Antibiotic consumption during the coronavirus disease 2019 pandemic and emergence of carbapenemase-producing klebsiella pneumoniae lineages among inpatients in a Chilean hospital: A time-series study and phylogenomic analysis
Allel K , Peters A , Conejeros J , Martínez JRW , Spencer-Sandino M , Riquelme-Neira R , Rivas L , Rojas P , Orellana Chea C , García P , Araos R , McGovern O , Patel TS , Arias CA , Lessa FC , Undurraga EA , Munita JM . Clin Infect Dis 2023 77 S20-s28 BACKGROUND: The impact of coronavirus disease 2019 (COVID-19) on antimicrobial use (AU) and resistance has not been well evaluated in South America. These data are critical to inform national policies and clinical care. METHODS: At a tertiary hospital in Santiago, Chile, between 2018 and 2022, subdivided into pre- (3/2018-2/2020) and post-COVID-19 onset (3/2020-2/2022), we evaluated intravenous AU and frequency of carbapenem-resistant Enterobacterales (CRE). We grouped monthly AU (defined daily doses [DDD]/1000 patient-days) into broad-spectrum β-lactams, carbapenems, and colistin and used interrupted time-series analysis to compare AU during pre- and post-pandemic onset. We studied the frequency of carbapenemase-producing (CP) CRE and performed whole-genome sequencing analyses of all carbapenem-resistant (CR) Klebsiella pneumoniae (CRKpn) isolates collected during the study period. RESULTS: Compared with pre-pandemic, AU (DDD/1000 patient-days) significantly increased after the pandemic onset, from 78.1 to 142.5 (P < .001), 50.9 to 110.1 (P < .001), and 4.1 to 13.3 (P < .001) for broad-spectrum β-lactams, carbapenems, and colistin, respectively. The frequency of CP-CRE increased from 12.8% pre-COVID-19 to 51.9% after pandemic onset (P < .001). The most frequent CRE species in both periods was CRKpn (79.5% and 76.5%, respectively). The expansion of CP-CRE harboring blaNDM was particularly noticeable, increasing from 40% (n = 4/10) before to 73.6% (n = 39/53) after pandemic onset (P < .001). Our phylogenomic analyses revealed the emergence of two distinct genomic lineages of CP-CRKpn: ST45, harboring blaNDM, and ST1161, which carried blaKPC. CONCLUSIONS: AU and the frequency of CP-CRE increased after COVID-19 onset. The increase in CP-CRKpn was driven by the emergence of novel genomic lineages. Our observations highlight the need to strengthen infection prevention and control and antimicrobial stewardship efforts. |
High burden of intestinal colonization with antimicrobial-resistant bacteria in Chile: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study
Araos R , Smith RM , Styczynski A , Sánchez F , Acevedo J , Maureira L , Paredes C , González M , Rivas L , Spencer-Sandino M , Peters A , Khan A , Sepulveda D , Wettig LR , Rioseco ML , Usedo P , Soto PR , Huidobro LA , Ferreccio C , Park BJ , Undurraga E , D'Agata EMC , Jara A , Munita JM . Clin Infect Dis 2023 77 S75-s81 BACKGROUND: Antimicrobial resistance is a global threat, heavily impacting low- and middle-income countries. This study estimated antimicrobial-resistant gram-negative bacteria (GNB) fecal colonization prevalence in hospitalized and community-dwelling adults in Chile before the coronavirus disease 2019 pandemic. METHODS: From December 2018 to May 2019, we enrolled hospitalized adults in 4 public hospitals and community dwellers from central Chile, who provided fecal specimens and epidemiological information. Samples were plated onto MacConkey agar with ciprofloxacin or ceftazidime added. All recovered morphotypes were identified and characterized according to the following phenotypes: fluoroquinolone-resistant (FQR), extended-spectrum cephalosporin-resistant (ESCR), carbapenem-resistant (CR), or multidrug-resistant (MDR; as per Centers for Disease Control and Prevention criteria) GNB. Categories were not mutually exclusive. RESULTS: A total of 775 hospitalized adults and 357 community dwellers were enrolled. Among hospitalized subjects, the prevalence of colonization with FQR, ESCR, CR, or MDR-GNB was 46.4% (95% confidence interval [CI], 42.9-50.0), 41.2% (95% CI, 37.7-44.6), 14.5% (95% CI, 12.0-16.9), and 26.3% (95% CI, 23.2-29.4). In the community, the prevalence of FQR, ESCR, CR, and MDR-GNB colonization was 39.5% (95% CI, 34.4-44.6), 28.9% (95% CI, 24.2-33.6), 5.6% (95% CI, 3.2-8.0), and 4.8% (95% CI, 2.6-7.0), respectively. CONCLUSIONS: A high burden of antimicrobial-resistant GNB colonization was observed in this sample of hospitalized and community-dwelling adults, suggesting that the community is a relevant source of antibiotic resistance. Efforts are needed to understand the relatedness between resistant strains circulating in the community and hospitals. |
Risk factors for colonization with multidrug-resistant bacteria in urban and rural communities in Kenya: An Antimicrobial Resistance in Communities and Hospitals (ARCH) Study
Caudell MA , Ayodo C , Ita T , Smith RM , Luvsansharav UO , Styczynski AR , Ramay BM , Kariuki S , Palmer GH , Call DR , Omulo S . Clin Infect Dis 2023 77 S104-s110 BACKGROUND: Colonization with antimicrobial-resistant bacteria increases the risk of drug-resistant infections. We identified risk factors potentially associated with human colonization with extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) in low-income urban and rural communities in Kenya. METHODS: Fecal specimens, demographic and socioeconomic data were collected cross-sectionally from clustered random samples of respondents in urban (Kibera, Nairobi County) and rural (Asembo, Siaya County) communities between January 2019 and March 2020. Presumptive ESCrE isolates were confirmed and tested for antibiotic susceptibility using the VITEK2 instrument. We used a path analytic model to identify potential risk factors for colonization with ESCrE. Only 1 participant was included per household to minimize household cluster effects. RESULTS: Stool samples from 1148 adults (aged ≥18 years) and 268 children (aged <5 years) were analyzed. The likelihood of colonization increased by 12% with increasing visits to hospitals and clinics. Furthermore, individuals who kept poultry were 57% more likely to be colonized with ESCrE than those who did not. Respondents' sex, age, use of improved toilet facilities, and residence in a rural or urban community were associated with healthcare contact patterns and/or poultry keeping and may indirectly affect ESCrE colonization. Prior antibiotic use was not significantly associated with ESCrE colonization in our analysis. CONCLUSIONS: The risk factors associated with ESCrE colonization in communities include healthcare- and community-related factors, indicating that efforts to control antimicrobial resistance in community settings must include community- and hospital-level interventions. |
Prevalence of colonization with antibiotic-resistant organisms in hospitalized and community individuals in Bangladesh, a phenotypic analysis: Findings from the Antibiotic Resistance in Communities and Hospitals (ARCH) Study
Chowdhury F , Mah EMuneer S , Bollinger S , Sharma A , Ahmed D , Hossain K , Hassan MZ , Rahman M , Vanderende D , Sen D , Mozumder P , Khan AA , Sarker M , Smith RM , Styczynski A , Luvsansharav UO . Clin Infect Dis 2023 77 S118-s124 BACKGROUND: Low- and middle-income countries bear a disproportionate burden of antimicrobial resistance (AMR) but often lack adequate surveillance to inform mitigation efforts. Colonization can be a useful metric to understand AMR burden. We assessed the colonization prevalence of Enterobacterales with resistance to extended-spectrum cephalosporins, carbapenems, colistin, and methicillin-resistant Staphylococcus aureus among hospital and community dwellers. METHODS: Between April and October 2019, we conducted a period prevalence study in Dhaka, Bangladesh. We collected stool and nasal specimens from adults in 3 hospitals and from community dwellers within the hospitals' catchment area. Specimens were plated on selective agar plates. Isolates underwent identification and antibiotic susceptibility testing using Vitek 2. We performed descriptive analysis and determined population prevalence estimates accounting for clustering at the community level. RESULTS: The majority of both community and hospital participants were colonized with Enterobacterales with resistance to extended-spectrum cephalosporins (78%; 95% confidence interval [95% CI], 73-83; and 82%; 95% CI, 79-85, respectively). Thirty-seven percent (95% CI, 34-41) of hospitalized patients were colonized with carbapenems compared with 9% (95% CI, 6-13) of community individuals. Colistin colonization prevalence was 11% (95% CI, 8-14) in the community versus 7% (95% CI, 6-10) in the hospital. Methicillin-resistant Staphylococcus aureus colonization was similar in both community and hospital participants (22%; 95% CI, 19-26 vs 21% (95% CI, 18-24). CONCLUSIONS: The high burden of AMR colonization observed among hospital and community participants may increase the risk for developing AMR infections and facilitating spread of AMR in both the community and hospital. |
Deep dive into gaps and barriers to implementation of antimicrobial stewardship programs in hospitals in Latin America
Fabre V , Secaira C , Cosgrove SE , Lessa FC , Patel TS , Alvarez AA , Anchiraico LM , Del Carmen Bangher M , Barberis MF , Burokas MS , Castañeda X , Colque AM , De Ascencao G , Esquivel C , Ezcurra C , Falleroni LA , Frassone N , Garzón MI , Gomez C , Gonzalez JA , Hernandez D , Laplume D , Lemir CG , Maldonado Briones H , Melgar M , Mesplet F , Martinez G , Pertuz CM , Moreno C , Nemirovsky C , Nuccetelli Y , Palacio B , Sandoval N , Vergara H , Videla H , Villamandos S , Villareal O , Viteri A , Quiros R . Clin Infect Dis 2023 77 S53-s61 BACKGROUND: Antimicrobial resistance has worsened in Latin America. There is an urgent need to understand the development of antimicrobial stewardship programs (ASPs) and the barriers to implementing effective ASPs in light of limited national action plans or policies to promote ASPs in the region. METHODS: We performed a descriptive mixed-methods study of ASPs in 5 Latin American countries in March-July 2022. An electronic questionnaire with an associated scoring system (hospital ASP self-assessment) was used, and ASP development was classified based on the scores (inadequate, 0-25; basic, 26-50; intermediate, 51-75; or advanced, 76-100). Interviews among healthcare workers (HCWs) involved in antimicrobial stewardship (AS) inquired about behavioral and organizational factors that influence AS activities. Interview data were coded into themes. Results from the ASP self-assessment and interviews were integrated to create an explanatory framework. RESULTS: Twenty hospitals completed the self-assessment, and 46 AS stakeholders from these hospitals were interviewed. ASP development was inadequate/basic in 35% of hospitals, intermediate in 50%, and advanced in 15%. For-profit hospitals had higher scores than not-for-profit hospitals. Interview data validated the self-assessment findings and provided further insight into ASP implementation challenges, which included limited formal hospital leadership support, inadequate staffing and tools to perform AS work more efficiently, limited awareness of AS principles by HCWs, and limited training opportunities. CONCLUSIONS: We identified several barriers to ASP development in Latin America, suggesting the need to create accurate business cases for ASPs to obtain the necessary funding for their effective implementation and sustainability. |
Risk factors for community colonization with extended-spectrum cephalosporin-resistant enterobacterales (escre) in Botswana: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study
Lautenbach E , Mosepele M , Smith RM , Styczynski A , Gross R , Cressman L , Jaskowiak-Barr A , Alby K , Glaser L , Richard-Greenblatt M , Cowden L , Sewawa K , Otukile D , Paganotti GM , Mokomane M , Bilker WB , Mannathoko N . Clin Infect Dis 2023 77 S89-s96 BACKGROUND: The epidemiology of extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) in low- and middle-income countries (LMICs) is poorly described. Identifying risk factors for ESCrE colonization is critical to inform antibiotic resistance reduction strategies because colonization is typically a precursor to infection. METHODS: From 15 January 2020 to 4 September 2020, we surveyed a random sample of clinic patients at 6 sites in Botswana. We also invited each enrolled participant to refer up to 3 adults and children. All participants had rectal swabs collected that were inoculated onto chromogenic media followed by confirmatory testing. Data were collected on demographics, comorbidities, antibiotic use, healthcare exposures, travel, and farm and animal contact. Participants with ESCrE colonization (cases) were compared with noncolonized participants (controls) to identify risk factors for ESCrE colonization using bivariable, stratified, and multivariable analyses. RESULTS: A total of 2000 participants were enrolled. There were 959 (48.0%) clinic participants, 477 (23.9%) adult community participants, and 564 (28.2%) child community participants. The median (interquartile range) age was 30 (12-41) and 1463 (73%) were women. There were 555 cases and 1445 controls (ie, 27.8% of participants were ESCrE colonized). Independent risk factors (adjusted odds ratio [95% confidence interval]) for ESCrE included healthcare exposure (1.37 [1.08-1.73]), foreign travel [1.98 (1.04-3.77]), tending livestock (1.34 [1.03-1.73]), and presence of an ESCrE-colonized household member (1.57 [1.08-2.27]). CONCLUSIONS: Our results suggest healthcare exposure may be important in driving ESCrE. The strong links to livestock exposure and household member ESCrE colonization highlight the potential role of common exposure or household transmission. These findings are critical to inform strategies to curb further emergence of ESCrE in LMICs. |
Antibiotic resistance: A global problem and the need to do more
Lessa FC , Sievert DM . Clin Infect Dis 2023 77 S1-s3 The discovery of penicillin in 1928 and its initial use in the 1940s to treat serious infections marked a turning point in modern medicine saving millions of lives [1]. However, antibiotic resistance (AR) has long threatened the advances of modern medicine. Widespread use of penicillin in clinical therapy started in 1943, and a decade later penicillin resistance had already become a major clinical problem [2]. This same phenomenon has been seen with each new antibiotic that has been approved for clinical use. A landmark study recently published showed that in 2019 AR killed more people than any other infectious diseases including human immunodeficiency virus (HIV) and malaria [3]. One in 8 deaths globally are linked to bacterial infections, the second leading cause of death after ischemic heart disease |
Risk factors for colonization with extended-spectrum cephalosporin-resistant and carbapenem-resistant enterobacterales among hospitalized patients in Kenya: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study
Omulo S , Ita T , Mugoh R , Ayodo C , Luvsansharav U , Bollinger S , Styczynski A , Ramay BM , Caudell MA , Palmer GH , Kariuki S , Call DR , Smith RM . Clin Infect Dis 2023 77 S97-s103 BACKGROUND: The spread of extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) represents a significant global public health threat. We identified putative risk factors for ESCrE and CRE colonization among patients in 1 urban and 3 rural hospitals in Kenya. METHODS: During a January 2019 and March 2020 cross-sectional study, stool samples were collected from randomized inpatients and tested for ESCrE and CRE. The Vitek2 instrument was used for isolate confirmation and antibiotic susceptibility testing, and least absolute shrinkage and selection operator (LASSO) regression models were used to identify colonization risk factors while varying antibiotic use measures. RESULTS: Most (76%) of the 840 enrolled participants received ≥1 antibiotic in the 14 days preceding their enrollment, primarily ceftriaxone (46%), metronidazole (28%), or benzylpenicillin-gentamycin (23%). For LASSO models that included ceftriaxone administration, ESCrE colonization odds were higher among patients hospitalized for ≥3 days (odds ratio, 2.32 [95% confidence interval, 1.6-3.37]; P < .001), intubated patients (1.73 [1.03-2.91]; P = .009), and persons living with human immunodeficiency virus (1.70 [1.03-2.8]; P = .029). CRE colonization odds were higher among patients receiving ceftriaxone (odds ratio, 2.23 [95% confidence interval, 1.14-4.38]; P = .025) and for every additional day of antibiotic use (1.08 [1.03-1.13]; P = .002). CONCLUSIONS: While CRE colonization was strongly associated with ceftriaxone use and duration of antibiotic use, the odds of ESCrE colonization increased with exposure to the hospital setting and invasive medical devices, which may reflect nosocomial transmission. These data suggest several areas where hospitals can intervene to prevent colonization among hospitalized patients, both through robust infection prevention and control practices and antibiotic stewardship programs. |
Trends in inpatient antibiotic use among adults hospitalized during the coronavirus disease 2019 pandemic in Argentina, Brazil, and Chile, 2018-2021
Patel TS , McGovern OL , Mahon G , Osuka H , Boszczowski I , Munita JM , Garzon MI , Salomao MC , Marssola G , Tavares BM , Francisco DB , Gurgel APA , Arantes T , Bori A , Nogueira C , Peters A , Spencer M , Orellana C , Barbe M , Lopez C , Stender S , Lessa FC . Clin Infect Dis 2023 77 S4-s11 BACKGROUND: High rates of antibiotic use (AU) among inpatients with coronavirus disease 2019 (COVID-19) despite low rates of bacterial coinfection and secondary infection have been reported. We evaluated the impact of the COVID-19 pandemic on AU in healthcare facilities (HCFs) in South America. METHODS: We conducted an ecologic evaluation of AU in inpatient adult acute care wards in 2 HCFs each in Argentina, Brazil, and Chile. The AU rates for intravenous antibiotics were calculated as the defined daily dose per 1000 patient-days, using pharmacy dispensing records and hospitalization data from March 2018-February 2020 (prepandemic) and March 2020-February 2021 (pandemic). Differences in median AU were compared between the prepandemic and pandemic periods, using the Wilcoxon rank sum test to determine significance. Interrupted time series analysis was used to analyze changes in AU during the COVID-19 pandemic. RESULTS: Compared with the prepandemic period, the median difference in AU rates for all antibiotics combined increased in 4 of 6 HCFs (percentage change, 6.7%-35.1%; P < .05). In the interrupted time series models, 5 of 6 HCFs had significant increases in use of all antibiotics combined immediately at the onset of the pandemic (immediate effect estimate range, 15.4-268), but only 1 of these 5 HCFs experienced a sustained increase over time (change in slope, +8.13; P < .01). The effect of the pandemic onset varied by antibiotic group and HCF. CONCLUSIONS: Substantial increases in AU were observed at the beginning of the COVID-19 pandemic, suggesting the need to maintain or strengthen antibiotic stewardship activities as part of pandemic or emergency HCF responses. |
Colonization with antibiotic-resistant bacteria in a hospital and associated communities in Guatemala: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study
Ramay BM , Castillo C , Grajeda L , Santos LF , Romero JC , Lopez MR , Gomez A , Caudell M , Smith RM , Styczynski A , Herzig CTA , Bollinger S , Ning MF , Horton J , Omulo S , Palmer GH , Cordon-Rosales C , Call DR . Clin Infect Dis 2023 77 S82-s88 BACKGROUND: We estimated the prevalence of colonization with extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) from a hospital and associated communities in western Guatemala. METHODS: Randomly selected infants, children, and adults (<1, 1-17, and ≥18 years, respectively) were enrolled from the hospital (n = 641) during the coronavirus disease 2019 (COVID-19) pandemic, March to September 2021. Community participants were enrolled using a 3-stage cluster design between November 2019 and March 2020 (phase 1, n = 381) and between July 2020 and May 2021 (phase 2, with COVID-19 pandemic restrictions, n = 538). Stool samples were streaked onto selective chromogenic agar, and a Vitek 2 instrument was used to verify ESCrE or CRE classification. Prevalence estimates were weighted to account for sampling design. RESULTS: The prevalence of colonization with ESCrE and CRE was higher among hospital patients compared to community participants (ESCrE: 67% vs 46%, P < .01; CRE: 37% vs 1%, P < .01). Hospital ESCrE colonization was higher for adults (72%) compared with children (65%) and infants (60%) (P < .05). Colonization was higher for adults (50%) than children (40%) in the community (P < .05). There was no difference in ESCrE colonization between phase 1 and 2 (45% and 47%, respectively, P > .05), although reported use of antibiotics among households declined (23% and 7%, respectively, P < .001). CONCLUSIONS: While hospitals remain foci for ESCrE and CRE colonization, consistent with the need for infection control programs, community prevalence of ESCrE in this study was high, potentially adding to colonization pressure and transmission in healthcare settings. Better understanding of transmission dynamics and age-related factors is needed. |
Maternal colonization versus nosocomial transmission as the source of drug-resistant bloodstream infection in an Indian neonatal intensive care unit: A prospective cohort study
Robinson ML , Johnson J , Naik S , Patil S , Kulkarni R , Kinikar A , Dohe V , Mudshingkar S , Kagal A , Smith RM , Westercamp M , Randive B , Kadam A , Babiker A , Kulkarni V , Karyakarte R , Mave V , Gupta A , Milstone AM , Manabe YC . Clin Infect Dis 2023 77 S38-s45 BACKGROUND: Drug-resistant gram-negative (GN) pathogens are a common cause of neonatal sepsis in low- and middle-income countries. Identifying GN transmission patterns is vital to inform preventive efforts. METHODS: We conducted a prospective cohort study, 12 October 2018 to 31 October 2019 to describe the association of maternal and environmental GN colonization with bloodstream infection (BSI) among neonates admitted to a neonatal intensive care unit (NICU) in Western India. We assessed rectal and vaginal colonization in pregnant women presenting for delivery and colonization in neonates and the environment using culture-based methods. We also collected data on BSI for all NICU patients, including neonates born to unenrolled mothers. Organism identification, antibiotic susceptibility testing, and next-generation sequencing (NGS) were performed to compare BSI and related colonization isolates. RESULTS: Among 952 enrolled women who delivered, 257 neonates required NICU admission, and 24 (9.3%) developed BSI. Among mothers of neonates with GN BSI (n = 21), 10 (47.7%) had rectal, 5 (23.8%) had vaginal, and 10 (47.7%) had no colonization with resistant GN organisms. No maternal isolates matched the species and resistance pattern of associated neonatal BSI isolates. Thirty GN BSI were observed among neonates born to unenrolled mothers. Among 37 of 51 BSI with available NGS data, 21 (57%) showed a single nucleotide polymorphism distance of ≤5 to another BSI isolate. CONCLUSIONS: Prospective assessment of maternal GN colonization did not demonstrate linkage to neonatal BSI. Organism-relatedness among neonates with BSI suggests nosocomial spread, highlighting the importance of NICU infection prevention and control practices to reduce GN BSI. |
Prescribing of outpatient antibiotics commonly used for respiratory infections among adults before and during the coronavirus disease 2019 pandemic in Brazil
Solanky D , McGovern OL , Edwards JR , Mahon G , Patel TS , Lessa FC , Hicks LA , Patel PK . Clin Infect Dis 2023 77 S12-s19 BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic may have impacted outpatient antibiotic prescribing in low- and middle-income countries such as Brazil. However, outpatient antibiotic prescribing in Brazil, particularly at the prescription level, is not well-described. METHODS: We used the IQVIA MIDAS database to characterize changes in prescribing rates of antibiotics commonly prescribed for respiratory infections (azithromycin, amoxicillin-clavulanate, levofloxacin/moxifloxacin, cephalexin, and ceftriaxone) among adults in Brazil overall and stratified by age and sex, comparing prepandemic (January 2019-March 2020) and pandemic periods (April 2020-December 2021) using uni- and multivariate Poisson regression models. The most common prescribing provider specialties for these antibiotics were also identified. RESULTS: In the pandemic period compared to the prepandemic period, outpatient azithromycin prescribing rates increased across all age-sex groups (incidence rate ratio [IRR] range, 1.474-3.619), with the greatest increase observed in males aged 65-74 years; meanwhile, prescribing rates for amoxicillin-clavulanate and respiratory fluoroquinolones mostly decreased, and changes in cephalosporin prescribing rates varied across age-sex groups (IRR range, 0.134-1.910). For all antibiotics, the interaction of age and sex with the pandemic in multivariable models was an independent predictor of prescribing changes comparing the pandemic versus prepandemic periods. General practitioners and gynecologists accounted for the majority of increases in azithromycin and ceftriaxone prescribing during the pandemic period. CONCLUSIONS: Substantial increases in outpatient prescribing rates for azithromycin and ceftriaxone were observed in Brazil during the pandemic with prescribing rates being disproportionally different by age and sex. General practitioners and gynecologists were the most common prescribers of azithromycin and ceftriaxone during the pandemic, identifying them as potential specialties for antimicrobial stewardship interventions. |
Using colonization to understand the burden of antimicrobial resistance across low- and middle-income countries
Styczynski A , Herzig C , Luvsansharav UO , McDonald LC , Smith RM . Clin Infect Dis 2023 77 S70-s74 Understanding the burden of antibiotic resistance globally is hindered by incomplete surveillance, particularly across low-resource settings. The Antibiotic Resistance in Communities and Hospitals (ARCH) consortium encompasses sites across 6 resource-limited settings and is intended to address these gaps. Supported by the Centers for Disease Control and Prevention, the ARCH studies seek to characterize the burden of antibiotic resistance by examining colonization prevalence at the community and hospital level and to evaluate for risk factors that are associated with colonization. In this supplement, 7 articles present results from these initial studies. Though future studies identifying and evaluating prevention strategies will be critical to mitigate spreading resistance and its impact on populations, the findings from these studies address important questions surrounding the epidemiology of antibiotic resistance. |
Survival from birth until young adulthood among individuals with congenital heart defects: CH STRONG
Downing KF , Nembhard WN , Rose CE , Andrews JG , Goudie A , Klewer SE , Oster ME , Farr SL . Circulation 2023 148 (7) 575-588 BACKGROUND: Limited population-based information is available on long-term survival of US individuals with congenital heart defects (CHDs). Therefore, we assessed patterns in survival from birth until young adulthood (ie, 35 years of age) and associated factors among a population-based sample of US individuals with CHDs. METHODS: Individuals born between 1980 and 1997 with CHDs identified in 3 US birth defect surveillance systems were linked to death records through 2015 to identify those deceased and the year of their death. Kaplan-Meier survival curves, adjusted risk ratios (aRRs) for infant mortality (ie, death during the first year of life), and Cox proportional hazard ratios for survival after the first year of life (aHRs) were used to estimate the probability of survival and associated factors. Standardized mortality ratios compared infant mortality, >1-year mortality, >10-year mortality, and >20-year mortality among individuals with CHDs with general population estimates. RESULTS: Among 11 695 individuals with CHDs, the probability of survival to 35 years of age was 81.4% overall, 86.5% among those without co-occurring noncardiac anomalies, and 92.8% among those who survived the first year of life. Characteristics associated with both infant mortality and reduced survival after the first year of life, respectively, included severe CHDs (aRR=4.08; aHR=3.18), genetic syndromes (aRR=1.83; aHR=3.06) or other noncardiac anomalies (aRR=1.54; aHR=2.53), low birth weight (aRR=1.70; aHR=1.29), and Hispanic (aRR=1.27; aHR=1.42) or non-Hispanic Black (aRR=1.43; aHR=1.80) maternal race and ethnicity. Individuals with CHDs had higher infant mortality (standardized mortality ratio=10.17), >1-year mortality (standardized mortality ratio=3.29), and >10-year and >20-year mortality (both standardized mortality ratios ≈1.5) than the general population; however, after excluding those with noncardiac anomalies, >1-year mortality for those with nonsevere CHDs and >10-year and >20-year mortality for those with any CHD were similar to the general population. CONCLUSIONS: Eight in 10 individuals with CHDs born between1980 and 1997 survived to 35 years of age, with disparities by CHD severity, noncardiac anomalies, birth weight, and maternal race and ethnicity. Among individuals without noncardiac anomalies, those with nonsevere CHDs experienced mortality between 1 and 35 years of age, similar to the general population, and those with any CHD experienced mortality between 10 and 35 years of age, similar to the general population. |
Risk of cardiovascular disease after COVID-19 diagnosis among adults with and without diabetes
Koyama AK , Imperatore G , Rolka DB , Lundeen E , Rutkowski RE , Jackson SL , He S , Kuklina EV , Park S , Pavkov ME . J Am Heart Assoc 2023 12 (13) e029696 Background Growing evidence suggests incident cardiovascular disease (CVD) may be a long-term outcome of COVID-19 infection, and chronic diseases, such as diabetes, may influence CVD risk associated with COVID-19. We evaluated the postacute risk of CVD >30 days after a COVID-19 diagnosis by diabetes status. Methods and Results We included adults ≥20 years old with a COVID-19 diagnosis from March 1, 2020 through December 31, 2021 in a retrospective cohort study from the IQVIA PharMetrics Plus insurance claims database. A contemporaneous control group comprised adults without recorded diagnoses for COVID-19 or other acute respiratory infections. Two historical control groups comprised patients with or without an acute respiratory infection. Cardiovascular outcomes included cerebrovascular disorders, dysrhythmia, inflammatory heart disease, ischemic heart disease, thrombotic disorders, other cardiac disorders, major adverse cardiovascular events, and any CVD. The total sample comprised 23 824 095 adults (mean age, 48.4 years [SD, 15.7 years]; 51.9% women; mean follow-up, 8.5 months [SD, 5.8 months]). In multivariable Cox regression models, patients with a COVID-19 diagnosis had a significantly greater risk of all cardiovascular outcomes compared with patients without a diagnosis of COVID-19 (hazard ratio [HR], 1.66 [1.62-1.71], with diabetes; HR, 1.75 [1.73-1.78], without diabetes). Risk was attenuated but still significant for the majority of outcomes when comparing patients with COVID-19 to both historical control groups. Conclusions In patients with COVID-19 infection, postacute risk of incident cardiovascular outcomes is significantly higher than among controls without COVID-19, regardless of diabetes status. Therefore, monitoring for incident CVD may be essential beyond the first 30 days after a COVID-19 diagnosis. |
Immunomodulatory therapy for MIS-C
Ouldali N , Son MBF , McArdle AJ , Vito O , Vaugon E , Belot A , Leblanc C , Murray NL , Patel MM , Levin M , Randolph AG , Angoulvant F . Pediatrics 2023 152 (1) CONTEXT: Studies comparing initial therapy for multisystem inflammatory syndrome in children (MIS-C) provided conflicting results. OBJECTIVE: To compare outcomes in MIS-C patients treated with intravenous immunoglobulin (IVIG), glucocorticoids, or the combination thereof. DATA SOURCES: Medline, Embase, CENTRAL and WOS, from January 2020 to February 2022. STUDY SELECTION: Randomized or observational comparative studies including MIS-C patients <21 years. DATA EXTRACTION: Two reviewers independently selected studies and obtained individual participant data. The main outcome was cardiovascular dysfunction (CD), defined as left ventricular ejection fraction < 55% or vasopressor requirement ≥ day 2 of initial therapy, analyzed with a propensity score-matched analysis. RESULTS: Of 2635 studies identified, 3 nonrandomized cohorts were included. The meta-analysis included 958 children. IVIG plus glucocorticoids group as compared with IVIG alone had improved CD (odds ratio [OR] 0.62 [0.42-0.91]). Glucocorticoids alone group as compared with IVIG alone did not have improved CD (OR 0.57 [0.31-1.05]). Glucocorticoids alone group as compared with IVIG plus glucocorticoids did not have improved CD (OR 0.67 [0.24-1.86]). Secondary analyses found better outcomes associated with IVIG plus glucocorticoids compared with glucocorticoids alone (fever ≥ day 2, need for secondary therapies) and better outcomes associated with glucocorticoids alone compared with IVIG alone (left ventricular ejection fraction < 55% ≥ day 2). LIMITATIONS: Nonrandomized nature of included studies. CONCLUSIONS: In a meta-analysis of MIS-C patients, IVIG plus glucocorticoids was associated with improved CD compared with IVIG alone. Glucocorticoids alone was not associated with improved CD compared with IVIG alone or IVIG plus glucocorticoids. |
A mixed-methods approach for evaluating implementation processes and program costs for a hypertension management program implemented in a federally qualified health center
Tucker-Brown A , Spafford M , Wittenborn J , Rein D , Marshall A , Beasley KL , Vaughan M , Nelson N , Dougherty M , Ahn R . Prev Sci 2023 Team-based care approaches are effective at improving hypertension control and have been used in clinical practice to improve hypertension outcomes. This study implemented and evaluated the Hypertension Management Program (HMP), which was originally developed in a high-resource health setting, in a health system with fewer resources and a patient population disproportionately affected by hypertension. Our objectives were to describe how a health system could adapt HMP to meet their needs and calculate total program costs. HMP uses a team-based, patient-centered approach involving clinical pharmacists who contribute to managing patients who have hypertension and ultimately preventing premature death due to uncontrolled hypertension. HMP has 10 components (e.g., EHR patient registries and outreach lists, no copayment walk-in blood pressure checks). Our project involved implementing the key components of HMP in a federally qualified health center (FQHC) in South Carolina. Adaptations from the key components of HMP were made to fit the participants' settings. A mixed-methods evaluation assessed implementation processes, program costs, and implementation facilitators and barriers. From September 2018 to December 2019, clinical pharmacists conducted 758 hypertension management visits (HMVs) with 316 patients with hypertension. Total program costs for HMP were $325,532 overall and $16,277 per month. Monthly cost per patient was $3.62. The high engagement among clinical pharmacists, along with provider engagements, followed up by the subsequent referral of patients to HMP, facilitated the implementation process. Staff members observed improvements in hypertension control, which increased participation buy-in. Barriers included staff turnover, the perception among some providers that HMP took too much time, as well as perception of HMP as a pharmacy-specific initiative. A team-based, patient-centered approach to hypertension management can be adapted for FQHCs or similar settings that serve patient populations disproportionately affected by hypertension. |
Fostering access to PrEP among adolescent girls and young women aged 16 to 24 years at high risk of HIV through the DREAMS initiative in four districts in Zambia
Chipukuma J , Lindsay B , Mwango LK , Olowski P , Baumhart C , Tembo K , Olufunso AA , Bwale C , Makasa P , Muchoka M , Tembo S , Mbokile W , Panda C , Malupande S , Lubinda R , Bwembelo B , Fundulu E , Munsongo C , Watala K , Musonda B , Chituwo O , Okuku J , Mwila A , Muleya C , Patel P , Claassen CW . AIDS Educ Prev 2023 35 52-66 Adolescent girls and young women (AGYW) in sub-Saharan Africa remain at high risk for HIV, yet limited data exist on implementation of HIV pre-exposure prophylaxis (PrEP) for this group. We examined PrEP uptake among AGYW using a retrospective cohort enrolled in the Determined Resilient Empowered AIDS-free Mentored Safe (DREAMS) initiative in Zambia between October 2020 and March 2022. Consent was obtained from eligible AGYW at substantial risk for HIV, and they voluntarily participated in PrEP. Multivariable logistic regression was used to examine factors associated with PrEP refills following initiation. Of 4,162 HIV-negative AGYW, 3,233 (77%) were at substantial risk and initiated on PrEP. Overall, 68% of AGYW had at least one refill, but this differed significantly by age group and district. DREAMS was successful at reaching AGYW with PrEP services. More evidence is needed to assess reasons for discontinuation and to improve persistence for those with sustained HIV risk. |
Population estimates of HIV risk factors to inform HIV prevention programming for adolescent girls and young women
Howard AL , Chiang L , Picchetti V , Zhu L , Hegle J , Patel P , Saul J , Wasula L , Nantume S , Coomer R , Kamuingona R , Oluoch RP , Mharadze T , Duffy M , Kambona CA , Ramphalla P , Fathim KM , Massetti GM . AIDS Educ Prev 2023 35 20-38 Violence Against Children and Youth Survey (VACS) data from seven countries were analyzed to estimate population-level eligibility for the President's Emergency Plan for AIDS Relief (PEPFAR) Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe (DREAMS) HIV prevention program for adolescent girls and young women (AGYW). The prevalence of overall eligibility and individual risk factors, including experiences of violence, social, and behavioral risks differ across countries and age groups. A large proportion of AGYW across all countries and age groups examined have at least one risk factor making them eligible for DREAMS. Experiencing multiple risks is also common, suggesting that researchers and programs could work together to identify combinations of risk factors that put AGYW at greatest risk of HIV acquisition, or that explain most new HIV infections, to more precisely target the most vulnerable AGYW. The VACS provides important data for such analyses to refine DREAMS and other youth programming. |
HIV recent infection and past HIV testing history among newly HIV-diagnosed 15-24-year-olds in Malawi: An analysis of 2019-2022 HIV recent infection surveillance data
Kabaghe AN , Stephens R , Payne D , Theu J , Luhanga M , Chalira D , Arons MM , O'Malley G , Thomson KA , Nyangulu M , Nyirenda R , Patel P , Wadonda-Kabondo N . AIDS Educ Prev 2023 35 4-19 Awareness of HIV status in Malawi is 88.3% and lowest among 15-24-year-olds (76.2%). There is a need to understand HIV testing history and transmission in this age group. We analyzed pooled HIV surveillance data to describe testing history and HIV recent infection among 8,389 HIV-positive 15-24-year-olds from 251 sites in Malawi between 2019 and 2022. Most HIV-positive 15-24-year-olds were female; aged 23-24 years; rural residents; and diagnosed at voluntary counseling and testing. No prior HIV testing was reported in 43.5% and 32.9% of 15-19-year-olds and males, respectively. Overall, 4.9% of HIV-positive diagnoses were classified as recent HIV infections, with the highest proportions among breastfeeding women (8.2%); persons tested at sexually transmitted infection clinics (9.0%); persons with a prior negative test within 6 months (13.0%); and 17-18-year-olds (7.3%). Tailored and innovative HIV prevention and testing strategies for young adolescents, young males, and pregnant and breastfeeding women are needed for HIV epidemic control. |
Influenza A virus multicycle replication yields comparable viral population emergence in human respiratory and ocular cell types
Kieran TJ , DaSilva J , Stark TJ , York IA , Pappas C , Barnes JR , Maines TR , Belser JA . Microbiol Spectr 2023 11 (4) e0116623 While primarily considered a respiratory pathogen, influenza A virus (IAV) is nonetheless capable of spreading to, and replicating in, numerous extrapulmonary tissues in humans. However, within-host assessments of genetic diversity during multicycle replication have been largely limited to respiratory tract tissues and specimens. As selective pressures can vary greatly between anatomical sites, there is a need to examine how measures of viral diversity may vary between influenza viruses exhibiting different tropisms in humans, as well as following influenza virus infection of cells derived from different organ systems. Here, we employed human primary tissue constructs emulative of the human airway or corneal surface, and we infected both with a panel of human- and avian-origin IAV, inclusive of H1 and H3 subtype human viruses and highly pathogenic H5 and H7 subtype viruses, which are associated with both respiratory disease and conjunctivitis following human infection. While both cell types supported productive replication of all viruses, airway-derived tissue constructs elicited greater induction of genes associated with antiviral responses than did corneal-derived constructs. We used next-generation sequencing to examine viral mutations and population diversity, utilizing several metrics. With few exceptions, generally comparable measures of viral diversity and mutational frequency were detected following homologous virus infection of both respiratory-origin and ocular-origin tissue constructs. Expansion of within-host assessments of genetic diversity to include IAV with atypical clinical presentations in humans or in extrapulmonary cell types can provide greater insight into understanding those features most prone to modulation in the context of viral tropism. IMPORTANCE Influenza A virus (IAV) can infect tissues both within and beyond the respiratory tract, leading to extrapulmonary complications, such as conjunctivitis or gastrointestinal disease. Selective pressures governing virus replication and induction of host responses can vary based on the anatomical site of infection, yet studies examining within-host assessments of genetic diversity are typically only conducted in cells derived from the respiratory tract. We examined the contribution of influenza virus tropism on these properties two different ways: by using IAV associated with different tropisms in humans, and by infecting human cell types from two different organ systems susceptible to IAV infection. Despite the diversity of cell types and viruses employed, we observed generally similar measures of viral diversity postinfection across all conditions tested; these findings nonetheless contribute to a greater understanding of the role tissue type contributes to the dynamics of virus evolution within a human host. |
A multicenter retrospective cohort study to characterize patients hospitalized with MIS-A and COVID-19 in the United States, 2020-2021
Melgar M , Abrams JY , Godfred-Cato S , Shah AB , Garg A , Strunk A , Narasimhan M , Koptyev J , Norden A , Musheyev D , Rashid F , Tannenbaum R , Estrada YMartin RM , Patel B , Karanth S , Achenbach CJ , Hall GT , Hockney SM , Caputo M , Abbo LM , Beauchamps L , Morris SB , Cifuentes RO , de St Maurice A , Bell DS , Prabaker KK , Sanz Vidorreta FJ , Bryant E , Cohen DK , Mohan R , Libby CP , SooHoo S , Domingo TJ , Campbell AP , Belay ED . Clin Infect Dis 2023 BACKGROUND: The diagnosis of SARS-CoV-2-associated multisystem inflammatory syndrome in adults (MIS-A) requires distinguishing it from acute COVID-19 and may impact clinical management. METHODS: In this retrospective cohort study, we applied the U.S. Centers for Disease Control and Prevention case definition to identify adults hospitalized with MIS-A at six academic medical centers during March 1, 2020-December 31, 2021. MIS-A patients were matched on age group, sex, site, and admission date at a 1:2 ratio to patients hospitalized with acute symptomatic COVID-19. Conditional logistic regression was used to compare demographics, presenting symptoms, laboratory and imaging results, treatments administered, and outcomes between cohorts. RESULTS: Through medical record review of 10,223 patients hospitalized with SARS-CoV-2-associated illness, we identified 53 MIS-A cases. Compared with 106 matched COVID-19 patients, MIS-A patients were more likely to be non-Hispanic Black and less likely to be non-Hispanic White. MIS-A patients more likely had laboratory-confirmed COVID-19 ≥ 14 days prior to hospitalization, more likely had positive in-hospital SARS-CoV-2 serologic testing, and more often presented with gastrointestinal symptoms and chest pain. They were less likely to have underlying medical conditions and to present with cough and dyspnea. On admission, MIS-A patients had higher neutrophil-to-lymphocyte ratio, C-reactive protein, ferritin, procalcitonin and D-dimer, compared with COVID-19 patients. MIS-A patients had longer hospitalization and more likely required intensive care admission, invasive mechanical ventilation, and vasopressors. Mortality was 6% in both cohorts. CONCLUSIONS: Compared with patients with acute symptomatic COVID-19, adults with MIS-A more often manifest certain symptoms and laboratory findings early during hospitalization. These features may facilitate diagnosis and management. |
Implementation of HIV prevention strategies globally
Patel P , Celum C , Bekker LG . Lancet HIV 2023 10 (8) e492-e494 Although pre-exposure prophylaxis (PrEP) with tenofovir and emtricitabine was first approved by the US Food and Drug Administration in 2012, uptake of PrEP has been slow, with challenges at many levels, including policy development, implementation, and societal acceptance. Innovations in PrEP delivery, such as community-based delivery and self-care interventions could address some of these challenges for improved oral PrEP use. A priority for the HIV prevention community is to implement differentiated service delivery models and pursue innovations to improve the uptake and persistence of oral PrEP. However, HIV epidemic control (ie, the point at which the total number of new HIV infections is less than the total number of deaths from all causes among people living with HIV, with both new infections and deaths low and declining) will be hard to realise with primary prevention limited to daily oral PrEP tablets. In addition, there are many barriers to uptake, including limited access, an inaccurate perceived risk of HIV acquisition, stigma, medical mistrust, and difficulties consistently taking a daily pill.1 |
Preventing HIV among adolescent boys and young men through PEPFAR-supported voluntary medical male circumcision in 15 Sub-Saharan African Countries, 2018-2021
Peck ME , Ong K , Lucas T , Thomas AG , Wandira R , Ntwaaga B , Mkhontfo M , Zegeye T , Yohannes F , Mulatu D , Gultie T , Juma AW , Odoyo-June E , Maida A , Msungama W , Canda M , Mutandi G , Zemburuka BLT , Kankindi I , Vranken P , Maphothi N , Loykissoonlal D , Bunga S , Grund JM , Kazaura KJ , Kabuye G , Chituwo O , Muyunda B , Kamboyi R , Lingenda G , Mandisarisa J , Peterson A , Malaba R , Xaba S , Moyo T , Toledo C . AIDS Educ Prev 2023 35 67-81 Voluntary medical male circumcision (VMMC) is an HIV prevention intervention that has predominantly targeted adolescent and young men, aged 10-24 years. In 2020, the age eligibility for VMMC shifted from 10 to 15 years of age. This report describes the VMMC client age distribution from 2018 to 2021, at the site, national, and regional levels, among 15 countries in southern and eastern Africa. Overall, in 2018 and 2019, the highest proportion of VMMCs were performed among 10-14-year-olds (45.6% and 41.2%, respectively). In 2020 and 2021, the 15-19-year age group accounted for the highest proportion (37.2% and 50.4%, respectively) of VMMCs performed across all age groups. Similarly, in 2021 at the site level, 68.1% of VMMC sites conducted the majority of circumcisions among men aged 15-24 years. This analysis highlights that adolescent boys and young men are the primary recipients of VMMC receiving an important lifetime reduction in HIV risk. |
A moving target: impacts of lowering viral load suppression cutpoints on progress towards HIV epidemic control goals
Rosen JG , Reynolds SJ , Galiwango RM , Kigozi G , Quinn TC , Ratmann O , Ndyanabo A , Nelson LJ , Nakigozi G , Nalugemwa M , Rucinski KB , Kennedy CE , Chang LW , Kagaayi J , Serwadda D , Grabowski MK . AIDS 2023 37 (9) 1486-1489 Redefining viral load suppression (VLS) using lower cutpoints could impact progress towards the United Nations Programme on HIV/AIDS 95-95-95 targets. We assessed impacts of lowering the VLS cutpoint on achieving the 'third 95' in the Rakai Community Cohort Study. Population VLS would fall from 86% to 84% and 76%, respectively, after lowering VLS cutpoints from <1000 to <200 and <50 copies/ml. The fraction of viremic persons increased by 17% after lowering the VLS cutpoint from <1000 to <200 copies/ml. |
Sexually transmitted infection/human immunodeficiency virus, pregnancy, and mental health-related services provided during visits with sexual assault and abuse diagnosis for US medicaid beneficiaries, 2019
Tao G , Li J , Johns M , Patel CG , Workowski K . Sex Transm Dis 2023 50 (7) 425-431 BACKGROUND: Centers for Disease Control recommends that the decision to provide sexually transmitted infection (STI)/human immunodeficiency virus (HIV) testing and presumptive treatment to patients who report sexual assault and abuse (SAA) be made on an individual basis. METHODS: The 2019 Centers for Medicare & Medicaid Services national Medicaid data set was used. The SAA visits were identified by International Classification of Diseases 10th Revision Clinical Modification (O9A4 for pregnancy-related sexual abuse, T74.2 for confirmed sexual abuse, and Z04.4 for alleged rape). The initial SAA visit was defined as the patient's first SAA-related visit. Medical services were identified by International Classification of Diseases 10th Revision Clinical Modification codes, Current Procedural Terminology codes, and National Drug Code codes. RESULTS: Of 55,113 patients at their initial SAA visits, 86.2% were female; 63.4% aged ≥13 years; 59.2% visited emergency department (ED); all STI/HIV tests were provided in ≤20% of visits; presumptive gonorrhea and chlamydia treatment was provided in 9.7% and 3.4% of visits, respectively; pregnancy test was provided in 15.7% of visits and contraception services was provided in 9.4% of visits; and diagnosed anxiety was provided in 6.4% of visits. Patients who visited ED were less likely to have STI testing and anxiety than those visited non-ED facilities, but more likely to receive presumptive treatment for gonorrhea, testing for pregnancy, and contraceptive services. About 14.2% of patients had follow-up SAA visits within 60 days after the initial SAA visit. Of 7821 patients with the follow-up SAA visits within 60 days, most medical services provided were chlamydia testing (13.8%), gonorrhea testing (13.5%), syphilis testing (12.8%), HIV testing (14.0%); diagnosed anxiety (15.0%), and posttraumatic stress disorder (9.8%). CONCLUSIONS: Current medical services during SAA visits for Medicaid patients are described in this evaluation. More collaboration with staff who handle SAA will improve SAA-related medical services. |
Changing pattern of respiratory virus detections among school-aged children in a small community - Dane County, Wisconsin, September to December 2022
Temte JL , Goss M , Bell C , Barlow S , Temte E , Bateman A , Uzicanin A . Influenza Other Respir Viruses 2023 17 (6) e13171 Widespread school closures and other non-pharmaceutical interventions (NPIs), used to limit the spread of SARS-CoV-2, significantly disrupted transmission patterns of seasonal respiratory viruses. As NPIs were relaxed, populations were vulnerable to resurgence. This study within a small community assessed acute respiratory illness among kindergarten through grade 12 students as they returned to public schools from September through December 2022 without masking and distancing requirements. The 277 specimens collected demonstrated a shift from rhinovirus to influenza. With continued circulation of SARS-CoV-2 and return of seasonal respiratory viruses, understanding evolving transmission patterns will play an important role in reducing disease burden. |
Hepatitis C virus clearance cascade - United States, 2013-2022
Wester C , Osinubi A , Kaufman HW , Symum H , Meyer WA 3rd , Huang X , Thompson WW . MMWR Morb Mortal Wkly Rep 2023 72 (26) 716-720 Approximately 2.4 million adults were estimated to have hepatitis C virus (HCV) infection in the United States during 2013-2016 (1). Untreated, hepatitis C can lead to advanced liver disease, liver cancer, and death (2). The Viral Hepatitis National Strategic Plan for the United States calls for ≥80% of persons with hepatitis C to achieve viral clearance by 2030 (3). Characterizing the steps that follow a person's progression from testing to viral clearance and subsequent infection (clearance cascade) is critical for monitoring progress toward national elimination goals. Following CDC guidance (4), a simplified national laboratory results-based HCV five-step clearance cascade was developed using longitudinal data from a large national commercial laboratory throughout the decade since highly effective hepatitis C treatments became available. During January 1, 2013-December 31, 2021, a total of 1,719,493 persons were identified as ever having been infected with HCV. During January 1, 2013-December 31, 2022, 88% of those ever infected were classified as having received viral testing; among those who received viral testing, 69% were classified as having initial infection; among those with initial infection, 34% were classified as cured or cleared (treatment-induced or spontaneous); and among those persons, 7% were categorized as having persistent infection or reinfection. Among the 1.0 million persons with evidence of initial infection, approximately one third had evidence of viral clearance (cured or cleared). This simplified national HCV clearance cascade identifies substantial gaps in cure nearly a decade since highly effective direct-acting antiviral (DAA) agents became available and will facilitate the process of monitoring progress toward national elimination goals. It is essential that increased access to diagnosis, treatment, and prevention services for persons with hepatitis C be addressed to prevent progression of disease and ongoing transmission and achieve national hepatitis C elimination goals. |
Introduction to the youth HIV prevention supplement
Benevides R , Logan J , Patel P . AIDS Educ Prev 2023 35 1-3 To achieve HIV epidemic control by 2030, global HIV prevention and treatment programs need to prioritize reaching out to populations at greatest risk of HIV acquisition. Globally, approximately 4,900 young women aged 15–24 years are infected | with HIV every week, and in sub-Saharan Africa, 63% of all new HIV infections | are among women and girls. Furthermore, in 2019, four in five new HIV infections | in sub-Saharan Africa were among girls 10–19 years old. Given the decline in child | mortality and improvements in health services over the past 30 years in sub-Saharan | Africa, many countries in this geographic region are experiencing a youth bulge, | with rapid growth in child and youth demographics, thereby rendering a significant | proportion of this population vulnerable to HIV |
Effect of CDC adjustment of state-reported data on community water fluoridation statistics
Hamilton EK , Griffin SO , Espinoza L . J Public Health Dent 2023 83 (3) 320-324 OBJECTIVES: Advancing community water fluoridation (CWF) coverage is a national health objective. The Centers for Disease Control and Prevention began adjusting state-reported data to calculate CWF coverage in 2012, and then modified methods in 2016. We evaluate improvements attributable to data adjustment and implications for interpreting trends. METHODS: To assess adjustment, we compared the percentage deviation of state-reported data and data adjusted by both methods to the standard estimated by the U.S. Geological Survey. To assess effects on estimated CWF trends, we compared statistics calculated with data adjusted by each method. RESULTS: The 2016 method outperformed on all points of evaluation. The CWF national objective measure (percentage of community water system population receiving fluoridated water) was negligibly affected by method. Percentage of US population receiving fluoridated water was lower with the 2016 method versus the 2012. CONCLUSIONS: Adjustment of state-reported data improved overall quality of CWF coverage measures and had minimal impact on key measures. |
Reaching youth through faith leaders: Evaluation of the Faith Matters! Initiative
Kanagasabai U , Aholou T , Chevalier MS , Tobias JL , Okuku J , Shiraishi RW , Sheneberger R , Pande YC , Chifuwe C , Mamane LE , Njika G , Obongo C , Thorsen VC . AIDS Educ Prev 2023 35 82-99 Faith leaders can be uniquely positioned to guide and support young people on health issues, particularly HIV/AIDS and sexual violence. Faith Matters!, a 2-day training workshop for faith leaders, was delivered in September 2021 in Zambia. Sixty-six faith leaders completed a questionnaire at baseline, 64 at posttraining, and 59 at 3-month follow-up. Participants' knowledge, beliefs, and comfort communicating about HIV/AIDS and sexual violence were assessed. More faith leaders accurately identified common places where sexual violence occurs at the 3-month point compared to baseline: at church (2 vs. 22, p = .000), the fields (16 vs. 29, p = .004), parties (22 vs. 36, p = .001), and clubs (24 vs. 35, p = .034). More faith leaders stated that they engaged in conversations that supported people living with HIV (48 at baseline vs. 53, p = .049 at 3-month follow-up). These findings can inform future HIV/AIDS initiatives focusing on increasing the capacity among communities of faith. |
Promising practices observed in high-throughput COVID-19 vaccination sites in the United States, February-May 2021
McColloch CE , Samson ME , Parris K , Stewart A , Robinson JA , Cooper B , Galloway E , Garcia R , Gilani Z , Jayapaul-Philip B , Lucas P , Nguyen KH , Noe RS , Trudeau AT , Kennedy ED . Am J Public Health 2023 113 (8) 909-918 Objectives. To identify promising practices for implementing COVID-19 vaccination sites. Methods. The Centers for Disease Control and Prevention (CDC) and Federal Emergency Management Agency (FEMA) assessed high-throughput COVID-19 vaccination sites across the United States, including Puerto Rico, after COVID-19 vaccinations began. Site assessors conducted site observations and interviews with site staff. Qualitative data were compiled and thematically analyzed. Results. CDC and FEMA conducted 134 assessments of high-throughput vaccination sites in 25 states and Puerto Rico from February 12 to May 28, 2021. Promising practices were identified across facility, clinical, and cross-cutting operational areas and related to 6 main themes: addressing health equity, leveraging partnerships, optimizing site design and flow, communicating through visual cues, using quick response codes, and prioritizing risk management and quality control. Conclusions. These practices might help planning and implementation of future vaccination operations for COVID-19, influenza, and other vaccine-preventable diseases. Public Health Implications. These practices can be considered by vaccination planners and providers to strengthen their vaccination site plans and implementation of future high-throughput vaccination sites. (Am J Public Health. 2023;113(8):909-918. https://doi.org/10.2105/AJPH.2023.307331). |
Multimodeling approach to evaluating the efficacy of layering pharmaceutical and nonpharmaceutical interventions for influenza pandemics
Prasad PV , Steele MK , Reed C , Meyers LA , Du Z , Pasco R , Alfaro-Murillo JA , Lewis B , Venkatramanan S , Schlitt J , Chen J , Orr M , Wilson ML , Eubank S , Wang L , Chinazzi M , Pastore YPiontti A , Davis JT , Halloran ME , Longini I , Vespignani A , Pei S , Galanti M , Kandula S , Shaman J , Haw DJ , Arinaminpathy N , Biggerstaff M . Proc Natl Acad Sci U S A 2023 120 (28) e2300590120 When an influenza pandemic emerges, temporary school closures and antiviral treatment may slow virus spread, reduce the overall disease burden, and provide time for vaccine development, distribution, and administration while keeping a larger portion of the general population infection free. The impact of such measures will depend on the transmissibility and severity of the virus and the timing and extent of their implementation. To provide robust assessments of layered pandemic intervention strategies, the Centers for Disease Control and Prevention (CDC) funded a network of academic groups to build a framework for the development and comparison of multiple pandemic influenza models. Research teams from Columbia University, Imperial College London/Princeton University, Northeastern University, the University of Texas at Austin/Yale University, and the University of Virginia independently modeled three prescribed sets of pandemic influenza scenarios developed collaboratively by the CDC and network members. Results provided by the groups were aggregated into a mean-based ensemble. The ensemble and most component models agreed on the ranking of the most and least effective intervention strategies by impact but not on the magnitude of those impacts. In the scenarios evaluated, vaccination alone, due to the time needed for development, approval, and deployment, would not be expected to substantially reduce the numbers of illnesses, hospitalizations, and deaths that would occur. Only strategies that included early implementation of school closure were found to substantially mitigate early spread and allow time for vaccines to be developed and administered, especially under a highly transmissible pandemic scenario. |
Evaluation of community-based vector surveillance system for routine entomological monitoring under low malaria vector densities and high bed net coverage in western Kenya
Abong'o B , Stanton MC , Donnelly MJ , Ochomo E , Ter Kuile FO , Samuels AM , Kariuki S , Musula G , Oxborough R , Munga S , Torr SJ , Gimnig JE . Malar J 2023 22 (1) 203 BACKGROUND: Entomological surveillance is traditionally conducted by supervised teams of trained technicians. However, it is expensive and limiting in the number of sites visited. Surveillance through community-based collectors (CBC) may be more cost-effective and sustainable for longitudinal entomological monitoring. This study evaluated the efficiency of CBCs in monitoring mosquito densities compared to quality-assured sampling conducted by experienced entomology technicians. METHODS: Entomological surveillance employing CBCs was conducted in eighteen clusters of villages in western Kenya using indoor and outdoor CDC light traps and indoor Prokopack aspiration. Sixty houses in each cluster were enrolled and sampled once every month. Collected mosquitoes were initially identified to the genus level by CBCs, preserved in 70% ethanol and transferred to the laboratory every 2 weeks. Parallel, collections by experienced entomology field technicians were conducted monthly by indoor and outdoor CDC light traps and indoor Prokopack aspiration and served as a quality assurance of the CBCs. RESULTS: Per collection, the CBCs collected 80% fewer Anopheles gambiae sensu lato (s.l.) [RR = 0.2; (95% CI 0.14-0.27)] and Anopheles coustani [RR = 0.2; (95% CI 0.06-0.53)] and 90% fewer Anopheles funestus [RR = 0.1; (95% CI 0.08-0.19)] by CDC light traps compared to the quality assured (QA) entomology teams. Significant positive correlations were however observed between the monthly collections by CBCs and QA teams for both An. gambiae and An. funestus. In paired identifications of pooled mosquitoes, the CBCs identified 4.3 times more Anopheles compared to experienced technicians. The cost per person-night was lower in the community-based sampling at $9.1 compared to $89.3 by QA per collection effort. CONCLUSION: Unsupervised community-based mosquito surveillance collected substantially fewer mosquitoes per trap-night compared to quality-assured collection by experienced field teams, while consistently overestimating the number of Anopheles mosquitoes during identification. However, the numbers collected were significantly correlated between the CBCs and the QA teams suggesting that trends observed by CBCs and QA teams were similar. Further studies are needed to evaluate whether adopting low-cost, devolved supervision with spot checks, coupled with remedial training of the CBCs, can improve community-based collections to be considered a cost-effective alternative to surveillance conducted by experienced entomological technicians. |
Insecticide resistance levels and associated mechanisms in three Aedes aegypti populations from Venezuela
Rubio-Palis Y , Dzuris N , Sandi C , Vizcaino-Cabarrus RL , Corredor-Medina C , González JA , Lenhart AE . Mem Inst Oswaldo Cruz 2023 118 e220210 BACKGROUND: The massive use of insecticides in public health has exerted selective pressure resulting in the development of resistance in Aedes aegypti to different insecticides in Venezuela. Between 2010 and 2020, the only insecticides available for vector control were the organophosphates (Ops) fenitrothion and temephos which were focally applied. OBJECTIVES: To determine the state of insecticide resistance and to identify the possible biochemical and molecular mechanisms involved in three populations of Ae. aegypti from Venezuela. METHODS: CDC bottle bioassays were conducted on Ae. aegypti collected between October 2019 and February 2020 in two hyperendemic localities for dengue in Aragua State and in a malaria endemic area in Bolívar State. Insecticide resistance mechanisms were studied using biochemical assays and polymerase chain reaction (PCR) to detect kdr mutations. FINDINGS: Bioassays showed contrasting results among populations; Las Brisas was resistant to malathion, permethrin and deltamethrin, Urbanización 19 de Abril was resistant to permethrin and Nacupay to malathion. All populations showed significantly higher activity of mixed function oxidases and glutathione-S-transferases (GSTs) in comparison with the susceptible strain. The kdr mutations V410L, F1534C, and V1016I were detected in all populations, with F1534C at higher frequencies. MAIN CONCLUSION: Insecticide resistance persists in three Ae. aegypti populations from Venezuela even in the relative absence of insecticide application. |
Adolescent endocrine disrupting chemical exposure and academic achievement
Shoaff JR , Hahn J , Calafat AM , Korrick SA . Environ Res 2023 234 116493 BACKGROUND: Epidemiologic studies support associations of exposure to endocrine disrupting chemicals (EDCs), such as some phthalates, phenols, and parabens with a wide range of cognitive and behavioral traits. While many of these traits are associated with academic achievement, the relationship of EDC exposure specifically with academic achievement in adolescence has not yet been studied. OBJECTIVE: We assessed the association of urinary biomarker concentrations of EDCs with academic achievement in adolescents as well as the potential for psychosocial factors to modify associations. METHODS: We quantified urinary concentrations of select EDCs in 205 adolescent participants from the New Bedford Cohort (NBC), a prospective birth cohort of children born to mothers residing near the New Bedford Harbor Superfund site in Massachusetts, and estimated associations between EDCs and adolescent academic achievement assessed with the Wide Range Achievement Test (WRAT). Measures of socioeconomic status and the home environment were used to estimate psychosocial stress. RESULTS: Urinary concentrations of antiandrogenic phthalates were inversely associated with Math Computation scores. For example, each doubling of the concentration of antiandrogenic phthalate metabolites in urine was associated with a 1.94 point decrease (95% CI: 3.84, -0.05) in Math Computation scores, indicating poorer performance. For the most part, associations were stronger in adolescents with more, as compared to less, social disadvantage, but most of these differences did not achieve statistical significance. CONCLUSION: Our findings support the potential for adolescents' exposure to antiandrogenic phthalates to correlate with poorer academic achievement in math, particularly among participants with greater psychosocial stress. |
Maternal serum per- and polyfluoroalkyl substances during pregnancy and breastfeeding duration
Friedman C , Dabelea D , Keil AP , Adgate JL , Glueck DH , Calafat AM , Starling AP . Environ Epidemiol 2023 7 (4) E260 Background/objectives: Per- and polyfluoroalkyl substances (PFAS) are endocrine-disrupting chemicals that may affect breastfeeding duration. We examined associations between maternal PFAS concentrations during pregnancy and breastfeeding cessation. We investigated potential effect modification by parity status. Methods: Among 555 women enrolled in the Healthy Start study (2009-2014), we quantified maternal serum concentrations of 5 PFAS during mid- to late-pregnancy (mean 27 weeks of gestation). Participants self-reported their breastfeeding practices through 18-24 months postnatally. Among all participants and stratified by parity, we estimated associations between maternal PFAS concentrations and breastfeeding discontinuation by 3 and 6 months, using Poisson regression, and breastfeeding duration, using Cox regression. Results: Median PFAS concentrations were similar to those in the general US population. Associations between PFAS and breastfeeding duration differed by parity status. After adjusting for covariates, among primiparous women, associations between PFAS and breastfeeding cessation by 3 and 6 months were generally null, with some inverse associations. Among multiparous women, there were positive associations between perfluorohexane sulfonate, perfluorooctane sulfonate, perfluorooctanoate (PFOA), and perfluorononanoate and breastfeeding cessation by 3 and 6 months. For example, per ln-ng/mL increase in PFOA, the risk ratio for breastfeeding discontinuation by 6 months was 1.45 (95% confidence interval, 1.18, 1.78). Hazard ratios reflected similar patterns between PFAS and breastfeeding duration. Conclusions: Among primiparous women, we did not find evidence for associations between PFAS concentrations and breastfeeding duration. In contrast, among multiparous women, PFAS serum concentrations were generally inversely associated with breastfeeding duration, though estimates may be biased due to confounding by unmeasured previous breastfeeding. © 2023 Wolters Kluwer Health. All rights reserved. |
Evaluating demographic representation in clinical trials: Use of the adaptive coronavirus disease 2019 treatment trial (ACTT) as a test case
Ortega-Villa AM , Hynes NA , Levine CB , Yang K , Wiley Z , Jilg N , Wang J , Whitaker JA , Colombo CJ , Nayak SU , Kim HJ , Iovine NM , Ince D , Cohen SH , Langer AJ , Wortham JM , Atmar RL , El Sahly HM , Jain MK , Mehta AK , Wolfe CR , Gomez CA , Beresnev T , Mularski RA , Paules CI , Kalil AC , Branche AR , Luetkemeyer A , Zingman BS , Voell J , Whitaker M , Harkins MS , Davey RT Jr , Grossberg R , George SL , Tapson V , Short WR , Ghazaryan V , Benson CA , Dodd LE , Sweeney DA , Tomashek KM . Open Forum Infect Dis 2023 10 (6) ofad290 BACKGROUND: Clinical trials initiated during emerging infectious disease outbreaks must quickly enroll participants to identify treatments to reduce morbidity and mortality. This may be at odds with enrolling a representative study population, especially when the population affected is undefined. METHODS: We evaluated the utility of the Centers for Disease Control and Prevention's COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), the COVID-19 Case Surveillance System (CCSS), and 2020 United States (US) Census data to determine demographic representation in the 4 stages of the Adaptive COVID-19 Treatment Trial (ACTT). We compared the cumulative proportion of participants by sex, race, ethnicity, and age enrolled at US ACTT sites, with respective 95% confidence intervals, to the reference data in forest plots. RESULTS: US ACTT sites enrolled 3509 adults hospitalized with COVID-19. When compared with COVID-NET, ACTT enrolled a similar or higher proportion of Hispanic/Latino and White participants depending on the stage, and a similar proportion of African American participants in all stages. In contrast, ACTT enrolled a higher proportion of these groups when compared with US Census and CCSS. The proportion of participants aged ≥65 years was either similar or lower than COVID-NET and higher than CCSS and the US Census. The proportion of females enrolled in ACTT was lower than the proportion of females in the reference datasets. CONCLUSIONS: Although surveillance data of hospitalized cases may not be available early in an outbreak, they are a better comparator than US Census data and surveillance of all cases, which may not reflect the population affected and at higher risk of severe disease. |
Using mortuary and burial data to place COVID-19 in Lusaka, Zambia within a global context
Sheppard RJ , Watson OJ , Pieciak R , Lungu J , Kwenda G , Moyo C , Chanda SL , Barnsley G , Brazeau NF , Gerard-Ursin ICG , Olivera Mesa D , Whittaker C , Gregson S , Okell LC , Ghani AC , MacLeod WB , Del Fava E , Melegaro A , Hines JZ , Mulenga LB , Walker PGT , Mwananyanda L , Gill CJ . Nat Commun 2023 14 (1) 3840 Reported COVID-19 cases and associated mortality remain low in many sub-Saharan countries relative to global averages, but true impact is difficult to estimate given limitations around surveillance and mortality registration. In Lusaka, Zambia, burial registration and SARS-CoV-2 prevalence data during 2020 allow estimation of excess mortality and transmission. Relative to pre-pandemic patterns, we estimate age-dependent mortality increases, totalling 3212 excess deaths (95% CrI: 2104-4591), representing an 18.5% (95% CrI: 13.0-25.2%) increase relative to pre-pandemic levels. Using a dynamical model-based inferential framework, we find that these mortality patterns and SARS-CoV-2 prevalence data are in agreement with established COVID-19 severity estimates. Our results support hypotheses that COVID-19 impact in Lusaka during 2020 was consistent with COVID-19 epidemics elsewhere, without requiring exceptional explanations for low reported figures. For more equitable decision-making during future pandemics, barriers to ascertaining attributable mortality in low-income settings must be addressed and factored into discourse around reported impact differences. |
Preliminary incidence and trends of infections caused by pathogens transmitted commonly through food - Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 2022
Delahoy MJ , Shah HJ , Weller DL , Ray LC , Smith K , McGuire S , Trevejo RT , Scallan Walter E , Wymore K , Rissman T , McMillian M , Lathrop S , LaClair B , Boyle MM , Harris S , Zablotsky-Kufel J , Houck K , Devine CJ , Lau CE , Tauxe RV , Bruce BB , Griffin PM , Payne DC . MMWR Morb Mortal Wkly Rep 2023 72 (26) 701-706 Each year, infections from major foodborne pathogens are responsible for an estimated 9.4 million illnesses, 56,000 hospitalizations, and 1,350 deaths in the United States (1). To evaluate progress toward prevention of enteric infections in the United States, the Foodborne Diseases Active Surveillance Network (FoodNet) conducts surveillance for laboratory-diagnosed infections caused by eight pathogens transmitted commonly through food at 10 U.S. sites. During 2020-2021, FoodNet detected decreases in many infections that were due to behavioral modifications, public health interventions, and changes in health care-seeking and testing practices during the COVID-19 pandemic. This report presents preliminary estimates of pathogen-specific annual incidences during 2022, compared with average annual incidences during 2016-2018, the reference period for the U.S. Department of Health and Human Services' Healthy People 2030 targets (2). Many pandemic interventions ended by 2022, resulting in a resumption of outbreaks, international travel, and other factors leading to enteric infections. During 2022, annual incidences of illnesses caused by the pathogens Campylobacter, Salmonella, Shigella, and Listeria were similar to average annual incidences during 2016-2018; however, incidences of Shiga toxin-producing Escherichia coli (STEC), Yersinia, Vibrio, and Cyclospora illnesses were higher. Increasing culture-independent diagnostic test (CIDT) usage likely contributed to increased detection by identifying infections that would have remained undetected before widespread CIDT usage. Reducing pathogen contamination during poultry slaughter and processing of leafy greens requires collaboration among food growers and processors, retail stores, restaurants, and regulators. |
Notes from the field: Multistate outbreak of Escherichia coli O157:H7 infections linked to a national fast-food chain - United States, 2022
Stager C , Donovan D , Edwards L , Pereira E , Williams L , Freiman J , Schwensohn C , Gieraltowski L . MMWR Morb Mortal Wkly Rep 2023 72 (26) 732-733 In August 2022, the Michigan Department of Health and Human Services alerted CDC to an approximately fivefold increase in regional cases of Escherichia coli O157:H7 infection. Whole genome sequencing was used to characterize isolates from laboratory-confirmed infections in ill persons. Initial patient interviews indicated that many had consumed meals from the same national fast-food chain. Federal, state, and local officials initiated an investigation to identify the outbreak source and prevent additional cases. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.* | | CDC defined a case as an E. coli O157:H7 infection with an isolate highly related to the outbreak strain (within 0–2 alleles) by core genome multilocus sequence typing, with illness onset during July 26–August 24, 2022. PulseNet, CDC’s national molecular subtyping network for enteric disease surveillance, detected 109 cases from six states, including Michigan (67; 61%), Ohio (24; 22%), Indiana (11; 10%), Pennsylvania (four; 4%), Kentucky (two; 2%) and New York (one; 1%). The median patient age was 22 years (range = 1–94 years), and 49 (45%) were female. Fifty-two (48%) patients were hospitalized, and 13 (12%) developed hemolytic-uremic syndrome, a recognized complication of E. coli O157:H7 infection; no deaths occurred. |
High subtelomeric GC content in the genome of a zoonotic Cryptosporidium species
Li J , Li N , Roellig DM , Zhao W , Guo Y , Feng Y , Xiao L . Microb Genom 2023 9 (7) Cryptosporidium canis is a zoonotic species causing cryptosporidiosis in humans in addition to its natural hosts dogs and other fur animals. To understand the genetic basis for host adaptation, we sequenced the genomes of C. canis from dogs, minks, and foxes and conducted a comparative genomics analysis. While the genomes of C. canis have similar gene contents and organisations, they (~41.0 %) and C. felis (39.6 %) have GC content much higher than other Cryptosporidium spp. (24.3-32.9 %) sequenced to date. The high GC content is mostly restricted to subtelomeric regions of the eight chromosomes. Most of these GC-balanced genes encode Cryptosporidium-specific proteins that have intrinsically disordered regions and are involved in host-parasite interactions. Natural selection appears to play a more important role in the evolution of codon usage in GC-balanced C. canis, and most of the GC-balanced genes have undergone positive selection. While the identity in whole genome sequences between the mink- and dog-derived isolates is 99.9 % (9365 SNVs), it is only 96.0 % (362 894 SNVs) between them and the fox-derived isolate. In agreement with this, the fox-derived isolate possesses more subtelomeric genes encoding invasion-related protein families. Therefore, the change in subtelomeric GC content appears to be responsible for the more GC-balanced C. canis genomes, and the fox-derived isolate could represent a new Cryptosporidium species. |
Prevalence and geographic patterns of self-reported short sleep duration among US adults, 2020
Pankowska MM , Lu H , Wheaton AG , Liu Y , Lee B , Greenlund KJ , Carlson SA . Prev Chronic Dis 2023 20 E53 We estimated the prevalence of short sleep duration (<7 hours per day) among US adults aged 18 years or older by using 2020 Behavioral Risk Factor Surveillance System data. Nationally, 33.2% of adults reported short sleep duration. We identified disparities across sociodemographic characteristics, including age, sex, race and ethnicity, marital status, education, income, and urbanicity. Counties with the highest model-based estimates of short sleep duration clustered in the Southeast and along the Appalachian Mountains. These findings identified subgroups and geographic areas in which tailored strategies for promotion of optimal sleep duration (≥7 hours per night) are most needed. |
Healthcare and socioeconomic outcomes among young adults with congenital heart defects and functional cognitive disabilities, CH STRONG 2016 to 2019
Downing KF , Klewer SE , Nembhard WN , Goudie A , Oster ME , Farr SL . Am J Cardiol 2023 201 229-231 Cognitive disability is the most prevalent disability type among young adults with congenital heart defects (CHD), reported by more than a quarter of young adults with CHD in CH STRONG (Congenital Heart Survey To Recognize Outcomes, Needs, and well-beinG).1 However, the long-term outcomes of adults with CHD and cognitive disabilities are not well understood. Therefore, we compared the socioeconomic and healthcare outcomes among adults (aged 19 to 38 years) with CHD with and without cognitive disabilities in CH STRONG and described the socioeconomic characteristics associated with the receipt of disability benefits among adults with CHD and cognitive disabilities. |
A test of the predictive validity of relative versus absolute income for self-reported health and well-being in the United States
Brady D , Curran M , Carpiano RM . Demogr Res 2023 48 775-808 BACKGROUND A classic debate concerns whether absolute or relative income is more salient. Absolute values resources as constant across time and place while relative contextualizes one’s hierarchical location in the distribution of a time and place. OBJECTIVE This study investigates specifically whether absolute income or relative income matters more for health and well-being. METHODS We exploit within-person, within-age, and within-time variation with higher-quality income measures and multiple health and well-being outcomes in the United States. Using the Panel Study of Income Dynamics and the Cross-National Equivalent File, we estimate three-way fixed effects models of self-rated health, poor health, psychological distress, and life satisfaction. RESULTS For all four outcomes, relative income has much larger standardized coefficients than absolute income. Robustly, the confidence intervals for relative income do not overlap with zero. By contrast, absolute income mostly has confidence intervals that overlap with zero, and its coefficient is occasionally signed in the wrong direction. A variety of robustness checks support these results. CONCLUSIONS Relative income has far greater predictive validity than absolute income for self-reported health and well-being. CONTRIBUTION Compared to earlier studies, this study provides a more rigorous comparison and test of the predictive validity of absolute and relative income that is uniquely conducted with data on the United States. This informs debates on income measurement, the sources of health and well-being, and inequalities generally. Plausibly, these results can guide any analysis that includes income in models. © 2023 David Brady, Michaela Curran & Richard M. Carpiano. All Rights Reserved. |
Combating racism through research, training, practice, and public health policies
Hall JE , Boulware LE . Prev Chronic Dis 2023 20 E54 Racism is “a system [of power and oppression] of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call “race”) that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources” (1). At a systems level, racism is a public health problem, threat, and crisis (2–4). Its presence in society’s policies, practices, and programs creates inequities in access to vital conditions for health and well-being based on social ascriptions of race and ethnicity — resulting, for instance, in disparate access to and the quality of basic requirements for health and safety; residential neighborhood and housing options; developmental and educational experiences; and jobs, careers, and lifestyles (5–11). These inequities, in turn, produce and perpetuate disparities in health and disease experiences and outcomes. Because of its omnipresence, racism permeates every level of society, including the health care and public health sectors, creating racial and ethnic inequities in the operations of their infrastructures and, accordingly, in the delivery of essential services |
Preventing chronic disease in 2023: More volunteers, new appointments, upcoming collections, acknowledgment of guest editorial board on racism, and updates on diversity, equity, and inclusion initiatives
Jack L Jr . Prev Chronic Dis 2023 20 E55 This year the motto for Preventing Chronic Disease (PCD) ought to be, “More of everything in 2023!” I’m pleased and proud to share the journal’s accomplishments to date and preview what we expect in the coming months. | | This has been a year of change and growth for the journal. While we continue to focus on content that aligns with our vision to disseminate peer-reviewed public health findings, innovations, and practices, we have also committed to publishing more collections in 2023 than ever before. The decision to publish up to 7 collections this year — almost twice as many as in 2022 — is due in part to our commitment to best practices related to health equity and to diversity, equity, and inclusion. This commitment is reflected not only in the topics that we will publish this year, but also in the makeup of the most recent appointments to our volunteer boards. | | We also seek to provide more detailed guidance to authors on addressing issues of health equity in preparing manuscripts. We have posted a series of questions on the PCD website that address health equity considerations both in the process of research and in manuscript preparation. In presenting these guidelines, PCD joins with other journals in the forefront of the scholarly publishing community to frankly and directly address issues such as racism, negative social determinants of health, and other health inequities, looking to solutions that ameliorate these conditions and substantively and equitably improve the health and well-being of everyone. |
Addressing health disparities using multiply imputed injury surveillance data
Liu Y , Wolkin AF , Kresnow MJ , Schroeder T . Int J Equity Health 2023 22 (1) 126 BACKGROUND: Assessing disparities in injury is crucial for injury prevention and for evaluating injury prevention strategies, but efforts have been hampered by missing data. This study aimed to show the utility and reliability of the injury surveillance system as a trustworthy resource for examining disparities by generating multiple imputed companion datasets. METHODS: We employed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) for the period 2014-2018. A comprehensive simulation study was conducted to identify the appropriate strategy for addressing missing data limitations in NEISS-AIP. To evaluate the imputation performance more quantitatively, a new method based on Brier Skill Score (BSS) was developed to assess the accuracy of predictions by different approaches. We selected the multiple imputations by fully conditional specification (FCS MI) to generate the imputed companion data to NEISS-AIP 2014-2018. We further assessed health disparities systematically in nonfatal assault injuries treated in U.S. hospital emergency departments (EDs) by race and ethnicity, location of injury and sex. RESULTS: We found for the first time that significantly higher age-adjusted nonfatal assault injury rates for ED visits per 100,000 population occurred among non-Hispanic Black persons (1306.8, 95% Confidence Interval [CI]: 660.1 - 1953.5), in public settings (286.3, 95% CI: 183.2 - 389.4) and for males (603.5, 95% CI: 409.4 - 797.5). We also observed similar trends in age-adjusted rates (AARs) by different subgroups for non-Hispanic Black persons, injuries occurring in public settings, and for males: AARs of nonfatal assault injury increased significantly from 2014 through 2017, then declined significantly in 2018. CONCLUSIONS: Nonfatal assault injury imposes significant health care costs and productivity losses for millions of people each year. This study is the first to specifically look at health disparities in nonfatal assault injuries using multiply imputed companion data. Understanding how disparities differ by various groups may lead to the development of more effective initiatives to prevent such injury. |
SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 Update
Popovich KJ , Aureden K , Ham DC , Harris AD , Hessels AJ , Huang SS , Maragakis LL , Milstone AM , Moody J , Yokoe D , Calfee DP . Infect Control Hosp Epidemiol 2023 44 (7) 1-29 Previously published guidelines have provided comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the "Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals" published in 2014.(1) This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. |
Nasal shedding of vaccine viruses after immunization with a Russian-backbone live attenuated influenza vaccine in India
Dar L , Krishnan A , Kumar R , Dhakad S , Choudekar A , Bagga S , Sharma A , Kumar A , Jethani J , Saha S , Amarchand R , Kumar R , Choudhary A , Narayan VV , Gopal G , Lafond KE , Lindstrom S . Influenza Other Respir Viruses 2023 17 (6) e13149 BACKGROUND: We present post-vaccination nasal shedding findings from the phase IV, community-based, triple-blinded RCT conducted to assess efficacy of trivalent LAIV and inactivated influenza vaccines in rural north India. METHODS: Children aged 2-10 years received LAIV or intranasal placebo across 2015 and 2016, as per initial allocation. On days 2 and 4 post-vaccination, trained study nurses collected nasal swabs from randomly selected subset of trial participants based on operational feasibility, accounting for 10.0% and 11.4% of enrolled participants in 2015 and 2016, respectively. Swabs were collected in viral transport medium and transported under cold chain to laboratory for testing by reverse transcriptase real-time polymerase chain reaction. RESULTS: In year 1, on day 2 post-vaccination, 71.2% (74/104) of LAIV recipients shed at least one of vaccine virus strains compared to 42.3% (44/104) on day 4. During year 1, on day 2 post-vaccination, LAIV-A(H1N1)pdm09 was detected in nasal swabs of 12% LAIV recipients, LAIV-A(H3N2) in 41%, and LAIV-B in 59%. In year 2, virus shedding was substantially lower; 29.6% (32/108) of LAIV recipients shed one of the vaccine virus strains on day 2 compared to 21.3% on day 4 (23/108). CONCLUSION: At day 2 post-vaccination in year 1, two-thirds of LAIV recipients were shedding vaccine viruses. Shedding of vaccine viruses varied between strains and was lower in year 2. More research is needed to determine the reason for lower virus shedding and vaccine efficacy for LAIV-A(H1N1)pdm09. |
Influenza and tetanus, diphtheria, and acellular pertussis vaccination coverage during pregnancy: Pregnancy Risk Assessment Monitoring System, 2020
Kortsmit K , Oduyebo T , Simeone RM , Kahn KE , Razzaghi H , Galang RR , Ellington S , Ruffo N , Barfield WD , Warner L , Cox S . Public Health Rep 2023 333549231179252 OBJECTIVES: Estimates of vaccination coverage during pregnancy and identification of disparities in vaccination coverage can inform vaccination campaigns and programs. We reported the prevalence of being offered or told to get the influenza vaccine by a health care provider (hereinafter, provider); influenza vaccination coverage during the 12 months before delivery; and tetanus, diphtheria, and acellular pertussis (Tdap) vaccination coverage during pregnancy among women with a recent live birth in the United States. METHODS: We analyzed 2020 data from the Pregnancy Risk Assessment Monitoring System from 42 US jurisdictions (n = 41 673). We estimated the overall prevalence of being offered or told to get the influenza vaccine by a provider and influenza vaccination coverage during the 12 months before delivery. We estimated Tdap vaccination coverage during pregnancy from 21 jurisdictions with available data (n = 22 020) by jurisdiction and select characteristics. RESULTS: In 2020, 84.9% of women reported being offered or told to get the influenza vaccine, and 60.9% received it, ranging from 35.0% in Puerto Rico to 79.7% in Massachusetts. Influenza vaccination coverage was lower among women who were not offered or told to get the influenza vaccine (21.4%) than among women who were offered or told to get the vaccine (68.1%). Overall, 72.7% of women received the Tdap vaccine, ranging from 52.8% in Mississippi to 86.7% in New Hampshire. Influenza and Tdap vaccination coverage varied by all characteristics examined. CONCLUSIONS: These results can inform vaccination programs and strategies to address disparities in vaccination coverage during pregnancy and may inform vaccination efforts for other infectious diseases among pregnant women. |
Increased vaccine sensitivity of an emerging SARS-CoV-2 variant
Lewnard JA , Hong V , Kim JS , Shaw SF , Lewin B , Takhar H , Lipsitch M , Tartof SY . Nat Commun 2023 14 (1) 3854 Host immune responses are a key source of selective pressure driving pathogen evolution. Emergence of many SARS-CoV-2 lineages has been associated with enhancements in their ability to evade population immunity resulting from both vaccination and infection. Here we show diverging trends of escape from vaccine-derived and infection-derived immunity for the emerging XBB/XBB.1.5 Omicron lineage. Among 31,739 patients tested in ambulatory settings in Southern California from December, 2022 to February, 2023, adjusted odds of prior receipt of 2, 3, 4, and ≥5 COVID-19 vaccine doses were 10% (95% confidence interval: 1-18%), 11% (3-19%), 13% (3-21%), and 25% (15-34%) lower, respectively, among cases infected with XBB/XBB.1.5 than among cases infected with other co-circulating lineages. Similarly, prior vaccination was associated with greater point estimates of protection against progression to hospitalization among cases with XBB/XBB.1.5 than among non-XBB/XBB.1.5 cases (70% [30-87%] and 48% [7-71%], respectively, for recipients of ≥4 doses). In contrast, cases infected with XBB/XBB.1.5 had 17% (11-24%) and 40% (19-65%) higher adjusted odds of having experienced 1 and ≥2 prior documented infections, respectively, including with pre-Omicron variants. As immunity acquired from SARS-CoV-2 infection becomes increasingly widespread, fitness costs associated with enhanced vaccine sensitivity in XBB/XBB.1.5 may be offset by increased ability to evade infection-derived host responses. |
Unvaccinated adolescents' COVID-19 vaccine intentions: Implications for public health messaging
Ryan GW , Askelson NM , Woodworth KR , Lindley MC , Gedlinske A , Parker AM , Gidengil CA , Petersen CA , Scherer AM . J Adolesc Health 2023 73 (4) 679-685 PURPOSE: COVID-19 vaccine uptake remains low for US adolescents and contributes to excess morbidity and mortality. Most research has assessed parental intention to vaccinate their children. We explored differences between vaccine-acceptant and vaccine-hesitant unvaccinated US adolescents using national survey data. METHODS: A nonprobability, quota-based sample of adolescents, aged 13-17 years, was recruited through an online survey panel in April 2021. One thousand nine hundred twenty seven adolescents were screened for participation and the final sample included 985 responses. We assessed responses from unvaccinated adolescents (n = 831). Our primary measure was COVID-19 vaccination intent ("vaccine-acceptant" defined as "definitely will" get a COVID-19 vaccine and any other response classified as "vaccine-hesitant") and secondary measures included reasons for intending or not intending to get vaccinated and trusted sources of COVID-19 vaccine information. We calculated descriptive statistics and chi-square tests to explore differences between vaccine-acceptant and vaccine-hesitant adolescents. RESULTS: Most (n = 831; 70.9%) adolescents were hesitant, with more hesitancy observed among adolescents with low levels of concern about COVID-19 and high levels of concern about side effects of COVID-19 vaccination. Among vaccine-hesitant adolescents, reasons for not intending to get vaccinated included waiting for safety data and having parents who would make the vaccination decision. Vaccine-hesitant adolescents had a lower number of trusted information sources than vaccine-acceptant adolescents. DISCUSSION: Differences identified between vaccine-acceptant and vaccine-hesitant adolescents can inform message content and dissemination. Messages should include accurate, age-appropriate information about side effects and risks of COVID-19 infection. Prioritizing dissemination of these messages through family members, state and local government officials, and healthcare providers may be most effective. |
Immunogenicity of adjuvanted versus high-dose inactivated influenza vaccines in older adults: a randomized clinical trial
Schmader KE , Liu CK , Flannery B , Rountree W , Auerbach H , Barnett ED , Schlaudecker EP , Todd CA , Poniewierski M , Staat MA , Harrington T , Li R , Broder KR , Walter EB . Immun Ageing 2023 20 (1) 30 BACKGROUND: Adjuvanted inactivated influenza vaccine (aIIV) and high-dose inactivated influenza vaccine (HD-IIV) are U.S.-licensed for adults aged ≥ 65 years. This study compared serum hemagglutination inhibition (HAI) antibody titers for the A(H3N2) and A(H1N1)pdm09 and B strains after trivalent aIIV3 and trivalent HD-IIV3 in an older adult population. RESULTS: The immunogenicity population included 342 participants who received aIIV3 and 338 participants who received HD-IIV3. The proportion of participants that seroconverted to A(H3N2) vaccine strains after allV3 (112 participants [32.8%]) was inferior to the proportion of participants that seroconverted after HD-IIV3 (130 participants [38.5%]) at day 29 after vaccination (difference, - 5.8%; 95%CI, - 12.9% to 1.4%). There were no significant differences between the vaccine groups in percent seroconversion to A(H1N1)pdm09 or B vaccine strains, in percent seropositivity for any of the strains, or in post-vaccination GMT for the A(H1N1)pdm09 strain. The GMTs for the post-vaccination A(H3N2) and B strains were higher after HD-IIV than after aIIV3. CONCLUSIONS: Overall immune responses were similar after aIIV3 and HD-IIV3. For the primary outcome, the aIIV3 seroconversion rate for H3N2 did not meet noninferiority criteria compared with HD-IIV3, but the HD-IIV3 seroconversion rate was not statistically superior to the aIIV3 seroconversion rate. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03183908. |
A practical strategy to use the ICD-11 for morbidity coding in the United States without a clinical modification
Fung KW , Xu J , McConnell-Lamptey S , Pickett D , Bodenreider O . J Am Med Inform Assoc 2023 30 (10) 1614-1621 OBJECTIVE: The aim of this study was to derive and evaluate a practical strategy of replacing ICD-10-CM codes by ICD-11 for morbidity coding in the United States, without the creation of a Clinical Modification. MATERIALS AND METHODS: A stepwise strategy is described, using first the ICD-11 stem codes from the Mortality and Morbidity Statistics (MMS) linearization, followed by exposing Foundation entities, then adding postcoordination (with existing codes and adding new stem codes if necessary), with creating new stem codes as the last resort. The strategy was evaluated by recoding 2 samples of ICD-10-CM codes comprised of frequently used codes and all codes from the digestive diseases chapter. RESULTS: Among the 1725 ICD-10-CM codes examined, the cumulative coverage at the stem code, Foundation, and postcoordination levels are 35.2%, 46.5% and 89.4% respectively. 7.1% of codes require new extension codes and 3.5% require new stem codes. Among the new extension codes, severity scale values and anatomy are the most common categories. 5.5% of codes are not one-to-one matches (1 ICD-10-CM code matched to 1 ICD-11 stem code or Foundation entity) which could be potentially challenging. CONCLUSION: Existing ICD-11 content can achieve full representation of almost 90% of ICD-10-CM codes, provided that postcoordination can be used and the coding guidelines and hierarchical structures of ICD-10-CM and ICD-11 can be harmonized. The various options examined in this study should be carefully considered before embarking on the traditional approach of a full-fledged ICD-11-CM. |
Understanding gender-based violence service delivery in CDC-supported health facilities: 15 Sub-Saharan African Countries, 2017-2021
Kanagasabai U , Valleau C , Cain M , Chevalier MS , Hegle J , Patel P , Benevides R , Trika JB , Angumua C , Mpingulu M , Ferdinand K , Sida F , Galloway K , Kambona C , Oluoch P , Msungama W , Katengeza H , Correia D , Duffy M , Cossa RMV , Coomer R , Ayo A , Ukanwa C , Tuyishime E , Dladla S , Drummond J , Magesa D , Kitalile J , Apondi R , Okuku J , Chisenga T , Cham HJ . AIDS Educ Prev 2023 35 39-51 Gender-based violence (GBV) is a complex issue deeply rooted in social structures, making its eradication challenging. GBV increases the risk of HIV transmission and is a barrier to HIV testing, care, and treatment. Quality clinical services for GBV, which includes the provision of HIV postexposure prophylaxis (PEP), vary, and service delivery data are lacking. We describe GBV clinical service delivery in 15 countries supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention. Through a descriptive statistical analysis of PEPFAR Monitoring, Evaluation, and Reporting (MER) data, we found a 252% increase in individuals receiving GBV clinical services, from 158,691 in 2017 to 558,251 in 2021. PEP completion was lowest (15%) among 15-19-year-olds. Understanding GBV service delivery is important for policy makers, program managers, and providers to guide interventions to improve the quality of service delivery and contribute to HIV epidemic control. |
Prevalence of adverse childhood experiences among U.S. Adults - Behavioral Risk Factor Surveillance System, 2011-2020
Swedo EA , Aslam MV , Dahlberg LL , Niolon PH , Guinn AS , Simon TR , Mercy JA . MMWR Morb Mortal Wkly Rep 2023 72 (26) 707-715 Adverse childhood experiences (ACEs) are defined as preventable, potentially traumatic events that occur among persons aged <18 years and are associated with numerous negative outcomes; data from 25 states indicate that ACEs are common among U.S. adults (1). Disparities in ACEs are often attributable to social and economic environments in which some families live (2,3). Understanding the prevalence of ACEs, stratified by sociodemographic characteristics, is essential to addressing and preventing ACEs and eliminating disparities, but population-level ACEs data collection has been sporadic (1). Using 2011-2020 Behavioral Risk Factor Surveillance System (BRFSS) data, CDC provides estimates of ACEs prevalence among U.S. adults in all 50 states and the District of Columbia, and by key sociodemographic characteristics. Overall, 63.9% of U.S. adults reported at least one ACE; 17.3% reported four or more ACEs. Experiencing four or more ACEs was most common among females (19.2%), adults aged 25-34 years (25.2%), non-Hispanic American Indian or Alaska Native (AI/AN) adults (32.4%), non-Hispanic multiracial adults (31.5%), adults with less than a high school education (20.5%), and those who were unemployed (25.8%) or unable to work (28.8%). Prevalence of experiencing four or more ACEs varied substantially across jurisdictions, from 11.9% (New Jersey) to 22.7% (Oregon). Patterns in prevalence of individual and total number of ACEs varied by jurisdiction and sociodemographic characteristics, reinforcing the importance of jurisdiction and local collection of ACEs data to guide targeted prevention and decrease inequities. CDC has released prevention resources, including Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence, to help provide jurisdictions and communities with the best available strategies to prevent violence and other ACEs, including guidance on how to implement those strategies for maximum impact (4-6). |
Comparison of an ID NOW COVID-19 assay used at the point of care to laboratory-based nucleic acid amplification tests
Payne D , Williams C , Jacob J , Chastain-Potts S , Adjei M , Taye B , Montalvo S , Short L , Tran A . J Clin Microbiol 2023 61 (7) e0041323 The emergence of a novel coronavirus, namely, SARS-CoV-2, necessitated the use of rapid, accurate diagnostics to quickly diagnose COVID-19. This need has increased with the emergence of new variants and continued waves of COVID-19 cases. The ID NOW COVID-19 assay is a rapid nucleic acid amplification test (NAAT) that is used by hospitals, urgent care facilities, medical clinics, and public health laboratories for rapid molecular SARS-CoV-2 testing at the point of care. The District of Columbia Department of Forensic Sciences Public Health Laboratory Division (DC DFS PHL) implemented ID NOW COVID-19 testing in nontraditional laboratory settings, including a mobile testing unit, health clinic, and emergency department, to assist with rapid identification and isolation for populations at high risk of SARS-CoV-2 transmission in the District of Columbia. The DC DFS PHL provided these nontraditional laboratories with safety risk assessment, assay training, competency assessment, and quality control monitoring as parts of a comprehensive quality management system (QMS). We assessed the accuracy of the ID NOW COVID-19 assay when operated in the context of these trainings and systems. This was done by comparing results from 9,518 paired tests, and strong agreement (κ = 0.88, OPA = 98.3%) was found between the ID NOW COVID-19 assay and laboratory-based NAATs. These findings indicate that the ID NOW COVID-19 assay can be used to detect SARS-CoV-2 in nontraditional laboratory settings when used within the context of a comprehensive QMS. |
Estimation of numbers of testing personnel and test volume in the clinical laboratory improvement amendments of 1988 certificate of accreditation and certificate of compliance laboratories in the United States
Xia Y , Taylor TH , Chen J , Hsia J . Arch Pathol Lab Med 2023 CONTEXT.—: Two major categories of laboratories performing nonwaived testing under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) are the Certificate of Accreditation (CoA) and Certificate of Compliance (CoC) laboratories. Accreditation organizations collect more detailed laboratory personnel information than the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES). OBJECTIVE.—: To estimate total numbers of testing personnel and testing volumes in CoA and CoC laboratories, by laboratory type and state. DESIGN.—: We developed a statistical inference method by using the respective correlations between testing personnel counts and test volume by laboratory type. RESULTS.—: QIES reported 33 033 active CoA and CoC laboratories in July 2021. We estimated testing personnel to be 328 000 (95% CI, 309 000-348 000), which is supported by the count of 318 780 reported by the US Bureau of Labor Statistics. There were twice as many testing personnel in hospital laboratories as in independent laboratories (158 778 versus 74 904, P < .001). Independent laboratories had the highest test volume per person, which was twice as high as physician office laboratories (62 228 versus 30 102, P < .001). Hospital and independent laboratories comprised 34% of all CoA and CoC laboratories but performed the largest portion of testing (81%). Physician office laboratories, accounting for 44% of all CoA and CoC laboratories, performed a comparatively low proportion of total tests (9%). CONCLUSIONS.—: Numbers of testing personnel vary considerably by laboratory type and across states. These data can provide valuable insight when assessing laboratory workforce training needs and planning for public health emergencies. |
Body mass index and associated medical expenditures in the US among privately insured individuals aged 2 to 19 years in 2018
Kumar A , Kompaniyets L , Belay B , Pierce SL , Grosse SD , Goodman AB . JAMA Pediatr 2023 IMPORTANCE: Nearly 40% of US youth aged 2 to 19 years do not have a body mass index (BMI) in the healthy weight category. However, there are no recent estimates for BMI-associated expenditures using clinical or claims data. OBJECTIVE: To estimate medical expenditures among US youth across all BMI categories along with sex and age groups. DESIGN, SETTING, PARTICIPANTS: This cross-sectional study used IQVIA's ambulatory electronic medical records (AEMR) data set linked with IQVIA's PharMetrics Plus Claims database from January 2018 through December 2018. Analysis was performed from March 25, 2022, through June 20, 2022. It included a convenience sample of a geographically diverse patient population from AEMR and PharMetrics Plus. The study sample included privately insured individuals with a BMI measurement in 2018 and excluded patients with pregnancy-related visits. EXPOSURE: BMI categories. MAIN OUTCOMES AND MEASURES: Total medical expenditures were estimated using generalized linear model regression with γ distribution and log-link function. For out-of-pocket (OOP) expenditures, a 2-part model was used that included logistic regression to estimate the probability of positive expenditures followed by generalized linear model. Estimates were shown with and without accounting for sex, race and ethnicity, payer type, geographic region, age interacted with sex and BMI categories, and confounding conditions. RESULTS: The sample included 20 876 individuals aged 2 to 19 years; 104 066 were male (50.5%) and the median age was 12 years. Compared with those with healthy weight, total and OOP expenditures were higher for all other BMI categories. Differences in total expenditures were highest for those with severe obesity ($909; 95% CI, $600-$1218) followed by underweight ($671; 95% CI, $286-$1055) compared with healthy weight. Differences in OOP expenditures were highest for those with severe obesity ($121; 95% CI, $86-$155) followed by underweight ($117; 95% CI, $78-$157) compared with healthy weight. Having underweight was associated with higher total expenditures at ages 2 to 5 years and 6 to 11 years by $679 (95% CI, $228-$1129) and $1166 (95% CI, $632-$1700), respectively; having severe obesity was associated with higher total expenditures at ages 2 to 5 years, 6 to 11 years, and 12 to 17 years by $1035 (95% CI, $208-$1863), $821 (95% CI, $414-$1227), and $1088 (95% CI, $594-$1582), respectively. CONCLUSIONS AND RELEVANCE: The study team found medical expenditures to be higher for all BMI categories when compared with those with healthy weight. These findings may indicate potential economic value of interventions or treatments aimed at reducing BMI-associated health risks. |
Single and combined effects of multiple intensities of behavioral modification and methylphenidate for children with ADHD in the home setting
Merrill BM , Macphee FL , Burrows-MacLean L , Coles EK , Wymbs BT , Chacko A , Walker K , Wymbs F , Garefino A , Robb Mazzant J , Gnagy EM , Waxmonsky JG , Massetti GM , Waschbusch DA , Fabiano GA , Pelham WE Jr . Res Child Adolesc Psychopathol 2023 51 (10) 1481-1495 Behavioral treatment, stimulants, and their combination are the recommended treatments for childhood attention-deficit/hyperactivity disorder (ADHD). The current study utilizes within-subjects manipulations of multiple doses of methylphenidate (placebo, 0.15, 0.30, and 0.60 mg/kg/dose t.i.d.) and intensities of behavioral modification (no, low, and high intensity) in the summer treatment program (STP) and home settings. Outcomes are evaluated in the home setting. Participants were 153 children (ages 5-12) diagnosed with ADHD. In alignment with experimental conditions implemented during the STP day, parents implemented behavioral modification levels in three-week intervals, child medication status varied daily, and the orders were randomized. Parents provided daily reports of child behavior, impairment, and symptoms and self-reported parenting stress and self-efficacy. At the end of the study, parents reported treatment preferences. Stimulant medication led to significant improvements across all outcome variables with higher doses resulting in greater improvement. Behavioral treatment significantly improved child individualized goal attainment, symptoms, and impairment in the home setting and parenting stress and self-efficacy. Effect sizes indicate that behavioral treatment combined with a low-medium dose (0.15 or 0.30 mg/kg/dose) of medication results in equivalent or superior outcomes compared to a higher dose (0.60 mg/kg/dose) of medication alone. This pattern was seen across outcomes. Parents overwhelmingly reported preferring treatment with a behavioral component as a first-choice treatment (99%). Results underscore the need to consider dosing as well as parent preference when utilizing combined treatment approaches. This study provides further evidence that combining behavioral treatment and stimulant medication may reduce the stimulant dose needed for beneficial effects. |
Association of anthropometric characteristics of law enforcement officers with perceived ratings of fit, comfort, and pain in the use of body armor
Hsiao H . Ergonomics 2023 1-26 Knowledge gaps exist on association between law enforcement officer (LEO) anthropometric characteristics and perceived body armor fit, armor discomfort, and armor-caused pain. This study assessed the correlation and identified influential torso dimensions for armor sizing and design applications. Nine-hundreds and seventy-four LEOs across the U.S. participated in a national study on LEO armor use and body dimensions. Perceived ratings of armor fit, armor discomfort, and body pain were found moderately correlated with each other. In addition, armor fit ratings were associated with certain torso anthropometric characteristics, such as chest circumference, chest breadth, chest depth, waist circumference, waist breadth (sitting), waist front length (sitting), body weight, and body mass index. LEOs who reported armor poor fit, armor discomfort, and armor-caused pain had a larger mean of body dimensions than the "armor good fit" group. More women than men had poor fit, discomfort, and body pain in the use of body armor.Practitioner summary: The identified influential body measurements can be used as the "drivers" for multivariate analyses to develop an improved armor sizing system to further LEO protection. The study also suggests consideration of gender specific armor sizing systems to accommodate differences in torso configurations between male and female officers and to resolve the concern that more female officers had poor armor fit than male officers. |
Evaluating earplug performance over a 2-hour work period with a fit-test system
Gong W , Murphy WJ , Meinke DK , Feng HA , Stephenson MR . Semin Hear 2023 44 (4) 470-484 Workers rely on hearing protection devices to prevent occupational noise-induced hearing loss. This study aimed to evaluate changes in attenuation over time for properly fit devices when worn by workers exposed to hazardous noise. Earplug fit testing was accomplished on 30 workers at a brewery facility with three types of foam and three types of premolded earplugs. The personal attenuation ratings (PARs) were measured before and after a 2-hour work period while exposed to hazardous noise levels. The minimum acceptable initial PAR was 15 dB. Average decreases in PAR ranged from -0.7 to -2.6 dB across all six earplug types. Significant changes in PAR were observed for the Foam-1 (p = 0.009) and Premold-3 (p = 0.004) earplugs. A linear mixed regression model using HPD type and study year as fixed effects and subject as random effect was not significant for either fixed effect (α = 0.05). Ninety-five percent of the final PAR measurements maintained the target attenuation of 15 dB. Properly fitting earplugs can be effective at reducing worker's noise exposures over time. The potential for a decrease in attenuation during the work shift should be considered when training workers and establishing the adequacy of protection from hazardous noise exposures. © 2023 Thieme Medical Publishers, Inc.. All rights reserved. |
Notes from the field: Outbreak of cryptosporidiosis among collegiate swimmers and evidence of secondary transmission - Massachusetts and Rhode Island, 2023
Chiumento G , Osinski A , DeVoe K , Houghton A , Joshi A , Ivanof C , Creegan E , Gosciminski M , Newman AP , Madison-Antenucci S , Hlavsa MC , Imada E , Lysen C , Miko S , Schultz J , Harvey E , Vostok J , Brown CM . MMWR Morb Mortal Wkly Rep 2023 72 (26) 734-735 Inadvertent ingestion of recreational waters contaminated with feces containing Cryptosporidium spp., an extremely chlorine-tolerant parasite, can result in gastrointestinal illness. In early 2023, a Massachusetts college notified the Massachusetts Department of Public Health (MDPH) that 19 of 50 (38%) members of the men’s and women’s swim teams had experienced diarrhea beginning 3 days after their return from a weeklong training trip to Puerto Rico. One ill swimmer reported receiving a positive ova and parasite test result for Cryptosporidium. On days 5 and 6 after return from Puerto Rico, symptomatic Massachusetts swimmers competed in two meets against New York and Rhode Island collegiate teams (meet 1 and meet 2, respectively), raising concern about the potential for secondary transmission. |
The perceived neighborhood walking environment and self-reported sleep health in a nationally representative sample of the United States
Adjaye-Gbewonyo D , Ng AE , Jackson CL , Johnson DA . Health Place 2023 83 103066 Neighborhood environment can influence sleep health; yet, there is a lack of data on specific environment features in nationally representative samples. We used the 2020 National Health Interview Survey to determine associations between perceived built and social environment factors related to pedestrian access (walking paths, sidewalks), amenities (shops, transit stops, entertainment/services, places to relax), and unsafe walking conditions (traffic, crime) and self-reported sleep duration and disturbances. Places to relax and pedestrian access were associated with better sleep health while unsafe walking conditions were associated with worse sleep health. Access to amenities (shops, transit stops, entertainment venues) had null associations with sleep health. |
Randomized controlled phase IIa clinical trial of safety, pharmacokinetics and pharmacodynamics of tenofovir and tenofovir plus levonorgestrel releasing intravaginal rings used by women in Kenya
Mugo NR , Mudhune V , Heffron R , Thomas KK , McLellan-Lemal E , Njoroge B , Peacock S , O'Connor SM , Nyagol B , Ouma E , Ridzon R , Wiener J , Isoherranen N , Erikson DW , Ouattara LA , Yousefieh N , Jacot TA , Haaland RE , Morrison SA , Haugen HS , Thurman AR , Allen SA , Baeten JM , Samandari T , Doncel GF . Front Reprod Health 2023 5 1118030 INTRODUCTION: Globally, many young women face the overlapping burden of HIV infection and unintended pregnancy. Protection against both may benefit from safe and effective multipurpose prevention technologies. METHODS: Healthy women ages 18-34 years, not pregnant, seronegative for HIV and hepatitis B surface antigen, not using hormonal contraception, and at low risk for HIV were randomized 2:2:1 to continuous use of a tenofovir/levonorgestrel (TFV/LNG), TFV, or placebo intravaginal ring (IVR). In addition to assessing genital and systemic safety, we determined TFV concentrations in plasma and cervicovaginal fluid (CVF) and LNG levels in serum using tandem liquid chromatography-mass spectrometry. We further evaluated TFV pharmacodynamics (PD) through ex vivo CVF activity against both human immunodeficiency virus (HIV)-1 and herpes simplex virus (HSV)-2, and LNG PD using cervical mucus quality markers and serum progesterone for ovulation inhibition. RESULTS: Among 312 women screened, 27 were randomized to use one of the following IVRs: TFV/LNG (n = 11); TFV-only (n = 11); or placebo (n = 5). Most screening failures were due to vaginal infections. The median days of IVR use was 68 [interquartile range (IQR), 36-90]. Adverse events (AEs) were distributed similarly among the three arms. There were two non-product related AEs graded >2. No visible genital lesions were observed. Steady state geometric mean amount (ssGMA) of vaginal TFV was comparable in the TFV/LNG and TFV IVR groups, 43,988 ng/swab (95% CI, 31,232, 61,954) and 30337 ng/swab (95% CI, 18,152, 50,702), respectively. Plasma TFV steady state geometric mean concentration (ssGMC) was <10 ng/ml for both TFV IVRs. In vitro, CVF anti-HIV-1 activity showed increased HIV inhibition over baseline following TFV-eluting IVR use, from a median of 7.1% to 84.4% in TFV/LNG, 15.0% to 89.5% in TFV-only, and -27.1% to -20.1% in placebo participants. Similarly, anti-HSV-2 activity in CVF increased >50 fold after use of TFV-containing IVRs. LNG serum ssGMC was 241 pg/ml (95% CI 185, 314) with rapid rise after TFV/LNG IVR insertion and decline 24-hours post-removal (586 pg/ml [95% CI 473, 726] and 87 pg/ml [95% CI 64, 119], respectively). CONCLUSION: TFV/LNG and TFV-only IVRs were safe and well tolerated among Kenyan women. Pharmacokinetics and markers of protection against HIV-1, HSV-2, and unintended pregnancy suggest the potential for clinical efficacy of the multipurpose TFV/LNG IVR. CLINICAL TRIAL REGISTRATION: NCT03762382 [https://clinicaltrials.gov/ct2/show/NCT03762382]. |
Contraception and intersection with HIV services in 11 high HIV burden sub-Saharan African countries: Results from the population-based HIV impact assessment cross-sectional studies conducted from 2015 to 2018
Solmo C , Yuengling KA , Cooney ML , Sachathep K , Ayton S , Phillip N , Greenleaf A , Gummerson E , Hennesy N , Lulseged S , Habt D , Kagashe M , Rogers JH , Kirungi W , Battey K , Pasipamire M , Namukanja P , Ndongmo C , Bodika S , Low A . Int J Gynaecol Obstet 2023 163 (3) 875-887 OBJECTIVE: The United Nations' Sustainable Development Goal 3.7.1 addresses the importance of family planning. The objective of this paper is to provide information on family planning to policymakers to help increase access to contraceptive methods to women in sub-Saharan Africa. METHODS: We analyzed data from the Population-based HIV Impact Assessment studies conducted in 11 sub-Saharan African countries from 2015 to 2018 to assess the relationship between HIV services and family planning. Analyses were restricted to women aged 15-49 years who reported being sexually active within the past 12 months and had data on contraceptive use. RESULTS: Approximately 46.4% of participants reported using any form of contraception; 93.6% of whom used modern contraceptives. Women with a positive HIV status were more likely to use contraceptives (P < 0.0001) than HIV-negative women. Unmet need was higher among women who were confirmed to be HIV-negative in Namibia, Uganda, and Zambia than confirmed to be positive. Women aged 15-19 years used contraception less than 40% of the time. CONCLUSION: This analysis highlights crucial gaps in progress among HIV-negative and young women (aged 15-19 years). To provide access to modern contraception for all women, programs and governments need to focus on women who desire but do not have access to these family planning resources. |
Illicitly manufactured fentanyl-involved overdose deaths with detected xylazine - United States, January 2019-June 2022
Kariisa M , O'Donnell J , Kumar S , Mattson CL , Goldberger BA . MMWR Morb Mortal Wkly Rep 2023 72 (26) 721-727 In 2022, provisional data indicated that more than two thirds (68%) of the reported 107,081 drug overdose deaths in the United States involved synthetic opioids other than methadone, principally illicitly manufactured fentanyls (IMFs) (1). Xylazine, a nonopioid sedative not approved for human use and with no known antidote, has been increasingly detected in IMF products in the U.S. drug supply* and in IMF-involved overdose deaths (2). Limited studies suggest xylazine can cause central nervous system depression, respiratory depression, bradycardia, and hypotension in humans (3,4); chronic use might lead to severe withdrawal symptoms(†) as well as skin ulcerations (4). This report uses data from CDC's State Unintentional Drug Overdose Reporting System (SUDORS) to describe IMF-involved(§) overdose deaths with and without xylazine detected that occurred during January 2019-June 2022. Among 21 jurisdictions, which included 20 states and the District of Columbia, the monthly percentage of IMF-involved deaths with xylazine detected increased 276%, from 2.9% to 10.9%. Among IMF-involved deaths during January 2021-June 2022 in 32 jurisdictions, xylazine was detected in a higher percentage of jurisdictions in the Northeast U.S. Census Bureau region; listing detected xylazine as a cause of death varied across jurisdictions. Expanded postmortem and illicit drug product testing for xylazine is needed to clarify prevalence in drug supplies; further investigation of xylazine's effects on humans is necessary to characterize morbidity and overdose risk. It is important for overdose prevention and response messages to highlight the potential presence of xylazine in IMF products and emphasize the need for respiratory and cardiovascular support to address the sedative effects of xylazine. |
Two decades of wildlife pathogen surveillance: Case study of choclo orthohantavirus and its wild reservoir oligoryzomys costaricensis
Gonzalez P , Salazar JR , Salinas TP , Avila M , Colella JP , Dunnum JL , Glass GE , Gonzalez G , Juarez E , Lindblade K , Pile E , Mendoza Y , Pascale JM , Armien AG , Cook JA , Armien B . Viruses 2023 15 (6) The Costa Rican pygmy rice rat (Oligoryzomys costaricensis) is the primary reservoir of Choclo orthohantavirus (CHOV), the causal agent of hantavirus disease, pulmonary syndrome, and fever in humans in Panama. Since the emergence of CHOV in early 2000, we have systematically sampled and archived rodents from >150 sites across Panama to establish a baseline understanding of the host and virus, producing a permanent archive of holistic specimens that we are now probing in greater detail. We summarize these collections and explore preliminary habitat/virus associations to guide future wildlife surveillance and public health efforts related to CHOV and other zoonotic pathogens. Host sequences of the mitochondrial cytochrome b gene form a single monophyletic clade in Panama, despite wide distribution across Panama. Seropositive samples were concentrated in the central region of western Panama, consistent with the ecology of this agricultural commensal and the higher incidence of CHOV in humans in that region. Hantavirus seroprevalence in the pygmy rice rat was >15% overall, with the highest prevalence in agricultural areas (21%) and the lowest prevalence in shrublands (11%). Host-pathogen distribution, transmission dynamics, genomic evolution, and habitat affinities can be derived from the preserved samples, which include frozen tissues, and now provide a foundation for expanded investigations of orthohantaviruses in Panama. |
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