease genotype
        Snyder AB, Lane PA, Zhou M, Paulukonis ST, Hulihan MM.
        J Rare Dis Res Treat. 2017 ;2(4):39-45.
        Sickle cell disease affects more than 100,000 individuals in the United States, among whom disease severity varies considerably. One factor that influences disease severity is the sickle cell disease genotype. For this reason, clinical prevention and treatment guidelines tend to differentiate between genotypes. However, previous research suggests caution when using a claimsbased determination of sickle cell disease genotype in healthcare quality studies. The objective of this study was to describe the extent of miscoding for the major sickle cell disease genotypes in hospital discharge data. Individuals with sickle cell disease were identified through newborn screening results or hemoglobinopathy specialty care centers, along with their sickle cell disease genotypes. These genotypes were compared to the diagnosis codes listed in hospital discharge data to assess the accuracy of the hospital codes in determining sickle cell disease genotype. Eighty-three percent (sickle cell anemia), 23% (Hemoglobin SC), and 31% (Hemoglobin Sbeta(+) thalassemia) of hospitalizations contained a diagnosis code that correctly reflected the individual’s true sickle cell disease genotype. The accuracy of the sickle cell disease genotype coding was indeterminate in 11% (sickle cell anemia), 12% (Hemoglobin SC), and 7% (Hemoglobin Sbeta(+) thalassemia) and incorrect in 3% (sickle cell anemia), 61% (Hemoglobin SC), and 52% (Hemoglobin Sbeta(+) thalassemia) of the hospitalizations. The use of ICD-9-CM codes from hospital discharge data for determining specific sickle cell disease genotypes is problematic. Research based solely on these or other types of administrative data could lead to incorrect understanding of the disease.

    • Health Disparities
      1. This essay examines how civil rights and their implementation have affected and continue to affect the health of racial and ethnic minority populations in the United States. Civil rights are characterized as social determinants of health. A brief review of US history indicates that, particularly for Blacks, Hispanics, and American Indians, the longstanding lack of civil rights is linked with persistent health inequities. Civil rights history since 1950 is explored in four domains-health care, education, employment, and housing. The first three domains show substantial benefits when civil rights are enforced. Discrimination and segregation in housing persist because anti-discrimination civil rights laws have not been well enforced. Enforcement is an essential component for the success of civil rights law. Civil rights and their enforcement may be considered a powerful arena for public health theorizing, research, policy, and action.

    • Immunity and Immunization
      1. Observations on the epidemiology of rotavirus infection among hospitalized children younger than 5 years in 2 Ukrainian hospitals, 2007-2015
        Chernyshova LI, Radionova NM, Demchyshyna IV, Kotlik LS, Sadkova OB, Samoilovich EO, Semeiko GV, Daniels DS, Cohen AL, Aliabadi N.
        Vaccine. 2017 Nov 29.
        BACKGROUND: Acute gastroenteritis remains a burden among children under 5 years of age. Ukraine joined the World Health Organization’s Global Rotavirus Surveillance Network in 2006, with a goal of providing accurate rotavirus burden data to aid policy makers in planning for rotavirus vaccine introduction. This analysis describes rotavirus epidemiology among Ukrainian children enrolled in Kyiv and Odesa, two large Ukrainian cities. METHODS: Children 0-59 months of age hospitalized for acute gastroenteritis at 2 sentinel sites in Kyiv and Odesa were enrolled into the active, prospective surveillance program. In Odesa, the surveillance period was during 2007-2015 and in Kyiv, it was during 2011-2015. Acute gastroenteritis was defined as 3 or more episodes of diarrhea per day during a 24 h period, with symptom duration before hospitalization not exceeding 7 days. Guardians of enrolled children completed a questionnaire including demographic, clinical and treatment information. Each child provided a stool specimen within 2days of hospitalization. Stools were tested for rotavirus using ProSpecT Rotavirus Kit (Oxoid Ltd., Great Britain), and positive specimens were genotyped. Descriptive data are reported, as well as comparison of demographic, clinical and treatment data among rotavirus positive and negative children. RESULTS: During July 2007-June 2015, 12,350 children were enrolled in the surveillance programs and had stool specimens collected and tested for rotavirus. Overall, rotavirus infection was diagnosed in 5412/12350 (44%) of children, 929/1734 (54%) of those in Kyiv and 4483/10616 (42%) in Odesa. Rotavirus infections peaked during the winter months. Children with rotavirus acute gastroenteritis displayed more severe clinical symptoms than those without rotavirus. Predominant genotypes identified included G1P[8], G2P[4], G3 P[8], G4 P[8] and G9 P[8]. CONCLUSION: Active surveillance of acute gastroenteritis in hospitalized children younger 5 years in two large Ukrainian cities reveals a significant burden of rotavirus infection. These data provide scientific justification for incorporating rotavirus vaccines into the Ukrainian national immunization schedule.

      2. Risk of rotavirus nosocomial spread after inpatient pentavalent rotavirus vaccination
        Hofstetter AM, Lacombe K, Klein EJ, Jones C, Strelitz B, Jacobson E, Ranade D, Ward ML, Mijatovic-Rustempasic S, Evans D, Wikswo M, Bowen MD, Parashar UD, Payne DC, Englund JA.
        Pediatrics. 2017 Dec 6.
        BACKGROUND: Infants born prematurely or with underlying conditions are at increased risk of severe rotavirus disease and associated complications. Given the theoretical risk of nosocomial transmission of vaccine-type rotavirus, rotavirus vaccination is recommended for infants at or after discharge from neonatal care settings. Because the first dose should be administered by 104 days of age, some infants may be age-ineligible for vaccination if delayed until discharge. METHODS: This prospective cohort included infants admitted to an urban academic medical center between birth and 104 days who received care in intensive care settings. Pentavalent human-bovine reassortant rotavirus vaccine (RV5) was used, per routine clinical care. Stool specimens were collected weekly (February 2013-April 2014) and analyzed for rotavirus strains using real-time reverse transcription-polymerase chain reaction. Demographic and vaccine data were collected. RV5 safety was not assessed. RESULTS: Of 385 study infants, 127 were age-eligible for routine vaccinations during hospitalization. At discharge, 32.7% were up-to-date for rotavirus vaccination, compared with 82.7% for other vaccinations. Of rotavirus-unvaccinated infants, 42.6% were discharged at age >104 days and thus vaccination-ineligible. Of 1192 stool specimens collected, rotavirus was detected in 13 (1.1%): 1 wild-type strain from an unvaccinated infant; 12 vaccine-type strains from 9 RV5-vaccinated infants. No vaccine-type rotavirus cases were observed among unvaccinated infants (incidence rate: 0.0 [95% confidence interval: 0.0-1.5] cases per 1000 patient days at risk). CONCLUSIONS: These data suggest that delaying rotavirus vaccination until discharge from the hospital could lead to missed vaccination opportunities and may be unnecessary in institutions using RV5 with comparable infection control standards.

      3. Anxiety-related adverse events following immunization (AEFI): A systematic review of published clusters of illness
        Loharikar A, Suragh TA, MacDonald NE, Balakrishnan MR, Benes O, Lamprianou S, Hyde TB, McNeil MM.
        Vaccine. 2017 Nov 29.
        BACKGROUND: Clusters of anxiety-related adverse events following immunization (AEFI) have been observed in several countries and have disrupted country immunization programs. We conducted a systematic literature review to characterize these clusters, to generate prevention and management guidance for countries. METHODS: We searched seven peer-reviewed databases for English language reports of anxiety-related AEFI clusters (>/=2 persons) with pre-specified keywords across 4 categories: symptom term, cluster term, vaccine term, and cluster AEFI phenomenon term/phrase. All relevant reports were included regardless of publication date, case-patient age, or vaccine. Two investigators independently reviewed abstracts and identified articles for full review. Data on epidemiologic/clinical information were extracted from full text review including setting, vaccine implicated, predominant case-patient symptoms, clinical management, community and media response, and outcome/impact on the vaccination program. RESULTS: Of 1472 abstracts reviewed, we identified eight published clusters, from all six World Health Organization (WHO) regions except the African Region. Seven clusters occurred among children in school settings, and one was among adult military reservists. The size and nature of these clusters ranged from 7 patients in one school to 806 patients in multiple schools. Patients’ symptoms included dizziness, headache, and fainting with rapid onset after vaccination. Implicated vaccines included tetanus (2), tetanus-diphtheria (1), hepatitis B (1), oral cholera (1), human papillomavirus (1), and influenza A (H1N1)pdm09 (2). In each report, all affected individuals recovered rapidly; however, vaccination program disruption was noted in some instances, sometimes for up to one year. CONCLUSIONS: Anxiety-related AEFI clusters can be disruptive to vaccination programs, reducing public trust in immunizations and impacting vaccination coverage; response efforts to restore public confidence can be resource intensive. Health care providers should have training on recognition and clinical management of anxiety-related AEFI; public health authorities should have plans to prevent and effectively manage anxiety-related AEFI clusters. Prompt management of these occurrences can be even more important in an era of social media, in which information is rapidly spread.

      4. Evaluation of the influence of gastrointestinal co-infections on rotavirus vaccine effectiveness in Botswana
        Mokomane M, Tate JE, Steenhoff AP, Esona MD, Bowen MD, Lechiile K, Pernica JM, Kasvosve I, Parashar UD, Goldfarb DM.
        Pediatr Infect Dis J. 2017 Nov 16.
        BACKGROUND: Studies have demonstrated reduced rotavirus vaccine effectiveness (VE) in resource-limited settings. Enteropathogen co-infections in rotavirus cases have been hypothesized to contribute to the lower vaccine effectiveness in such settings. We sought to determine if co-infections affect rotavirus VE in Botswana. METHODS: Between June 2013 and April 2015, children <60 months old, presenting with severe gastroenteritis at four hospitals as part of a national rotavirus surveillance were enrolled. Rotavirus EIA positive samples were tested with an in-house real-time polymerase chain reaction (PCR) panel that detected nine pathogens and a commercial 15 multiplex PCR gastrointestinal pathogen panel (GPP). Co-infection was defined as detection of rotavirus plus one of the five pathogens with the highest attributable fractions for diarrhea. Vaccine status was compared between rotavirus case patients and non-rotavirus “test-negative” controls. Vaccine effectiveness was also calculated restricting cases to those with rotavirus as the only pathogen detected. RESULTS: 242 children tested rotavirus EIA positive and 368 children were negative. Of the 182 rotavirus EIA-positive samples tested with the GPP assay, co-infections were detected in60 (33%). The overall adjusted 2-dose VE was 59% (95% CI 27-77) in the rotavirus co-infection group and 51% (95% CI -14-79) in the rotavirus mono-infection subgroup. Using in-house multiplex PCR panel, out of 213 rotavirus EIA positive subjects, co-infections were detected in 98 samples (46%). The overall adjusted VE for two doses was 48% (95% CI -2-74) and 62% (95% CI 25-80) in rotavirus mono-infection subgroup. CONCLUSIONS: We could not find evidence of an effect of enteric co-infections on the effectiveness of rotavirus vaccine.

      5. BACKGROUND: Highly pathogenic avian influenza A (HPAI) viruses found in poultry and wild birds occasionally infect humans and can cause serious disease. In 2014, the Advisory Committee on Immunization Practices (ACIP) reviewed data from one licensed ASO3-adjuvanted influenza A(H5N1) vaccine for consideration of use during inter-pandemic periods among persons with occupational exposure. To guide vaccine policy decisions, we conducted a survey of laboratory workers to assess demand for HPAI vaccination. METHODS: We designed an anonymous web survey (EpiInfo 7.0) to collect information on demographics, type of work and time spent with HPAI viruses, and interest in HPAI vaccination. Eligible participants were identified from 42 entities registered with United States Department of Agriculture’s Agricultural Select Agent program in 2016 and emailed electronic surveys. Personnel with Biosafety Level 3 enhanced (BSL-3E) laboratory access were surveyed. Descriptive analysis was performed. RESULTS: Overall, 131 responses were received from 33 principal investigators, 26 research scientists, 24 technicians, 15 postdoctoral fellows, 6 students, and 27 others. The estimated response rate was 15% among the laboratory personnel of responding principal investigators. One hundred respondents reported working in a BSL-3E area where HPAI experiments occurred with a mean time of 5.1-11.7h per week. Overall, 49% were interested in receiving an A(H5N1) vaccine. By role, interest was highest among students (80%) and among those who spent >50% of their time in a BSL-3E area (64%). Most (61%) of those who said they might be or were not interested in vaccine believed it would not provide additional protection to current safety practices. CONCLUSIONS: Half of responding laboratory workers was interested in receiving an influenza A(H5N1) vaccine. HPAI vaccination of laboratory workers at risk of occupational exposure could be used along with existing safety practices to protect this population.

      6. Influenza vaccination in tropical and subtropical areas
        Xu C, Thompson MG, Cowling BJ.
        Lancet Respir Med. 2017 Dec;5(12):920-922.

        [No abstract]

    • Laboratory Sciences
      1. Promoting good laboratory practices for waived infectious disease and provider-performed microscopy testing
        Anderson N, Stang H.
        Clin Microbiol Newsl. 2017 1 December;39(23):183-188.
        Laboratory testing at the point of patient care was documented hundreds of years ago and has greatly expanded in the last 25 years due to improvements in technology, miniaturization, and the availability of rapid tests for a wide variety of analytes and microorganisms. Since the implementation of the Clinical Laboratory Improvement Amendments of 1988, the number of non-traditional testing sites that provide testing with minimal oversight through a Certificate of Waiver (CW) or Certificate of Provider-Performed Microscopy (PPM) has increased. Concerns have been expressed about some practices, and data have identified quality gaps in these sites where testing may be performed by personnel who do not have laboratory training or experience. The Centers for Disease Control and Prevention has developed free educational tools to promote regulatory compliance and good laboratory practices in CW and PPM sites. Uptake and positive reviews of these materials indicate their value as a resource to improve testing quality.

      2. Suppression of poxvirus replication by resveratrol
        Cao S, Realegeno S, Pant A, Satheshkumar PS, Yang Z.
        Front Microbiol. 2017 ;8:2196.
        Poxviruses continue to cause serious diseases even after eradication of the historically deadly infectious human disease, smallpox. Poxviruses are currently being developed as vaccine vectors and cancer therapeutic agents. Resveratrol is a natural polyphenol stilbenoid found in plants that has been shown to inhibit or enhance replication of a number of viruses, but the effect of resveratrol on poxvirus replication is unknown. In the present study, we found that resveratrol dramatically suppressed the replication of vaccinia virus (VACV), the prototypic member of poxviruses, in various cell types. Resveratrol also significantly reduced the replication of monkeypox virus, a zoonotic virus that is endemic in Western and Central Africa and causes human mortality. The inhibitory effect of resveratrol on poxviruses is independent of VACV N1 protein, a potential resveratrol binding target. Further experiments demonstrated that resveratrol had little effect on VACV early gene expression, while it suppressed VACV DNA synthesis, and subsequently post-replicative gene expression.

      3. Diagnostic assay development for poliovirus eradication
        Gerloff N, Sun H, Mandelbaum M, Maher C, Nix WA, Zaidi S, Shaukat S, Seakamela L, Nalavade UP, Sharma DK, Oberste MS, Vega E.
        J Clin Microbiol. 2017 Dec 6.
        With poliovirus eradication nearing, few pockets of active wild poliovirus (WPV) transmission remain in the world. Intratypic differentiation (ITD) plays a crucial part in laboratory surveillance as the molecular detection method that can identify and distinguish wild and vaccine-like polioviruses isolated from acute flaccid paralysis cases or environmental sources. The need to detect new variants of WPV serotype 1 (WPV1), and the containment of all serotype 2 polioviruses (PV2) in 2015 required changes to the previous version of the method. The ITD version 5.0 is a set of six real-time RT-PCR (rRT-PCR) assays that serve as accurate diagnostic tools to easily detect and differentiate PV serotypes and genotypes. We describe the creation and properties of quantitation standards, including 16 control RNA transcripts, and nine plaque-isolated viruses. All ITD rRT-PCR assays were validated using these standards and the limits of detection were determined for each assay. We designed and pilot-tested two new assays targeting recently circulating WPV1 genotypes and all PV2. The WPV1 assay specificity was 99.1%, and sensitivity 100%, and the PV2 assay had 97.7% specificity, and 92% sensitivity.Before proceeding to the next step in the global poliovirus eradication program we needed to gain a better understanding of the performance of the ITD 5.0 suite of molecular assays and their limits of detection and specificities. The findings and conclusions in this evaluation serve as building blocks for future development work.

      4. Integration among databases and data sets to support productive nanotechnology: Challenges and recommendations
        Karcher S, Willighagen EL, Rumble J, Ehrhart F, Evelo CT, Fritts M, Gaheen S, Harper SL, Hoover MD, Jeliazkova N, Lewinski N, Marchese Robinson RL, Mills KC, Mustad AP, Thomas DG, Tsiliki G, Hendren CO.
        NanoImpact. 2018 ;9:85-101.
        Many groups within the broad field of nanoinformatics are already developing data repositories and analytical tools driven by their individual organizational goals. Integrating these data resources across disciplines and with non-nanotechnology resources can support multiple objectives by enabling the reuse of the same information. Integration can also serve as the impetus for novel scientific discoveries by providing the framework to support deeper data analyses. This article discusses current data integration practices in nanoinformatics and in comparable mature fields, and nanotechnology-specific challenges impacting data integration. Based on results from a nanoinformatics-community-wide survey, recommendations for achieving integration of existing operational nanotechnology resources are presented. Nanotechnology-specific data integration challenges, if effectively resolved, can foster the application and validation of nanotechnology within and across disciplines. This paper is one of a series of articles by the Nanomaterial Data Curation Initiative that address data issues such as data curation workflows, data completeness and quality, curator responsibilities, and metadata.

      5. Mediation of the single-walled carbon nanotubes induced pulmonary fibrogenic response by osteopontin and TGF-beta1
        Khaliullin TO, Kisin ER, Murray AR, Yanamala N, Shurin MR, Gutkin DW, Fatkhutdinova LM, Kagan VE, Shvedova AA.
        Exp Lung Res. 2017 Oct;43(8):311-326.
        PURPOSE OF THE STUDY: A number of in vivo studies have shown that pulmonary exposure to carbon nanotubes (CNTs) may lead to an acute local inflammatory response, pulmonary fibrosis, and granulomatous lesions. Among the factors that play direct roles in initiation and progression of fibrotic processes are epithelial-mesenchymal transition and myofibroblasts recruitment/differentiation, both mediated by transforming growth factor-beta1 (TGF-beta1). Yet, other contributors to TGF-beta1 associated signaling, such as osteopontin (OPN) has not been fully investigated. MATERIALS AND METHODS: OPN-knockout female mice (OPN-KO) along with their wild-type (WT) counterparts were exposed to single-walled carbon nanotubes (SWCNT) (40 microg/mouse) via pharyngeal aspiration and fibrotic response was assessed 1, 7, and 28 days post-exposure. Simultaneously, RAW 264.7 and MLE-15 cells were treated with SWCNT (24 hours, 6 microg/cm(2) to 48 microg/cm(2)) or bleomycin (0.1 microg/ml) in the presence of OPN-blocking antibody or isotype control, and TGF-beta1 was measured in supernatants. RESULTS AND CONCLUSIONS: Diminished lactate dehydrogenase activity at all time points, along with less pronounced neutrophil influx 24 h post-exposure, were measured in broncho-alveolar lavage (BAL) of OPN-KO mice compared to WT. Pro-inflammatory cytokine release (IL-6, TNF-alpha, MCP-1) was reduced. A significant two-fold increase of TGF-beta1 was found in BAL of WT mice at 7 days, while TGF-beta1 levels in OPN-KO animals remained unaltered. Histological examination revealed marked decrease in granuloma formation and less collagen deposition in the lungs of OPN-KO mice compared to WT. RAW 264.7 but not MLE-15 cells exposed to SWCNT and bleomycin had significantly less TGF-beta1 released in the presence of OPN-blocking antibody. We believe that OPN is important in initiating the cellular mechanisms that produce an overall pathological response to SWCNT and it may act upstream of TGF-beta1. Further investigation to understand the mechanistic details of such interactions is critical to predict outcomes of pulmonary exposure to CNT.

      6. The emerging role of ASC in dendritic cell metabolism during Chlamydia infection
        McKeithen DN, Omosun YO, Ryans K, Mu J, Xie Z, Simoneaux T, Blas-Machado U, Eko FO, Black CM, Igietseme JU, He Q.
        PLoS One. 2017 ;12(12):e0188643.
        Chlamydia trachomatis is a bacterial agent that causes sexually transmitted infections worldwide. The regulatory functions of dendritic cells (DCs) play a major role in protective immunity against Chlamydia infections. Here, we investigated the role of ASC in DCs metabolism and the regulation of DCs activation and function during Chlamydia infection. Following Chlamydia stimulation, maturation and antigen presenting functions were impaired in ASC-/- DCs compared to wild type (WT) DCs, in addition, ASC deficiency induced a tolerant phenotype in Chlamydia stimulated DCs. Using real-time extracellular flux analysis, we showed that activation in Chlamydia stimulated WT DCs is associated with a metabolic change in which mitochondrial oxidative phosphorylation (OXPHOS) is inhibited and the cells become committed to utilizing glucose through aerobic glycolysis for differentiation and antigen presenting functions. However, in ASC-/- DCs Chlamydia-induced metabolic change was prevented and there was a significant effect on mitochondrial morphology. The mitochondria of Chlamydia stimulated ASC-/- DCs had disrupted cristae compared to the normal narrow pleomorphic cristae found in stimulated WT DCs. In conclusion, our results suggest that Chlamydia-mediated activation of DCs is associated with a metabolic transition in which OXPHOS is inhibited, thereby dedicating the DCs to aerobic glycolysis, while ASC deficiency disrupts DCs function by inhibiting the reprogramming of DCs metabolism within the mitochondria, from glycolysis to electron transport chain.

      7. Methylprednisolone acetate induces, and Delta7-dafachronic acid suppresses, Strongyloides stercoralis hyperinfection in NSG mice
        Patton JB, Bonne-Annee S, Deckman J, Hess JA, Torigian A, Nolan TJ, Wang Z, Kliewer SA, Durham AC, Lee JJ, Eberhard ML, Mangelsdorf DJ, Lok JB, Abraham D.
        Proc Natl Acad Sci U S A. 2017 Dec 4.
        Strongyloides stercoralis hyperinfection causes high mortality rates in humans, and, while hyperinfection can be induced by immunosuppressive glucocorticoids, the pathogenesis remains unknown. Since immunocompetent mice are resistant to infection with S. stercoralis, we hypothesized that NSG mice, which have a reduced innate immune response and lack adaptive immunity, would be susceptible to the infection and develop hyperinfection. Interestingly, despite the presence of large numbers of adult and first-stage larvae in S. stercoralis-infected NSG mice, no hyperinfection was observed even when the mice were treated with a monoclonal antibody to eliminate residual granulocyte activity. NSG mice were then infected with third-stage larvae and treated for 6 wk with methylprednisolone acetate (MPA), a synthetic glucocorticoid. MPA treatment of infected mice resulted in 50% mortality and caused a significant >10-fold increase in the number of parasitic female worms compared with infected untreated mice. In addition, autoinfective third-stage larvae, which initiate hyperinfection, were found in high numbers in MPA-treated, but not untreated, mice. Remarkably, treatment with Delta7-dafachronic acid, an agonist of the parasite nuclear receptor Ss-DAF-12, significantly reduced the worm burden in MPA-treated mice undergoing hyperinfection with S. stercoralis Overall, this study provides a useful mouse model for S. stercoralis autoinfection and suggests a therapeutic strategy for treating lethal hyperinfection.

      8. Characterization of engineered nanoparticles in commercially available spray disinfectant products advertised to contain colloidal silver
        Rogers KR, Navratilova J, Stefaniak A, Bowers L, Knepp AK, Al-Abed SR, Potter P, Gitipour A, Radwan I, Nelson C, Bradham KD.
        Sci Total Environ. 2018 01 Apr;619-620:1375-1384.
        Given the potential for human exposure to silver nanoparticles from spray disinfectants and dietary supplements, we characterized the silver-containing nanoparticles in 22 commercial products that advertised the use of silver or colloidal silver as the active ingredient. Characterization parameters included: total silver, fractionated silver (particulate and dissolved), primary particle size distribution, hydrodynamic diameter, particle number, and plasmon resonance absorbance. A high degree of variability between claimed and measured values for total silver was observed. Only 7 of the products showed total silver concentrations within 20% of their nominally reported values. In addition, significant variations in the relative percentages of particulate vs. soluble silver were also measured in many of these products reporting to be colloidal. Primary silver particle size distributions by transmission electron microscopy (TEM) showed two populations of particles – smaller particles (< 5 nm) and larger particles between 20 and 40 nm. Hydrodynamic diameter measurements using nanoparticle tracking analysis (NTA) correlated well with TEM analysis for the larger particles. Z-average (Z-Avg) values measured using dynamic light scattering (DLS); however, were typically larger than both NTA or TEM particle diameters. Plasmon resonance absorbance signatures (peak absorbance at around 400 nm indicative of metallic silver nanoparticles) were only noted in 4 of the 9 yellow-brown colored suspensions. Although the total silver concentrations were variable among products, ranging from 0.54 mg/L to 960 mg/L, silver containing nanoparticles were identified in all of the product suspensions by TEM.

    • Maternal and Child Health
      1. Importance: In 2011, critical congenital heart disease was added to the US Recommended Uniform Screening Panel for newborns, but whether state implementation of screening policies has been associated with infant death rates is unknown. Objective: To assess whether there was an association between implementation of state newborn screening policies for critical congenital heart disease and infant death rates. Design, Setting, and Participants: Observational study with group-level analyses. A difference-in-differences analysis was conducted using the National Center for Health Statistics’ period linked birth/infant death data set files for 2007-2013 for 26546503 US births through June 30, 2013, aggregated by month and state of birth. Exposures: State policies were classified as mandatory or nonmandatory (including voluntary policies and mandates that were not yet implemented). As of June 1, 2013, 8 states had implemented mandatory screening policies, 5 states had voluntary screening policies, and 9 states had adopted but not yet implemented mandates. Main Outcomes and Measures: Numbers of early infant deaths (between 24 hours and 6 months of age) coded for critical congenital heart disease or other/unspecified congenital cardiac causes for each state-month birth cohort. Results: Between 2007 and 2013, there were 2734 deaths due to critical congenital heart disease and 3967 deaths due to other/unspecified causes. Critical congenital heart disease death rates in states with mandatory screening policies were 8.0 (95% CI, 5.4-10.6) per 100000 births (n = 37) in 2007 and 6.4 (95% CI, 2.9-9.9) per 100000 births (n = 13) in 2013 (for births by the end of July); for other/unspecified cardiac causes, death rates were 11.7 (95% CI, 8.6-14.8) per 100000 births in 2007 (n = 54) and 10.3 (95% CI, 5.9-14.8) per 100000 births (n = 21) in 2013. Early infant deaths from critical congenital heart disease through December 31, 2013, decreased by 33.4% (95% CI, 10.6%-50.3%), with an absolute decline of 3.9 (95% CI, 3.6-4.1) deaths per 100000 births after states implemented mandatory screening compared with prior periods and states without screening policies. Early infant deaths from other/unspecified cardiac causes declined by 21.4% (95% CI, 6.9%-33.7%), with an absolute decline of 3.5 (95% CI, 3.2-3.8) deaths per 100000 births. No significant decrease was associated with nonmandatory screening policies. Conclusions and Relevance: Statewide implementation of mandatory policies for newborn screening for critical congenital heart disease was associated with a significant decrease in infant cardiac deaths between 2007 and 2013 compared with states without these policies.

      2. Disparities in hospital-reported breast milk use in neonatal intensive care units – United States, 2015
        Boundy EO, Perrine CG, Nelson JM, Hamner HC.
        MMWR Morb Mortal Wkly Rep. 2017 Dec 8;66(48):1313-1317.
        Breast milk is the recommended nutrition for infants. For preterm infants, when mother’s milk is not available, pasteurized donor milk is recommended (1). Non-Hispanic black mothers are at increased risk for having a preterm birth and for not breastfeeding (2,3); however, it is not known whether demographic disparities exist in the use of breast milk in neonatal intensive care units (NICUs). Data from CDC’s 2015 Maternity Practices in Infant Nutrition and Care (mPINC) survey, which does not collect patient-level demographics, were linked to the 2011-2015 U.S. Census Bureau’s American Community Survey (ACS)* to examine use of breast milk in NICUs based on demographic makeup of the hospital’s postal code area. Among U.S. hospitals with a NICU, the use of mother’s own milk and donor milk were examined by the percentage of non-Hispanic black (black) residents in the hospital postal code area, categorized as being above or below the national average (12.3%). In postal codes with >12.3% black residents, 48.9% of hospitals reported using mothers’ own milk in >/=75% of infants in the NICU, and 38.0% reported not using donor milk, compared with 63.8% and 29.6% of hospitals, respectively, in postal codes with </=12.3% black residents. Further investigation is needed to understand variations in breast milk use in NICUs. Targeted efforts to increase breast milk use in hospitals located in postal codes where the percentage of black mothers is above the national average might help ensure more equitable access to breast milk for preterm and other high-risk infants.

      3. OBJECTIVES: In 2011, the American Academy of Pediatrics updated its guidelines for the diagnosis and treatment of children with attention-deficit/hyperactivity disorder (ADHD) to recommend that clinicians refer parents of preschoolers (aged 4-5) for training in behavior therapy and subsequently treat with medication if behavior therapy fails to sufficiently improve functioning. Data available from just before the release of the guidelines suggest that fewer than half of preschoolers with ADHD received behavior therapy and about half received medication. About half of those who received medication also received behavior therapy. Prior authorization policies for ADHD medication may guide physicians toward recommended behavior therapy. Characterizing existing prior authorization policies is an important step toward evaluating the impact of these policies on treatment patterns. We inventoried existing prior authorization policies and characterized policy components to inform future evaluation efforts. METHODS: A 50-state legal assessment characterized ADHD prior authorization policies in state Medicaid programs. We designed a database to capture data on policy characteristics and authorization criteria, including data on age restrictions and fail-first behavior therapy requirements. RESULTS: In 2015, 27 states had Medicaid policies that prevented approval of pediatric ADHD medication payment without additional provider involvement. Seven states required that prescribers indicate whether nonmedication treatments were considered before Medicaid payment for ADHD medication could be approved. CONCLUSION: Medicaid policies on ADHD medication treatment are diverse; some policies are tied to the diagnosis and treatment guidelines of the American Academy of Pediatrics. Evaluations are needed to determine if certain policy interventions guide families toward the use of behavior therapy as the first-line ADHD treatment for young children.

      4. Comparison of state risk-appropriate neonatal care policies with the 2012 AAP policy statement
        Kroelinger CD, Okoroh EM, Goodman DA, Lasswell SM, Barfield WD.
        J Perinatol. 2017 Dec 5.
        OBJECTIVE: Compare state policies with standards outlined in the 2012 AAP Policy Statement on Levels of Neonatal Care. STUDY DESIGN: Systematic, web-based review of publicly available policies on levels of care in all states in 2014. Infant risk information, equipment capabilities, and specialty staffing were abstracted from published rules, statutes, and regulations. RESULT: Twenty-two states had a policy on regionalized perinatal care. State policies vary in consistency with the AAP Policy, with 60% of states including standards consistent with Level I criteria, 48% Level II, 14% Level III, and one state with Level IV. Ventilation capability standards are highly consistent (66-100%), followed by imaging capability standards (50-90%). Policy language on specialty staffing (44-68%), and subspecialty staffing (39-50%) are moderately consistent. CONCLUSION: State policies vary in consistency, a potentially significant barrier to monitoring, regulation, uniform care provision and measurement, and reporting of national-level measures on risk-appropriate care.

      5. Birth defect survival for Hispanic subgroups
        Lopez KN, Nembhard WN, Wang Y, Liu G, Kucik JE, Copeland G, Gilboa SM, Kirby RS, Canfield M.
        Birth Defects Res. 2017 Dec 1.
        BACKGROUND: Previous studies demonstrate that infant and childhood mortality differ among children with birth defects by maternal race/ethnicity, but limited mortality information is published for Hispanic ethnic subgroups. METHODS: We performed a retrospective cohort study using data for children with birth defects born to Hispanic mothers during 1999-2007 from 12 population-based state birth defects surveillance programs. Deaths were ascertained through multiple sources. Survival probabilities were estimated by the Kaplan-Meier method. Cox proportional hazards regression was used to examine the effect of clinical and demographic factors on mortality risk. RESULTS: Among 28,497 Hispanic infants and children with major birth defects, 1-year survival was highest for infants born to Cuban mothers at 94.6% (95% confidence intervals [CI] 92.7-96.0) and the lowest for Mexicans at 90.2% (95% CI 89.7-90.6; p < .0001). For children aged up to 8 years, survival remained highest for Cuban Americans at 94.1% (95% CI 91.8-95.7) and lowest for Mexican Americans at 89.2% (95% CI 88.7-89.7; p = .0002). In the multivariable analysis using non-Hispanic White as the reference group, only infants and children born to Mexican mothers were noted to have a higher risk of mortality for cardiovascular defects. CONCLUSIONS: This analysis provides a better understanding of survival and mortality for Hispanic infants and children with selected birth defects. The differences found in survival, particularly the highest survival rates for Cuban American children and lowest for Mexican American children with birth defects, underscores the importance of assessing Hispanic ethnic subgroups, as differences among subgroups appear to exist.

      6. Accuracy of birth certificate head circumference measurements: Massachusetts, 2012-2013
        Somerville NJ, Chen X, Heinke D, Stone SL, Higgins C, Manning SE, Pagnano S, Yazdy MM, Anderka M.
        Birth Defects Res. 2017 Dec 1.
        BACKGROUND: Zika virus has recently emerged as a novel cause of microcephaly. CDC has asked states to rapidly ascertain and report cases of Zika-linked birth defects, including microcephaly. Massachusetts added head circumference to its birth certificate (BC) in 2011. The accuracy of head circumference measurements from state vital records data has not been reported. METHODS: We sought to assess the accuracy of Massachusetts BC head circumference measurements by comparing them to measurements for 2,217 infants born during 2012-2013 captured in the Massachusetts Birth Defects Monitoring Program (BDMP) data system. BDMP contains information abstracted directly from infant medical records and served as the true head circumference value (i.e., gold standard) for analysis. We calculated the proportion of head circumference measurements in agreement between the BC and BDMP data. We assigned growth chart head circumference percentile categories to each BC and BDMP measurement, and calculated the sensitivity and specificity of BC-based categories to predict BDMP-based categories. RESULTS: No difference was found in head circumference measurements between the two sources in 77.9% (n = 1,727) of study infants. The sensitivity of BC-based head circumference percentile categories ranged from 85.6% (<3rd percentile) to 92.7% (>/=90th percentile) and the specificity ranged from 97.6% (>/=90th percentile) to 99.3% (<3rd percentile). CONCLUSIONS: BC head circumference measurements agreed with those abstracted from the medical chart the majority of the time. Head circumference measurements on the BC were more specific than sensitive across all standardized growth chart percentile categories.

      7. Challenges and opportunities in identifying, reviewing, and preventing maternal deaths
        St Pierre A, Zaharatos J, Goodman D, Callaghan WM.
        Obstet Gynecol. 2017 Dec 4.
        Despite many efforts at the state, city, and national levels over the past 70 years, a nationwide consensus on how best to identify, review, and prevent maternal deaths remains challenging. We present a brief history of maternal death surveillance in the United States and compare the three systems of national surveillance that exist today: the National Vital Statistics System, the Pregnancy Mortality Surveillance System, and maternal mortality review committees. We discuss strategies to address the perennial challenges of shared terminology and accurate, comparable data among maternal mortality review committees. Finally, we propose that with the opportunity presented by a systematized shared data system that can accurately account for all maternal deaths, state and local-level maternal mortality review committees could become the gold standard for understanding the true burden of maternal mortality at the national level.

    • Military Medicine and Health
      1. Advancing the role of neuroimmunity and genetic susceptibility in Gulf War Illness
        O’Callaghan JP, Michalovicz LT, Miller JV, Kelly KA.
        EBioMedicine. 2017 .

        [No abstract]

    • Mining
      1. Float coal dust, generated by mining operations, is distributed throughout mine airways by ventilating air designed to purge gases and respirable dust. Float coal dust poses an explosion hazard in the event of a methane ignition. Current regulation requires the application of inert rock dust in areas subjected to float coal dust in order to mitigate the hazard. An alternate method using water sprays, which have been effective in controlling respirable dust hazards, has been proposed as a way to control float coal dust generated on longwall faces. However, the knockdown efficiency of the proposed water sprays on float coal dust needs to be verified. This study used gravimetric isokinetic Institute of Occupational Medicine (IOM) samplers alongside a real-time aerosol monitor (Cloud Aerosol Spectrometer with polarization; CAS-POL) to study the effects of spray type, operating pressure, and spray orientation on knockdown efficiencies for seven different water sprays. Because the CAS-POL has not been used to study mining dust, the CAS-POL measurements were validated with respect to the IOM samplers. This study found that the CAS-POL was able to resolve the same trends measured by the IOM samplers, while providing additional knockdown information for specific particle size ranges and locations in the test area. In addition, the CAS-POL data was not prone to the same process errors, which may occur due to the handling of the IOM filter media, and was able to provide a faster analysis of the data after testing. This study also determined that pressure was the leading design criteria influencing spray knockdown efficiency, with spray type also having some effect and orientation having little to no effect. The results of this study will be used to design future full-scale float coal dust capture tests involving multiple sprays, which will be evaluated using the CAS-POL.

      2. Determination of velocity correction factors for real-time air velocity monitoring in underground mines
        Zhou L, Yuan L, Thomas R, Iannacchione A.
        Int J Coal Sci Technol. 2017 ;2017.
        When there are installations of air velocity sensors in the mining industry for real-time airflow monitoring, a problem exists with how the monitored air velocity at a fixed location corresponds to the average air velocity, which is used to determine the volume flow rate of air in an entry with the cross-sectional area. Correction factors have been practically employed to convert a measured centerline air velocity to the average air velocity. However, studies on the recommended correction factors of the sensor-measured air velocity to the average air velocity at cross sections are still lacking. A comprehensive airflow measurement was made at the Safety Research Coal Mine, Bruceton, PA, using three measuring methods including single-point reading, moving traverse, and fixed-point traverse. The air velocity distribution at each measuring station was analyzed using an air velocity contour map generated with Surfer((R)). The correction factors at each measuring station for both the centerline and the sensor location were calculated and are discussed.

    • Nutritional Sciences
      1. Point-of-use fortification of foods with micronutrient powders containing iron in children of preschool and school-age
        De-Regil LM, Jefferds ME, Pena-Rosas JP.
        Cochrane Database Syst Rev. 2017 Nov 23;11:Cd009666.
        BACKGROUND: Approximately 600 million children of preschool and school age are anaemic worldwide. It is estimated that at least half of the cases are due to iron deficiency. Point-of-use fortification of foods with micronutrient powders (MNP) has been proposed as a feasible intervention to prevent and treat anaemia. It refers to the addition of iron alone or in combination with other vitamins and minerals in powder form, to energy-containing foods (excluding beverages) at home or in any other place where meals are to be consumed. MNPs can be added to foods either during or after cooking or immediately before consumption without the explicit purpose of improving the flavour or colour. OBJECTIVES: To assess the effects of point-of-use fortification of foods with iron-containing MNP alone, or in combination with other vitamins and minerals on nutrition, health and development among children at preschool (24 to 59 months) and school (five to 12 years) age, compared with no intervention, a placebo or iron-containing supplements. SEARCH METHODS: In December 2016, we searched the following databases: CENTRAL, MEDLINE, Embase, BIOSIS, Science Citation Index, Social Science Citation Index, CINAHL, LILACS, IBECS, Popline and SciELO. We also searched two trials registers in April 2017, and contacted relevant organisations to identify ongoing and unpublished trials. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs trials with either individual or cluster randomisation. Participants were children aged between 24 months and 12 years at the time of intervention. For trials with children outside this age range, we included studies where we were able to disaggregate the data for children aged 24 months to 12 years, or when more than half of the participants were within the requisite age range. We included trials with apparently healthy children; however, we included studies carried out in settings where anaemia and iron deficiency are prevalent, and thus participants may have had these conditions at baseline. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the eligibility of trials against the inclusion criteria, extracted data from included trials, assessed the risk of bias of the included trials and graded the quality of the evidence. MAIN RESULTS: We included 13 studies involving 5810 participants from Latin America, Africa and Asia. We excluded 38 studies and identified six ongoing/unpublished trials. All trials compared the provision of MNP for point-of-use fortification with no intervention or placebo. No trials compared the effects of MNP versus iron-containing supplements (as drops, tablets or syrup).The sample sizes in the included trials ranged from 90 to 2193 participants. Six trials included participants younger than 59 months of age only, four included only children aged 60 months or older, and three trials included children both younger and older than 59 months of age.MNPs contained from two to 18 vitamins and minerals. The iron doses varied from 2.5 mg to 30 mg of elemental iron. Four trials reported giving 10 mg of elemental iron as sodium iron ethylenediaminetetraacetic acid (NaFeEDTA), chelated ferrous sulphate or microencapsulated ferrous fumarate. Three trials gave 12.5 mg of elemental iron as microencapsulated ferrous fumarate. Three trials gave 2.5 mg or 2.86 mg of elemental iron as NaFeEDTA. One trial gave 30 mg and one trial provided 14 mg of elemental iron as microencapsulated ferrous fumarate, while one trial gave 28 mg of iron as ferrous glycine phosphate.In comparison with receiving no intervention or a placebo, children receiving iron-containing MNP for point-of-use fortification of foods had lower risk of anaemia prevalence ratio (PR) 0.66, 95% confidence interval (CI) 0.49 to 0.88, 10 trials, 2448 children; moderate-quality evidence) and iron deficiency (PR 0.35, 95% CI 0.27 to 0.47, 5 trials, 1364 children; moderate-quality evidence) and had higher haemoglobin (mean difference (MD) 3.37 g/L, 95% CI 0.94 to 5.80, 11 trials, 2746 children; low-quality evidence).Only one trial with 115 children reported on all-cause mortality (zero cases; low-quality evidence). There was no effect on diarrhoea (risk ratio (RR) 0.97, 95% CI 0.53 to 1.78, 2 trials, 366 children; low-quality evidence). AUTHORS’ CONCLUSIONS: Point-of-use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool- and school-age children. However, information on mortality, morbidity, developmental outcomes and adverse effects is still scarce.

      2. Early outcomes of state public health actions’ school nutrition strategies
        Pitt Barnes S, Skelton-Wilson S, Cooper A, Merlo C, Lee S.
        Prev Chronic Dis. 2017 Dec 7;14:E128.
        INTRODUCTION: Since 2013, the State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health (State Public Health Actions) program has been implemented to support and reinforce healthy choices and healthy behaviors among the US population. The Centers for Disease Control and Prevention’s Division of Population Health’s School Health Branch has been a critical component, ensuring that state health departments support schools in adopting nutrition standards and creating a supportive nutrition environment. The objective of this article was to describe early outcomes of the school nutrition strategies of State Public Health Actions. METHODS: We examined the extent of progress for short-term performance measures and for school nutrition evaluation questions, using data secured from 51 grantees through the performance measures database and state evaluation reports. RESULTS: During the first 4 years of the cooperative agreement, grantees demonstrated significant progress compared with year 2 for school nutrition performance measures. Collectively, grantees provided professional development and technical assistance to staff in 7,672 local education agencies and reached more than 29 million students. Success was also noted for several nutrition practices in schools. CONCLUSION: These early outcomes suggest that State Public Health Actions has had a positive impact on the nutrition environment of US schools. Systematically addressing areas for improvement could further expand the reach of these efforts during the remainder of the cooperative agreement.

    • Occupational Safety and Health
      1. Medical monitoring for occupational asthma among toluene diisocyanate production workers in the United States
        Cassidy LD, Doney B, Wang ML, Kurth L, Conner PR, Collins JJ, Carson M, Molenaar D, Redlich CA, Storey E.
        J Occup Environ Med. 2017 Dec;59 Suppl 12:S13-s21.
        OBJECTIVE: The aim of this study was to describe a study of medical monitoring methods and lessons learned in detecting health outcomes in U.S. plants producing toluene diisocyanate (TDI). METHODS: A multidisciplinary team implemented a medical and environmental monitoring program in three TDI plants. RESULTS: Of 269 eligible workers, 197 (73%) participated and 42 (21%) met symptom and/or lung function criteria that would trigger evaluation for possible asthma over 5 years of data collection. Subsequent evaluation was delayed for most, and a web-based data collection system improved timeliness. CONCLUSION: Medical monitoring of TDI workers identified workers triggering further assessment per study protocol. Systems and/or personnel to ensure rapid follow-up are needed to highlight when triggering events represent potential cases of asthma needing further evaluation. Implementation of a research protocol requires resources and oversight beyond an occupational health program.

      2. Inflammatory proteins in nasal lavage of workers exposed to occupational agents
        Castano R, Yucesoy B, Johnson VJ, Castellanos L, Cartier A.
        Clin Exp Allergy. 2017 Dec;47(12):1566-1573.
        BACKGROUND: Low-molecular-weight (LMW) and high-molecular-weight (HMW) agents have been recognized as causes of occupational rhinitis (OR). Immunological mechanisms underlying OR differ according to the type of exposure. While HMW agents act mainly through IgE-mediated mechanisms, LMW agents appear to act through both immunological and non-immunological mechanisms. OBJECTIVE: The objective of this study was to identify potential differences in the upper airways inflammatory response after exposure to LMW and HMW agents by specific inhalation challenge test (SIC). METHODS: Nasal lavage (NL) samples from 20 subjects who were exposed to HMW (n = 10, Group I) and LMW (n = 10, Group II) at their workplaces were collected after SIC with control and specific occupational agents. These samples were analysed for 47 inflammatory markers using multiplex bead technology. RESULTS: After exposure to specific agent, Group I exhibited higher concentrations of the following proteins compared to Group II: fibrinogen (median (interquartile range) Group I: 0.09 (0.00) mug/mL, Group II: 0.04 (0.05) mug/mL, P = .05); haptoglobin (Group I: 0.86 (0.01) mug/mL, Group II: 0.14 (0.20) mug/mL, P = .02); vascular cell adhesion molecule-1 (VCAM-1) (Group I: 0.34 (0.67) ng/mL, Group II: 0.11 (0.11) ng/mL, P = .01); vascular endothelial growth factor (VEGF) (Group I: 157.0 (154.0) pg/mL, Group II: 98.0 (20.25) pg/mL, P = .01); and vitamin D (VDBP) (Group I: 0.06 (0.13) mug/mL, Group II: 0.03 (0.03) mug/mL, P = .04). No statistically significant differences in proteins profiles were observed between the groups after exposure to control agent. Also, subjects exposed to HMW agents showed a significant increase in NL levels of C-reactive protein compared to control-day exposure. CONCLUSIONS AND CLINICAL RELEVANCE: Exposure to HMW and LMW agents by SIC induced a differential nasal airway response including acute-phase reactants proteins (fibrinogen, haptoglobin and CRP), cell adhesion molecules (VCAM-1), endothelial growth factors (VEGF) and VDBP.

      3. Background: According to the US Bureau of Labor Statistics, musculoskeletal disorders (MSDs) accounted for 32% of all nonfatal injury and illness cases in 2014 among full-time workers. Our objective was to review and summarize the evidence linking occupational exposures to vibration and awkward posture with MSDs of the shoulder and neck. Methods: A literature search was conducted using the terms musculoskeletal disorders, vibration, and awkward posture. All types of observational epidemiologic studies, with the exception of case reports, published during 1998-2015 were included. Databases searched were MEDLINE (Ovid), Embase (Ovid), Scopus, Ergonomic Abstracts, NIOSHTIC-2, and Health and Safety Science Abstracts. Results: Occupational exposures to whole-body or hand-arm vibration were significantly associated with or resulted in MSDs of the shoulder and neck. Awkward postures while working were also associated with MSDs in these locations. These findings were consistent across study designs, populations, and countries. Conclusion: Occupational exposure to vibration and awkward posture are associated with shoulder and neck MSDs. Longitudinal studies are required to elucidate the mechanisms responsible for these associations, and intervention studies are warranted.

      4. Incidence of occupational asthma and exposure to toluene diisocyanate in the United States toluene diisocyanate production industry
        Collins JJ, Anteau S, Conner PR, Cassidy LD, Doney B, Wang ML, Kurth L, Carson M, Molenaar D, Redlich CA, Storey E.
        J Occup Environ Med. 2017 Dec;59 Suppl 12:S22-s27.
        OBJECTIVE: This study examines asthma risk in facilities producing toluene diisocyanate (TDI). METHODS: A total of 197 workers were monitored from 2007 to 2012. TDI air concentrations were used to estimate exposures. RESULTS: The incidence of cases consistent with TDI-induced asthma was 0.009 per person-years (seven cases) or consistent with TDI-induced asthma or asthma indeterminate regarding work-relatedness was 0.012 (nine cases). Increased risk of cases consistent with TDI asthma was observed for cumulative (odds ratio [OR] = 2.08, 95% confidence interval [CI] 1.07 to 4.05) per logarithm parts per billion-years and peak TDI exposures (OR = 1.18, 95% CI 1.06 to 1.32) (logarithm parts per billion). There was a weak association with cumulative and peak exposures for decline of short-term forced expiratory volume in one second (FEV1). Asthma symptoms were associated with workers noticing an odor of TDI (OR 6.02; 95% CI 1.36 to 26.68). CONCLUSIONS: There is evidence that cumulative and peak exposures are associated with TDI-induced asthma.

      5. Differences in safety training among smaller and larger construction firms with non-native workers: Evidence of overlapping vulnerabilities
        Cunningham TR, Guerin RJ, Keller BM, Flynn MA, Salgado C, Hudson D.
        Safety Science. 2018 March;103:62-69.
        Collaborative efforts between the National Institute for Occupational Safety and Health (NIOSH) and the American Society of Safety Engineers (ASSE) led to a report focusing on overlapping occupational vulnerabilities, specifically small construction businesses employing young, non-native workers. Following the report, an online survey was conducted by ASSE with construction business representatives focusing on training experiences of non-native workers. Results were grouped by business size (50 or fewer employees or more than 50 employees). Smaller businesses were less likely to employ a supervisor who speaks the same language as immigrant workers (p <.001). Non-native workers in small businesses received fewer hours of both initial safety training (p =.005) and monthly ongoing safety training (p =.042). Immigrant workers in smaller businesses were less likely to receive every type of safety training identified in the survey (including pre-work safety orientation [p <.001], job-specific training [p <.001], OSHA 10-hour training [p =.001], and federal/state required training [p <.001]). The results highlight some of the challenges a vulnerable worker population faces in a small business, and can be used to better focus intervention efforts. Among businesses represented in this sample, there are deficits in the amount, frequency, and format of workplace safety and health training provided to non-native workers in smaller construction businesses compared to those in larger businesses. The types of training conducted for non-native workers in small business were less likely to take into account the language and literacy issues faced by these workers. The findings suggest the need for a targeted approach in providing occupational safety and health training to non-native workers employed by smaller construction businesses.

      6. Methodological, political and legal issues in the assessment of the effects of nanotechnology on human health
        Guseva Canu I, Schulte PA, Riediker M, Fatkhutdinova L, Bergamaschi E.
        J Epidemiol Community Health. 2017 Dec 4.
        Engineered nanomaterials (ENMs) raise questions among the scientific community and public health authorities about their potential risks to human health. Studying a prospective cohort of workers exposed to ENMs would be considered the gold standard for identifying potential health effects of nanotechnology and confirming the ‘no effect’ levels derived from cellular and animal models. However, because only small, cross-sectional studies have been conducted in the past 5 years, questions remain about the health risks of ENMs. This essay addresses the scientific, methodological, political and regulatory issues that make epidemiological research in nanotechnology-exposed communities particularly complex. Scientific challenges include the array of physicochemical parameters and ENM production conditions, the lack of universally accepted definitions of ENMs and nanotechnology workers, and the lack of information about modes of action, target organs and likely dose-response functions of ENMs. Standardisation of data collection and harmonisation of research protocols are needed to eliminate misclassification of exposures and health effects. Forming ENM worker cohorts from a combination of smaller cohorts and overcoming selection bias are also challenges. National or international registries for monitoring the exposures and health of ENM workers would be helpful for epidemiological studies, but the creation of such a registry and ENM worker cohorts will require political support and dedicated funding at the national and international levels. Public authorities and health agencies should consider carrying out an ENM awareness campaign to educate and engage all stakeholders and concerned communities in discussion of such a project.

      7. OBJECTIVE: The objective of this study was to characterize workplace toluene diisocyanate (TDI) exposures using standardized industrial hygiene exposure assessment procedures for use in a prospective epidemiologic study of occupational asthma. METHODS: Over 2300 representative routine full shift time-weighted average (TWA) and short-term high potential exposure tasks (HPETs) air samples in groups across three TDI plants were collected over a nearly 7-year period. RESULTS: Data-derived similar exposure groups (SuperSEGs) were developed across the plants based on TWA sampling using cluster analysis. Individual cumulative exposure estimates were developed on the basis of the SuperSEGs. CONCLUSION: Workplace TWA exposures to TDI were adequately characterized quantitatively, but HPET exposures were adequately characterized only by qualitative measures. The mean TWA exposure was 0.65 parts per billion for 1594 routine samples. These TWA and HPET exposures can be used to support exposure-response analyses.

      8. Longitudinal and cross-sectional analyses of lung function in toluene diisocyanate production workers
        Wang ML, Storey E, Cassidy LD, Doney B, Conner PR, Collins JJ, Carson M, Molenaar D.
        J Occup Environ Med. 2017 Dec;59 Suppl 12:S28-s35.
        OBJECTIVE: The aim of this study was to investigate lung function among toluene diisocyanate (TDI) production workers. METHODS: One hundred ninety-seven U.S workers performed spirometry from 2006 through 2012. Results were compared within the study cohort and with U.S. population measures. A mixed-effects model assessed factors affecting repeated forced expiratory volume in 1 second (FEV1) measurements. RESULTS: The cohort’s mean FEV1 and forced vital capacity (FVC) percent reference values, although greater than 90%, were significantly lower and the prevalence of abnormal spirometry (predominantly restrictive pattern) was significantly higher than in the U.S. POPULATION: Differences in lung function among workers with higher cumulative TDI exposure were in the direction of an exposure effect, but not significant. CONCLUSION: We found little evidence of an adverse effect of TDI exposure on longitudinal spirometry in these workers. The association between TDI exposure and the increasing prevalence of a restrictive pattern needs further exploration.

    • Occupational Safety and Health – Mining
      1. Evaluating hearing loss risks in the mining industry through MSHA citations
        Sun K, Azman AS.
        J Occup Environ Hyg. 2017 Dec 4:0.
        A new noise regulation for the mining industry became effective in 2000, providing a consistent regulatory requirement for both coal and non-coal mining divisions. The new rule required mines to implement hearing conservation programs, including a system of continuous noise monitoring, provision of hearing protection devices, audiometric testing, hearing loss training, and record keeping. The goal of this study was to assess hearing conservation program compliance, and excessive noise exposure and hearing loss risks for both coal and non-coal mining divisions through evaluating MSHA citations. We analyzed 13,446 MSHA citations from 2000 to 2014 pertinent to 30 CFR Part 62. Descriptive statistics were generated and comparisons were made among mines of different commodities. In addition, one-way ANOVA on ranks was conducted to estimate the correlation between excess risks and establishment size. Results showed that 25.6% of coal mines and 14.7% of non-coal mines were cited at least once during this period of time. Larger numbers of noncompliance were seen in stone, sand and gravel mines (SSG). Results also suggested inadequate efforts in both audiometric testing and minimizing risk after excessive noise exposure. Finally, establishment size of mine was correlated with the increasing risk of noncompliance. We anticipate that this study can guide resource allocation for preventing noise-induced hearing loss, and help improve risk management in mining.

    • Parasitic Diseases
      1. Progress toward global eradication of dracunculiasis, January 2016-June 2017
        Hopkins DR, Ruiz-Tiben E, Eberhard ML, Roy SL, Weiss AJ.
        MMWR Morb Mortal Wkly Rep. 2017 Dec 8;66(48):1327-1331.
        Dracunculiasis (Guinea worm disease) is caused by Dracunculus medinensis, a parasitic worm. Approximately 1 year after a person acquires infection from contaminated drinking water, the worm emerges through the skin, usually on a lower limb (1). Pain and secondary bacterial infection can cause temporary or permanent disability that disrupts work and schooling. The campaign to eradicate dracunculiasis worldwide began in 1980 at CDC. In 1986, the World Health Assembly called for dracunculiasis elimination,* and the global Guinea Worm Eradication Program, led by the Carter Center and supported by the World Health Organization (WHO), United Nations Children’s Fund, CDC, and other partners, began assisting ministries of health in countries with endemic dracunculiasis. In 1986, an estimated 3.5 million cases occurred each year in 20 countries in Africa and Asia (2). Since then, although the goal of eradicating dracunculiasis has not been achieved, considerable progress has been made. Compared with the 1986 estimate, the annual number of reported cases in 2016 has declined by >99%, and cases are confined to three countries with endemic disease. This report updates published (3-4) and unpublished surveillance data reported by ministries of health and describes progress toward dracunculiasis eradication during January 2016-June 2017. In 2016, a total of 25 cases were reported from three countries (Chad [16], South Sudan [six], Ethiopia [three]), compared with 22 cases reported from the same three countries and Mali in 2015 (Table 1). The 14% increase in cases from 2015 to 2016 was offset by the 25% reduction in number of countries with indigenous cases. During the first 6 months of 2017, the overall number of cases declined to eight, all in Chad, from 10 cases in three countries (Chad [four], South Sudan [four] and Ethiopia [two]) during the same period of 2016. Continued active surveillance, aggressive detection, and appropriate management of cases are essential eradication program components; however, epidemiologic challenges, civil unrest, and insecurity pose potential barriers to eradication.

    • Physical Activity
      1. [No abstract]

      2. Physical activity as a vital sign: A systematic review
        Golightly YM, Allen KD, Ambrose KR, Stiller JL, Evenson KR, Voisin C, Hootman JM, Callahan LF.
        Prev Chronic Dis. 2017 Nov 30;14:E123.
        INTRODUCTION: Physical activity (PA) is strongly endorsed for managing chronic conditions, and a vital sign tool (indicator of general physical condition) could alert providers of inadequate PA to prompt counseling or referral. This systematic review examined the use, definitions, psychometric properties, and outcomes of brief PA instruments as vital sign measures, with attention primarily to studies focused on arthritis. METHODS: Electronic databases were searched for English-language literature from 1985 through 2016 using the terms PA, exercise, vital sign, exercise referral scheme, and exercise counseling. Of the 838 articles identified for title and abstract review, 9 articles qualified for full text review and data extraction. RESULTS: Five brief PA measures were identified: Exercise Vital Sign (EVS), Physical Activity Vital Sign (PAVS), Speedy Nutrition and Physical Activity Assessment (SNAP), General Practice Physical Activity Questionnaire (GPPAQ), and Stanford Brief Activity Survey (SBAS). Studies focusing on arthritis were not found. Over 1.5 years of using EVS in a large hospital system, improvements occurred in relative weight loss among overweight patients and reduction in glycosylated hemoglobin among diabetic patients. On PAVS, moderate physical activity of 5 or more days per week versus fewer than 5 days per week was associated with a lower body mass index (-2.90 kg/m(2)). Compared with accelerometer-defined physical activity, EVS was weakly correlated (r = 0.27), had low sensitivity (27%-59%), and high specificity (74%-89%); SNAP showed weak agreement (kappa = 0.12); GPPAQ had moderate sensitivity (46%) and specificity (50%), and SBAS was weakly correlated (r = 0.10-0.28), had poor to moderate sensitivity (18%-67%), and had moderate specificity (58%-79%). CONCLUSION: Few studies have examined a brief physical activity tool as a vital sign measure. Initial investigations suggest the promise of these simple and quick assessment tools, and research is needed to test the effects of their use on chronic disease outcomes.

    • Reproductive Health
      1. Attitudes to sexual health in the United States: results from a national survey of youth aged 15-25 years
        Hogben M, Harper C, Habel MA, Brookmeyer K, Friedman A.
        Sex Health. 2017 Nov;14(6):540-547.
        Background Several common global definitions of sexual health refer to physical, emotional and social well-being, with respect to sexuality, and also to the need for this well-being to be reflected for all individuals in relationships. How well sexual health definitions fit US youths’ attitudes to sexual health, and associations between these attitudes, sexual behaviours and sexual health care were assessed. METHODS: In total, 4017 youth aged between 15 and 25 years via an online survey panel, weighted to be representative of the US population, were surveyed. Respondents reported their attitudes towards seven dimensions of sexual health that we abstracted from existing global definitions (emotional fulfillment, social connectedness, spirituality, overall pleasure, physical intimacy, mental fulfillment, reciprocal benefits). Respondents also reported on sexual health-related discussions with partners, sexual behaviours, and their use of sexual health care. Outcomes through weighted frequency estimates and ordinal regression models were reported. RESULTS: Youth generally construed all seven dimensions as important to sexual health, with the emotional dimension rated most favourably. Attitudes to the dimensions of overall pleasure, physical intimacy and spirituality were most consistently related to sexual health discussions and behaviours. The behaviours most consistently related to sexual health attitudes were going for a sexual health check-up, discussing birth control/pregnancy and discussing risk before sex without a condom. CONCLUSIONS: Youth construal of sexual health fits well with global sexual health definitions. Attitudes to dimensions of sexual health were related to some sexual health-related behaviours, especially healthcare use and complex discussions.

    • Substance Use and Abuse
      1. Reducing smoking in the US federal workforce: 5-year health and economic impacts from improved cardiovascular disease outcomes
        Asay GR, Homa DM, Abramsohn EM, Xu X, O’Connor EL, Wang G.
        Public Health Rep. 2017 Nov/Dec;132(6):646-653.
        OBJECTIVE: We estimated the reduction in number of hospitalizations for acute myocardial infarction and stroke as well as the associated health care costs resulting from reducing the number of smokers in the US federal workforce during a 5-year period. METHODS: We developed a 5-year spreadsheet-based cohort model with parameter values from past literature and analysis of national survey data. We obtained 2015 data on the federal workforce population from the US Office of Personnel Management and data on smoking prevalence among federal workers from the 2013-2015 National Health Interview Survey. We adjusted medical costs and productivity losses for inflation to 2015 US dollars, and we updated future productivity losses for growth. Because of uncertainty about the achievable reduction in smoking prevalence and input values (eg, relative risk for acute myocardial infarction and stroke, medical costs, and absenteeism), we performed a Monte Carlo simulation and sensitivity analysis. RESULTS: We estimated smoking prevalence in the federal workforce to be 13%. A 5 percentage-point reduction in smoking prevalence could result in 1106 fewer hospitalizations for acute myocardial infarction (range, 925-1293), 799 fewer hospitalizations for stroke (range, 530-1091), and 493 fewer deaths (range, 494-598) during a 5-year period. Similarly, estimated costs averted would be $59 million (range, $49-$63 million) for medical costs, $332 million (range, $173-$490 million) for absenteeism, and $117 million (range, $93-$142 million) for productivity. CONCLUSION: Reductions in the prevalence of smoking in the federal workforce could substantially reduce the number of hospitalizations for acute myocardial infarction and stroke, lower medical costs, and improve productivity.

      2. Objectives: This is the first statewide census of the product availability, price promotions, and product messaging of vape shops. Methods: A comprehensive list of New Hampshire vape shops was developed through a previously validated online search method. Store audits were conducted in 55 stores between January and February 2016 using the Vape Shop Standardized Tobacco Assessment for Retail Settings (V-STARS). Results: Modifiable devices and cig-alikes were sold in 92.6% and 14.6% of stores, respectively. Cross-product promotions with tobacco products were rare, and messaging promoting e-cigarettes as effective cessation devices was found in 27.3% of all stores. Candy/fruit and menthol e-liquids were most commonly found in stores, and sampling of products was available in 83.6% of stores. Ten (18.2%) stores did not have a minimum age sign posted, and self-service sampling displays were available in about one-fifth of stores. Conclusions: Using V-STARS to conduct retail assessments of vape shops is feasible and is important for assessing the changing retail environment of vape shops. Vape shops distinguish themselves from traditional tobacco product retailers and offer a variety of products to customize a consumer’s experience. Regulations and effective enforcement ensuring accurate health messages is essential.

      3. Attitudes toward smokeless tobacco use at all public sports venues among U.S. adults, 2016
        Odani S, O’Flaherty K, Veatch N, Tynan MA, Agaku IT.
        Prev Med. 2017 Nov 29.
        Policies prohibiting smokeless tobacco (SLT) use at sports venues have been enacted in California and nine U.S. cities. We measured opposition toward SLT use at all public sports venues and its correlates among U.S. adults. Data were from the 2016 SummerStyles, a web-based survey of U.S. adults aged >/=18years (n=4203). Weighted estimates of opposition (“strongly” or “somewhat”) SLT use were computed overall and by selected characteristics. Multivariable Poisson regression analyses were performed to identify determinants of opposition toward SLT use overall and among current tobacco product users. Overall, 81.8% of U.S. adults opposed SLT use at all public sports venues. Opposition varied by tobacco product use status: 85.9%, 86.9% and 60.4% among never, former, and current tobacco product users, respectively. Among all adults, the likelihood of opposition was higher among females than males (Adjusted Prevalence Ratio [APR]=1.05; 95%CI=1.01-1.08) and increased with every 10-year increase in age (APR=1.01; 95%CI=1.00-1.02). Likelihood was lower among persons with a high school diploma (APR=0.92; 95%CI=0.88-0.96) than those with college degree or higher; persons widowed/divorced/separated (APR=0.92; 95%CI=0.87-0.97) than those married; and current tobacco product users (APR=0.70; 95%CI=0.65-0.76) than never users. Among current tobacco product users, likelihood was lower among persons living in the Midwest (APR=0.81; 95%CI=0.66-0.98) and South (APR=0.78; 95%CI=0.65-0.94) than the Northeast. Most U.S. adults, including three-fifths of current tobacco product users, oppose SLT use at all public sports venues. Complete tobacco-free policies for sports venues that prohibit all forms of tobacco product use can help reduce the social acceptability of SLT use.

      4. A qualitative examination of increased alcohol use after bariatric surgery among racially/ethnically diverse young adults
        Spadola CE, Wagner EF, Varga LM, Syvertsen JL, De La Cruz Munoz NF, Messiah SE.
        Obes Surg. 2017 Nov 19.
        INTRODUCTION: Mounting evidence suggests that bariatric surgery, or weight loss surgery (WLS), patients might be vulnerable to developing post-operative alcohol use problems. While the majority of published research offers information concerning the prevalence of problematic alcohol use post-WLS, the literature lacks comprehensive, qualitative explorations examining why alcohol misuse might emerge after WLS. Such data-driven hypotheses are needed to effectively target this emerging concern. Additionally, young adults and racial/ethnic minorities are both increasingly undergoing WLS and are at heightened risk for problems related to alcohol use. To date, these groups have been under-represented in study samples. METHODS: To address these important gaps in the literature, racially/ethnically diverse, young adult WLS patients who indicated a post-WLS increase in alcohol use (n = 12) participated in an individual, semi-structured qualitative interview. Data were analyzed through two coding cycles; an external audit of the emerging themes was also conducted to further ensure the trustworthiness of the data. RESULTS: Interviews revealed four major themes prompting an increase in alcohol use after WLS: (1) increased sensitivity to alcohol intoxication, (2) utilizing alcohol as a replacement self-soothing mechanism for food, (3) increase in socialization, and (4) utilizing alcohol as a coping mechanism. CONCLUSIONS: By understanding the drivers of increases in alcohol use after WLS, precision-targeted pre- and post-surgical counseling interventions can be developed to address this emerging concern.

    • Zoonotic and Vectorborne Diseases
      1. Outbreak of severe histoplasmosis among tunnel workers – Dominican Republic, 2015
        Armstrong PA, Beard JD, Bonilla L, Arboleda N, Lindsley MD, Chae S, Castillo D, Nunez R, Chiller T, de Perio MA, Pimentel R, Vallabhaneni S.
        Clin Infect Dis. 2017 Dec 2.
        Background: Histoplasmosis is a fungal infection associated with exposure to bat guano. An outbreak of an unknown severe febrile illness occurred among tunnel workers in the Dominican Republic (DR), and resulted in several deaths. We conducted an investigation to confirm etiology and recommend control measures. Methods: A case was defined as fever and >/=2 symptoms consistent with histoplasmosis in a tunnel worker, July-September, 2015. We interviewed workers and family members, reviewed medical records, tested serum and urine for Histoplasma antigen/antibody, and conducted a cohort study to identify risk factors for histoplasmosis and severe infection (intensive care). Results: A crew of 36 male workers removed large amounts of bat guano from tunnels without respiratory protection for a median of 24 days per worker (range: 1-25). Median age was 32 years (range: 18-62); none were immunocompromised. Thirty (83%) workers had illness that met the case definition of whom 28 (93%) were hospitalized, 9 (30%) required intensive care, 6 (20%) required intubation, and 3 (10%) died. The median time from symptom onset to antifungal treatment was 6 days (range: 1-11). Twenty-two of 34 (65%) workers had laboratory evidence of histoplasmosis infection. Conclusions: Severe illnesses and death likely resulted from exposure to large inocula of Histoplasma capsulatum spores in an enclosed space, lack of respiratory protection, and delay in recognition and treatment. Clinician education about histoplasmosis, improved laboratory capacity to diagnose fungal infections, and occupational health guidance to protect workers against endemic fungi are recommended in the DR to prevent future outbreaks.

      2. Investigation of acute flaccid paralysis reported with La Crosse virus infection, Ohio, USA, 2008-2014
        Hennessey MJ, Pastula DM, Machesky K, Fischer M, Lindsey NP, DiOrio M, Staples JE, de Fijter S.
        Emerg Infect Dis. 2017 Dec;23(12):2075-2077.
        Infection with La Crosse virus can cause meningoencephalitis, but it is not known to cause acute flaccid paralysis (AFP). During 2008-2014, nine confirmed or probable La Crosse virus disease cases with possible AFP were reported in Ohio, USA. After an epidemiologic and clinical investigation, we determined no patients truly had AFP.

      3. Differences in prevalence of symptomatic Zika virus infection by age and sex – Puerto Rico, 2016
        Lozier MJ, Burke RM, Lopez J, Acevedo V, Amador M, Read JS, Jara A, Waterman SH, Barrera R, Munoz-Jordan J, Garcia-Rivera B, Sharp TM.
        J Infect Dis. 2017 Dec 6.
        Background: During the Zika virus (ZIKV) outbreak in Puerto Rico in 2016, non-pregnant women aged 20-39 years were disproportionately identified with ZIKV disease. We used household-based cluster investigations to determine if this disparity was associated with age- or sex-dependent differences in the rate of ZIKV infection or reporting symptoms. Methods: Participation was offered to residents of households within a 100-meter radius of the residences of a convenience sample of 19 laboratory-confirmed ZIKV disease cases. Participants answered a questionnaire and provided specimens for diagnostic testing by RT-PCR and ELISA. Results: Among 367 study participants, 114 (31.1%) were laboratory-positive for ZIKV infection, of which 30% reported a recent illness (defined as self-reported rash or arthralgia) attributable to ZIKV infection. Age and sex were not associated with ZIKV infection. Female sex (adjusted prevalence ratio [aPR]=2.28; 95% confidence interval [CI]=1.40, 3.67), age <40 years (aPR=2.39; 95% CI=1.55, 3.70), and asthma (aPR=1.63; 95% CI=1.12, 2.37) were independently associated with symptomatic infection. Conclusions: Although neither female sex nor age were associated with increased prevalence of ZIKV infection, both were associated with symptomatic infection. Further investigation to identify a potential mechanism of age- and sex-dependent differences in reporting symptomatic ZIKV infection is warranted.

      4. Avian influenza A(H7N2) virus in human exposed to sick cats, New York, USA, 2016
        Marinova-Petkova A, Laplante J, Jang Y, Lynch B, Zanders N, Rodriguez M, Jones J, Thor S, Hodges E, De La Cruz JA, Belser J, Yang H, Carney P, Shu B, Berman L, Stark T, Barnes J, Havers F, Yang P, Trock SC, Fry A, Gubareva L, Bresee JS, Stevens J, Daskalakis D, Liu D, Lee CT, Torchetti MK, Newbury S, Cigel F, Toohey-Kurth K, St George K, Wentworth DE, Lindstrom S, Davis CT.
        Emerg Infect Dis. 2017 Dec;23(12).
        An outbreak of influenza A(H7N2) virus in cats in a shelter in New York, NY, USA, resulted in zoonotic transmission. Virus isolated from the infected human was closely related to virus isolated from a cat; both were related to low pathogenicity avian influenza A(H7N2) viruses detected in the United States during the early 2000s.

      5. Second International Conference on Crimean-Congo hemorrhagic fever
        Spengler JR, Bente DA, Bray M, Burt F, Hewson R, Korukluoglu G, Mirazimi A, Weber F, Papa A.
        Antiviral Res. 2017 Nov 30.
        The Second International Conference on Crimean-Congo Hemorrhagic Fever (CCHF) was held in Thessaloniki, Greece, from September 10-13, 2017, and brought together international public health professionals, clinicians, ecologists, and basic laboratory researchers. Nearly 100 participants, representing 24 countries and the World Health Organization (WHO), were in attendance. Meeting sessions covered the epidemiology of CCHF in humans; ticks and virus-tick interactions; wild and domestic animal hosts; molecular virology; taxonomic classification; pathogenesis and animal models; clinical aspects and diagnosis; clinical management and clinical trials; and disease prevention in humans. The concluding session focused on recent WHO recommendations for public health measures and future research. This report summarizes lectures by the invited speakers and highlights advances in the field.

      6. Tool for eliminating dog-mediated human rabies through mass dog vaccination campaigns
        Undurraga EA, Blanton JD, Thumbi SM, Mwatondo A, Muturi M, Wallace RM.
        Emerg Infect Dis. 2017 Dec;23(12):2114-2116.
        The World Health Organization and collaborating agencies have set the goal of eliminating dog-mediated human rabies by 2030. Building on experience with rabies endemic countries, we constructed a user-friendly tool to help public health officials plan the resources needed to achieve this goal through mass vaccination of dogs.

      7. West Nile virus lineage 2 in horses and other animals with neurologic disease, South Africa, 2008-2015
        Venter M, Pretorius M, Fuller JA, Botha E, Rakgotho M, Stivaktas V, Weyer C, Romito M, Williams J.
        Emerg Infect Dis. 2017 Dec;23(12):2060-2064.
        During 2008-2015 in South Africa, we conducted West Nile virus surveillance in 1,407 animals with neurologic disease and identified mostly lineage 2 cases in horses (7.4%, 79/1,069), livestock (1.5%, 2/132), and wildlife (0.5%, 1/206); 35% were fatal. Geographic correlation of horse cases with seropositive veterinarians suggests disease in horses can predict risk in humans.

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