Risk factors for amyotrophic lateral sclerosis: a regional U.S. case-control study
Andrew AS , Bradley WG , Peipert D , Butt T , Amoako K , Pioro EP , Tandan R , Novak J , Quick A , Pugar KD , Sawlani K , Katirji B , Hayes TA , Cazzolli P , Gui J , Mehta P , Horton DK , Stommel EW . Muscle Nerve 2020 63 (1) 52-59 INTRODUCTION: Most amyotrophic lateral sclerosis (ALS) cases are considered sporadic, without a known genetic basis, and environmental exposures are thought to play a causal role. METHODS: To learn more about sporadic ALS etiology, we recruited n=188 ALS patients from Northern New England and Ohio and matched controls 2:1 from the general population of the same regions. Questionnaires evaluated the association between a variety of lifestyle, behavioral (i.e., hobbies and activities), and occupational factors and the risk of ALS, including the duration of time between exposure and ALS onset, and exposure frequency. RESULTS: Head trauma was associated with increased ALS risk (adjusted OR 1.60 95% CI 1.04-2.45), with significantly greater effects for injuries occurring 10 or more years prior to symptom onset (p=0.037). ALS risk was increased for those reporting severe electrical burns (adjusted OR 2.86, 95% CI 1.37-6.03), with odds ratios highest for burns after age 30 (OR 3.14), and for burns 10 or more years prior to symptom onset (OR 3.09). Hobbies involving lead were the most strongly associated with ALS risk (adjusted OR 2.92, 95%CI 1.45-5.91). Exposures to lead 20 or more years prior to diagnosis had larger effect sizes compared to those occurring more recently. Holding a job in mechanics, painting, or construction was associated with ALS. DISCUSSION: The identification of these specific environmental factors associated with ALS highlight the need for future prospective and laboratory studies to assess causality, biological mechanisms, and find prevention or treatment opportunities. |
Examining the effectiveness of provider incentives to increase CRC screening uptake in neighborhood healthcare: A California Federally Qualified Health Center
Barajas M , Tangka FKL , Schultz J , Tantod K , Kempster YM , Omelu N , Hoover S , Thomas M , Richmond-Reese V , Subramanian S . Health Promot Pract 2020 21 (6) 898-904 As an awardee of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program, the California Department of Public Health partnered with Neighborhood Healthcare to implement evidence-based interventions and provider incentives (incentives offered to support staff, e.g., medical assistants, phlebotomists, front office staff, lab technicians) to improve colorectal cancer screening uptake. The objective of this study was to evaluate the effectiveness and cost of the provider incentive intervention implemented by Neighborhood Healthcare to increase colorectal cancer screening uptake. We collected and analyzed process and cost data to assess fecal immunochemical test (FIT) kit return rates to the health centers and the number of completed FIT kits. We estimated the costs of the preexisting interventions and the new interventions. Analyses were conducted for two time periods: preimplementation and implementation. Most Neighborhood Healthcare health centers experienced an increase in the percentage of FIT kit returns (average of 3.6 percentage points) and individuals screened (an average increase of 111 FIT kits per month) from the baseline period through the implementation period. The cost of the incentive intervention for each additional screen was $66.79. In conclusion, the results indicate that incentive programs can have an overall positive impact on both the percentage of FIT kits returned and the number of individuals screened. |
Cost and effectiveness of reminders to promote colorectal cancer screening uptake in rural Federally Qualified Health Centers in West Virginia
Conn ME , Kennedy-Rea S , Subramanian S , Baus A , Hoover S , Cunningham C , Tangka FKL . Health Promot Pract 2020 21 (6) 891-897 The purpose of this study is to evaluate the effectiveness of the West Virginia Program to Increase Colorectal Cancer Screening in implementing patient reminders to increase fecal immunochemical test (FIT) kit return rates in nine federally qualified health centers (FQHCs). Using process measures and cost data collected, the authors examined the differences in the intensity of the phone calls across FQHCs and compared them with the return rates achieved. They also reported the cost per kit successfully returned as a result of the intervention. Across all FQHCs, 5,041 FIT kits were ordered, and the initial return rate (without a reminder) was 41.1%. A total of 2,201 patients received reminder phone calls; on average, patients received 1.61 reminder calls each. The reminder interventions increased the average FIT kit return rate to 60.7%. The average total cost per FIT kit returned across all FQHCs was $60.18, and the average cost of only the reminders was $11.20 per FIT kit returned. FQHCs achieved an average increase of 19.6 percentage points in FIT kit return rates, and costs across clinics varied. Clinics with high-quality health information systems that enabled tracking of patients with minimal effort were able to implement lower cost reminder interventions. |
The accuracy of provider diagnosed diabetes type in youth compared to an etiologic criteria in the SEARCH for Diabetes in Youth Study
Crume TL , Hamman RF , Isom S , Divers J , Mayer-Davis EJ , Liese AD , Saydah S , Lawrence JM , Pihoker C , Dabelea D . Pediatr Diabetes 2020 21 (8) 1403-1411 BACKGROUND: Although surveillance for diabetes in youth relies on provider-assigned diabetes type from medical records, its accuracy compared to an etiologic definition is unknown. METHODS: Using the SEARCH for Diabetes in Youth Registry, we evaluated the validity and accuracy of provider-assigned diabetes type abstracted from medical records against etiologic criteria that included the presence of diabetes autoantibodies (DAA) and insulin sensitivity. Youth who were incident for diabetes in 2002-06, 2008, or 2012 and had complete data on key analysis variables were included (n=4,001, 85% provider diagnosed type 1). The etiologic definition for type 1 diabetes was ≥1 positive DAA titer(s) or negative DAA titers in the presence of insulin sensitivity and for type 2 diabetes was negative DAA titers in the presence of insulin resistance. RESULTS: Provider diagnosed diabetes type correctly agreed with the etiologic definition of type for 89.9% of cases. Provider diagnosed type 1 diabetes was 96.9% sensitive, 82.8% specific, had a positive predictive value (PPV) of 97.0% and a negative predictive value (NPV) of 82.7%. Provider diagnosed type 2 diabetes was 82.8% sensitive, 96.9% specific, had a PPV and NPV of 82.7% and 97.0%, respectively. CONCLUSION: Provider diagnosis of diabetes type agreed with etiologic criteria for 90% of the cases. While the sensitivity and PPV were high for youth with type 1 diabetes, the lower sensitivity and PPV for type 2 diabetes highlights the value of DAA testing and assessment of insulin sensitivity status to ensure estimates are not biased by misclassification. |
Identification of measurement needs to prevent childhood obesity in high-risk populations and environments
Foti KE , Perez CL , Knapp EA , Kharmats AY , Sharfman AS , Arteaga SS , Moore LV , Bennett WL . Am J Prev Med 2020 59 (5) 746-754 INTRODUCTION: Children at highest obesity risk include those from certain racial/ethnic groups, from low-income families, with disabilities, or living in high-risk communities. However, a 2013 review of the National Collaborative for Childhood Obesity Research Measures Registry identified few measures focused on children at highest obesity risk. The objective is to (1) identify individual and environmental measures of diet and physical activity added to the Measures Registry since 2013 used among high-risk populations or settings and (2) describe methods for their development, adaptation, or validation. METHODS: Investigators screened references in the Measures Registry from January 2013 to September 2017 (n=351) and abstracted information about individual and environmental measures developed for, adapted for, or applied to high-risk populations or settings, including measure type, study population, adaptation and validation methods, and psychometric properties. RESULTS: A total of 38 measures met inclusion criteria. Of these, 30 assessed individual dietary (n=25) or physical activity (n=13) behaviors, and 11 assessed the food (n=8) or physical activity (n=7) environment. Of those, 17 measures were developed for, 9 were applied to (i.e., developed in a general population and used without modification), and 12 were adapted (i.e., modified) for high-risk populations. Few measures were used in certain racial/ethnic groups (i.e., American Indian/Alaska Native, Hawaiian/Pacific Islander, and Asian), children with disabilities, and rural (versus urban) communities. CONCLUSIONS: Since 2013, a total of 38 measures were added to the Measures Registry that were used in high-risk populations. However, many of the previously identified gaps in population coverage remain. Rigorous, community-engaged methodologic research may help researchers better adapt and validate measures for high-risk populations. |
The effectiveness and cost to improve colorectal cancer screening in a federally qualified homeless clinic in eastern Kentucky
Hardin V , Tangka FKL , Wood T , Boisseau B , Hoover S , DeGroff A , Boehm J , Subramanian S . Health Promot Pract 2020 21 (6) 905-909 The objective of this study was to analyze the effectiveness and cost of patient incentives, together with patient navigation and patient reminders, to increase fecal immunochemical test (FIT) kit return rates and colorectal cancer screening uptake in one federally qualified health center (FQHC) in Appalachia. This FQHC is a designated homeless clinic, as 79.7% of its patient population are homeless. We collected process, outcome, and cost data from the FQHC for two time periods: usual care (September 2016-August 2017) and implementation (September 2017-September 2018). We reported the FIT kit return rate, the increase in return rate, and the additional number of individual screens. We also calculated the incremental cost per additional screen. The patient incentive program, with patient navigation and patient reminders, increased the number of FIT kits returned from the usual care period to the implementation period. The return rate increased by 25.9 percentage points (from 21.7% to 47.6%) with an additional 91 people screened at an incremental cost of $134.61 per screen. A patient incentive program, together with the assistance of patient navigators and supplemented with patient reminders, can help improve CRC screening uptake among vulnerable and homeless populations. |
Childhood obesity evidence base project: A rationale for taxonomic versus conventional meta-analysis
Hedges LV , Saul JA , Cyr C , Magnus M , Scott-Sheldon LAJ , Young-Hyman D , Khan LK . Child Obes 2020 16 S21-s26 Introduction: There is a great need for analytic techniques that allow for the synthesis of learning across seemingly idiosyncratic interventions. Objectives: The primary objective of this paper is to introduce taxonomic meta-analysis and explain how it is different from conventional meta-analysis. Results: Conventional meta-analysis has previously been used to examine the effectiveness of childhood obesity prevention interventions. However, these tend to examine narrowly defined sections of obesity prevention initiatives, and as such, do not allow the field to draw conclusions across settings, participants, or subjects. Compared with conventional meta-analysis, taxonomic meta-analysis widens the aperture of what can be examined to synthesize evidence across interventions with diverse topics, goals, research designs, and settings. A component approach is employed to examine interventions at the level of their essential features or activities to identify the concrete aspects of interventions that are used (intervention components), characteristics of the intended populations (target population or intended recipient characteristics), and facets of the environments in which they operate (contextual elements), and the relationship of these components to effect size. In addition, compared with conventional meta-analysis methods, taxonomic meta-analyses can include the results of natural experiments, policy initiatives, program implementation efforts and highly controlled experiments (as examples) regardless of the design of the report being analyzed as long as the intended outcome is the same. It also characterizes the domain of interventions that have been studied. Conclusion: Taxonomic meta-analysis can be a powerful tool for summarizing the evidence that exists and for generating hypotheses that are worthy of more rigorous testing. |
Effectiveness and cost of implementing evidence-based interventions to increase colorectal cancer screening among an underserved population in Chicago
Kim KE , Tangka FKL , Jayaprakash M , Randal FT , Lam H , Freedman D , Carrier LA , Sargant C , Maene C , Hoover S , Joseph D , French C , Subramanian S . Health Promot Pract 2020 21 (6) 884-890 With funding from the Centers for Disease Control and Prevention's Colorectal Cancer Control Program, The University of Chicago Center for Asian Health Equity partnered with a federally qualified health center (FQHC) to implement multiple evidence-based interventions (EBIs) in order to improve colorectal cancer (CRC) screening uptake. The purpose of this study is to determine the effectiveness and cost of implementing a provider reminder system entered manually and supplemented with patient reminders and provider assessment and feedback. The FQHC collected demographic characteristics of the FQHC and outcome data from January 2015 through December 2015 (preimplementation period) and cost from January 2016 through September 2017 (implementation period). Cost data were collected for the implementation period. We report on the demographics of the eligible population, CRC screening order, completion rates by sociodemographic characteristics, and, overall, the effectiveness and cost of implementation. From the preimplementation phase to the implementation phase, there was a 21.2 percentage point increase in CRC screens completed. The total cost of implementing EBIs was $40908.97. We estimated that an additional 283 screens were completed because of the interventions, and the implementation cost of the interventions was $144.65 per additional screen. With the interventions, CRC screening uptake in Chicago increased for all race/ethnicity and demographic backgrounds at the FQHC, particularly for patients aged 50 to 64 years and for Asian, Hispanic, and uninsured patients. |
Childhood obesity evidence base project: Methods for taxonomy development for application in taxonomic meta-analysis
King H , Magnus M , Hedges LV , Cyr C , Young-Hyman D , Kettel Khan L , Scott-Sheldon LAJ , Saul JA , Arteaga S , Cawley J , Economos CD , Haire-Joshu D , Hunter CM , Lee BY , Kumanyika SK , Ritchie LD , Robinson TN , Schwartz MB . Child Obes 2020 16 S27-s220 Meta-analysis has been used to examine the effectiveness of childhood obesity prevention efforts, yet traditional conventional meta-analytic methods restrict the kinds of studies included, and either narrowly define mechanisms and agents of change, or examine the effectiveness of whole interventions as opposed to the specific actions that comprise interventions. Taxonomic meta-analytic methods widen the aperture of what can be included in a meta-analysis data set, allowing for inclusion of many types of interventions and study designs. The National Collaborative on Childhood Obesity Research Childhood Obesity Evidence Base (COEB) project focuses on interventions intended to prevent childhood obesity in children 2-5 years old who have an outcome measure of BMI. The COEB created taxonomies, anchored in the Social Ecological Model, which catalog specific outcomes, intervention components, intended recipients, and contexts of policies, initiatives, and interventions conducted at the individual, interpersonal, organizational, community, and societal level. Taxonomies were created by discovery from the literature itself using grounded theory. This article describes the process used for a novel taxonomic meta-analysis of childhood obesity prevention studies between the years 2010 and 2019. This method can be applied to other areas of research, including obesity prevention in additional populations. |
Associations between household water fluoridation status and plain tap or bottled water consumption
Lin M , Griffin SO , Park S , Li C , Robison V , Espinoza L . JDR Clin Trans Res 2020 6 (4) 440-447 INTRODUCTION: The benefits of community water fluoridation for preventing dental caries are attenuated if people do not consume tap water. OBJECTIVES: We examined associations between household water fluoride content and consuming plain tap or bottled water among US youth. METHODS: We used National Health and Nutrition Examination Survey data for 2013 to 2016 for 5,193 youth aged 2 to 19 y. Fluoride content in youth's household tap water samples was measured electrometrically with ion-specific electrodes and designated low (<0.6 mg/L) or about optimal (0.6 to 1.2 mg/L). Plain tap and bottled water consumption was obtained from one 24-h dietary recall. We used binomial regression models to estimate adjusted prevalence ratios (APRs) and 95% CIs for consuming plain tap water (including tap only or both tap and bottled) and consuming only bottled water as related to household water fluoride content (low or about optimal) and sociodemographic characteristics. RESULTS: On a given day, 52.6% of youth consumed plain tap water (43.8% exclusively and 8.8% both tap and bottled) and 28%, only bottled water. Neither tap water (APR, 0.96; 95% CI, 0.84 to 1.10) nor only bottled water (APR, 1.03; 95% CI, 0.86 to 1.22) consumption was associated with household water fluoride content. Non-Hispanic Black youth and Hispanic youth were about 30% relatively less likely to consume tap water and 60% to 80% relatively more likely to consume only bottled water than non-Hispanic Whites. Low income, low parental education, and no past-year dental visit were associated with not consuming tap water. CONCLUSION: Half of youth consumed plain tap water on a given day. Consuming plain tap water was not associated with community water fluoridation status. This study is the first to find that up to 50% of the population served by fluoridated water may not receive its full caries-preventive benefits due to not consuming plain tap water. KNOWLEDGE TRANSFER STATEMENT: Half of US youth consumed plain tap water on a given day. Consuming plain tap water was not associated with community water fluoridation status. This finding suggests that up to 50% of the population served by fluoridated water systems may not receive its full caries-preventive benefits due to not consuming plain tap water. Our findings add support for the need to identify and address barriers to tap water consumption and promote health benefits of fluoridation. |
Trends in sickle cell disease-related mortality in the United States, 1979 to 2017
Payne AB , Mehal JM , Chapman C , Haberling DL , Richardson LC , Bean CJ , Hooper WC . Ann Emerg Med 2020 76 S28-s36 STUDY OBJECTIVE: We provide an updated assessment of trends in sickle cell disease (SCD)-related mortality, a significant source of mortality in the United States among black persons, using 1979 to 2017 US mortality data. METHODS: SCD-related deaths were identified with International Classification of Diseases codes. Because SCD-related death is rare in other races, the analysis focused on black decedents. Age-specific and average annual SCD-related death rates were calculated. Causes of death codes were categorized into 20 groups relevant to SCD outcomes. SCD-related deaths were compared with non-SCD-related deaths after matching on race, sex, age group, and year of death. RESULTS: There were 25,665 SCD-related deaths reported among blacks in the United States from 1979 through 2017. During that period, the annual SCD-related death rate declined in children and increased in adults, and the median age at death increased from 28 to 43 years. Acute causes of death, such as infection and cerebrovascular complications, were more common in younger age groups. Chronic complications were more common in adults. SCD-related deaths were more likely to be related to acute cardiac, pulmonary, and cerebrovascular complications; acute infections; and chronic cardiac and pulmonary complications and renal disorders; and less likely to be related to drug overdose and chronic infections than non-SCD-related deaths. CONCLUSION: These data indicate SCD-related deaths are now more likely to be related to chronic complications of the disease than to acute complications. More research regarding prevention and treatment of chronic complications of SCD is necessary because persons with SCD are living longer. |
Trends in office visits during which opioids were prescribed for adults with arthritis: United States, 2006-2015
Santo L , Schappert SM , Hootman JM , Helmick CG . Arthritis Care Res (Hoboken) 2020 73 (10) 1430-1435 OBJECTIVE: To analyze trends in opioid prescriptions during visits to office-based physicians made by adults with arthritis in the US from 2006 to 2015. METHODS: We analyzed nationally representative data on patient visits to office-based physicians from the National Ambulatory Medical Care Survey (NAMCS) 2006-2015. Visit percentages for first- and any-listed diagnosis of arthritis by age groups and sex are reported. Time points were grouped into 2-year intervals to increase the reliability of estimates. Annual percentage point change and 95% CI were reported from linear regression models. RESULTS: During 2006-2015, the percentage of visits to office-based physicians by adults with a first-listed diagnosis of arthritis increased from 4.1% (95%CI: 3.5%-4.7%) in 2006-2007 to 5.1% (95% CI: 3.9%-6.6%) in 2014-2015 (p=.033). Among these visits, the percentage of visits with opioids prescribed increased from 16.5% (95%CI: 13.1%-20.5%) in 2006-2007 to 25.6% (95%CI: 17.9%-34.6%) in 2014-2015 (p=.017). The percentage of visits with any-listed diagnosis of arthritis increased from 6.6% (95%CI: 5.9%-7.4%) in 2006-2007 to 8.4% (95%CI: 7.0%-10.0%) in 2014-2015 (p=.001). Among these visits the percentage of visits with opioids prescribed increased from 17.4% (95%CI: 14.6%-20.4%) in 2006-2007 to 25.0% (95%CI: 19.7%-30.8%) in 2014-2015 (p=.004). CONCLUSION: During 2006-2015, the percentage of arthritis visits by adults to office-based physicians increased and the percentage of opioids prescribed at these visits increased as well. NAMCS data will allow continued monitoring of these trends after guidelines were implemented. |
Childhood obesity evidence base project: A systematic review and meta-analysis of a new taxonomy of intervention components to improve weight status in children 2-5 years of age, 2005-2019
Scott-Sheldon LAJ , Hedges LV , Cyr C , Young-Hyman D , Khan LK , Magnus M , King H , Arteaga S , Cawley J , Economos CD , Haire-Joshu D , Hunter CM , Lee BY , Kumanyika SK , Ritchie LD , Robinson TN , Schwartz MB . Child Obes 2020 16 S221-s248 Objective: To evaluate the efficacy of childhood obesity interventions and conduct a taxonomy of intervention components that are most effective in changing obesity-related health outcomes in children 2-5 years of age. Methods: Comprehensive searches located 51 studies from 18,335 unique records. Eligible studies: (1) assessed children aged 2-5, living in the United States; (2) evaluated an intervention to improve weight status; (3) identified a same-aged comparison group; (4) measured BMI; and (5) were available between January 2005 and August 2019. Coders extracted study, sample, and intervention characteristics. Effect sizes [ESs; and 95% confidence intervals (CIs)] were calculated by using random-effects models. Meta-regression was used to determine which intervention components explain variability in ESs. Results: Included were 51 studies evaluating 58 interventions (N = 29,085; mean age = 4 years; 50% girls). Relative to controls, children receiving an intervention had a lower BMI at the end of the intervention (g = 0.10, 95% CI = 0.02-0.18; k = 55) and at the last follow-up (g = 0.17, 95% CI = 0.04-0.30; k = 14; range = 18-143 weeks). Three intervention components moderated efficacy: engage caregivers in praise/encouragement for positive health-related behavior; provide education about the importance of screen time reduction to caregivers; and engage pediatricians/health care providers. Conclusions: Early childhood obesity interventions are effective in reducing BMI in preschool children. Our findings suggest that facilitating caregiver education about the importance of screen time reduction may be an important strategy in reducing early childhood obesity. |
Economic evaluation of interventions to increase colorectal cancer screening at Federally Qualified Health Centers
Tangka FKL , Subramanian S , Hoover S , DeGroff A , Joseph D , Wong FL , Richardson LC . Health Promot Pract 2020 21 (6) 877-883 The Centers for Disease Control and Prevention (CDC) has a long-standing commitment to increase colorectal cancer (CRC) screening for vulnerable populations. In 2005, the CDC began a demonstration in five states and, with lessons learned, launched a national program, the Colorectal Cancer Control Program (CRCCP), in 2009. The CRCCP continues today and its current emphasis is the implementation of evidence-based interventions to promote CRC screening. The purpose of this article is to provide an overview of four CRCCP awardees and their federally qualified health center partners as an introduction to the accompanying series of research briefs where we present individual findings on impacts of evidence-based interventions on CRC screening uptake for each awardee. We also include in this article the conceptual framework used to guide our research. Our findings contribute to the evidence base and guide future program implementation to improve sustainability, increase CRC screening, and address disparities in screening uptake. |
State and regional variation in prescription- and payment-related promoters of adherence to blood pressure medication
Yang PK , Ritchey MD , Tsipas S , Loustalot F , Wozniak GD . Prev Chronic Dis 2020 17 E112 INTRODUCTION: Medication adherence can improve hypertension management. How blood pressure medications are prescribed and purchased can promote or impede adherence. METHODS: We used comprehensive dispensing data on prescription blood pressure medication from Symphony Health's 2017 Integrated Dataverse to assess how prescription- and payment-related factors that promote medication adherence (ie, fixed-dose combinations, generic formulations, mail order, low-cost or no-copay medications) vary across US states and census regions and across the market segments (grouped by patient age, prescriber type, and payer type) responsible for the greatest number of blood pressure medication fills. RESULTS: In 2017, 706.5 million prescriptions for blood pressure medication were filled, accounting for $29.0 billion in total spending (17.0% incurred by patients). As a proportion of all fills, factors that promoted adherence varied by state: fixed-dose combinations (from 5.8% in Maine to 17.9% in Mississippi); generic formulations (from 95.2% in New Jersey to 98.4% in Minnesota); mail order (from 4.7% in Rhode Island to 14.5% in Delaware); and lower or no copayment (from 56.6% in Utah to 72.8% in California). Furthermore, mean days' supply per fill (from 43.1 in Arkansas to 63.8 in Maine) and patient spending per therapy year (from $38 in Hawaii to $76 in Georgia) varied. Concentration of adherence factors differed by market segment. Patients aged 18 to 64 with a primary care physician prescriber and Medicaid coverage had the lowest concentration of fixed-dose combination fills, mean days' supply per fill, and patient spending per therapy year. Patients aged 65 years or older with a primary care physician prescriber and commercial insurance had the highest concentration of fixed-dose combinations fills and mail order fills. CONCLUSION: Addressing regional and market segment variation in factors promoting blood pressure medication adherence may increase adherence and improve hypertension management. |
Childhood obesity evidence base project: Building translational capacity through meta-analytic methods
Young-Hyman D , Kettel Khan L . Child Obes 2020 16 S249-s254 Purpose: The purpose of this article is to demonstrate the need for and utility of using a taxonomic approach for evidence aggregation and meta-analyses, with focus on prevention and reduction of childhood obesity in very young children. As evidence has been generated through heterogeneous efforts, it is important that the field makes use of all available evidence to learn what works, for who, and in what circumstances. Methods: The Childhood Obesity Evidence Base (COEB) project conducted a taxonomic meta-analysis, using Grounded Theory to code elements present in reports of existing studies and initiatives, of diverse design and evaluation approaches, which were then mapped onto the levels of the socio-ecologic model. This article is the fourth in a series that describes the COEB project overall. It discusses both generally and specifically how taxonomies contribute to traditional meta-analytic methods, what questions can and cannot be answered, the method's contribution to translational (implementation) capacity, and ability to inform future efforts. Results: The COEB project illustrates how the taxonomic meta-analytic approach broadens the evidence base, increases translational capacity for effective intervention components, and evaluates the influence of contextual elements to inform future initiatives. How the method is used to establish associations between varying intervention components, contextual elements, and outcomes is discussed. Conclusions: Taxonomies generated through this process can be used for meta-analysis, serving to generate topic-specific questions associated with intervention approaches and outcomes in context, which is adjunctive to traditional meta-analytic methods and can inform public health approaches. |
High levels of HIV drug resistance among adults failing second-line antiretroviral therapy in Namibia.
Jordan MR , Hamunime N , Bikinesi L , Sawadogo S , Agolory S , Shiningavamwe AN , Negussie T , Fisher-Walker CL , Raizes EG , Mutenda N , Hunter CJ , Dean N , Steegen K , Kana V , Carmona S , Yang C , Tang AM , Parkin N , Hong SY . Medicine (Baltimore) 2020 99 (37) e21661 To support optimal third-line antiretroviral therapy (ART) selection in Namibia, we investigated the prevalence of HIV drug resistance (HIVDR) at time of failure of second-line ART. A cross-sectional study was conducted between August 2016 and February 2017. HIV-infected people ≥15 years of age with confirmed virological failure while receiving ritonavir-boosted protease inhibitor (PI/r)-based second-line ART were identified at 15 high-volume ART clinics representing over >70% of the total population receiving second-line ART. HIVDR genotyping of dried blood spots obtained from these individuals was performed using standard population sequencing methods. The Stanford HIVDR algorithm was used to identify sequences with predicted resistance; genotypic susceptibility scores for potential third-line regimens were calculated. Two hundred thirty-eight individuals were enrolled; 57.6% were female. The median age and duration on PI/r-based ART at time of enrolment were 37 years and 3.46 years, respectively. 97.5% received lopinavir/ritonavir-based regimens. The prevalence of nucleoside reverse transcriptase inhibitor (NRTI), non-nucleoside reverse transcriptase inhibitor (NNRTI), and PI/r resistance was 50.6%, 63.1%, and 13.1%, respectively. No significant association was observed between HIVDR prevalence and age or sex. This study demonstrates high levels of NRTI and NNRTI resistance and moderate levels of PI resistance in people receiving PI/r-based second-line ART in Namibia. Findings underscore the need for objective and inexpensive measures of adherence to identify those in need of intensive adherence counselling, routine viral load monitoring to promptly detect virological failure, and HIVDR genotyping to optimize selection of third-line drugs in Namibia. |
Cryptic transmission of SARS-CoV-2 in Washington state.
Bedford T , Greninger AL , Roychoudhury P , Starita LM , Famulare M , Huang ML , Nalla A , Pepper G , Reinhardt A , Xie H , Shrestha L , Nguyen TN , Adler A , Brandstetter E , Cho S , Giroux D , Han PD , Fay K , Frazar CD , Ilcisin M , Lacombe K , Lee J , Kiavand A , Richardson M , Sibley TR , Truong M , Wolf CR , Nickerson DA , Rieder MJ , Englund JA , Hadfield J , Hodcroft EB , Huddleston J , Moncla LH , Müller NF , Neher RA , Deng X , Gu W , Federman S , Chiu C , Duchin JS , Gautom R , Melly G , Hiatt B , Dykema P , Lindquist S , Queen K , Tao Y , Uehara A , Tong S , MacCannell D , Armstrong GL , Baird GS , Chu HY , Shendure J , Jerome KR . Science 2020 370 (6516) 571-575 Following its emergence in Wuhan, China, in late November or early December 2019, the SARS-CoV-2 virus has rapidly spread globally. Genome sequencing of SARS-CoV-2 allows reconstruction of its transmission history, although this is contingent on sampling. We have analyzed 453 SARS-CoV-2 genomes collected between 20 February and 15 March 2020 from infected patients in Washington State, USA. We find that most SARS-CoV-2 infections sampled during this time derive from a single introduction in late January or early February 2020 which subsequently spread locally before active community surveillance was implemented. |
Serial Testing for SARS-CoV-2 and Virus Whole Genome Sequencing Inform Infection Risk at Two Skilled Nursing Facilities with COVID-19 Outbreaks - Minnesota, April-June 2020.
Taylor J , Carter RJ , Lehnertz N , Kazazian L , Sullivan M , Wang X , Garfin J , Diekman S , Plumb M , Bennet ME , Hale T , Vallabhaneni S , Namugenyi S , Carpenter D , Turner-Harper D , Booth M , Coursey EJ , Martin K , McMahon M , Beaudoin A , Lifson A , Holzbauer S , Reddy SC , Jernigan JA , Lynfield R . MMWR Morb Mortal Wkly Rep 2020 69 (37) 1288-1295 SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), can spread rapidly in high-risk congregate settings such as skilled nursing facilities (SNFs) (1). In Minnesota, SNF-associated cases accounted for 3,950 (8%) of 48,711 COVID-19 cases reported through July 21, 2020; 35% of SNF-associated cases involved health care personnel (HCP*), including six deaths. Facility-wide, serial testing in SNFs has been used to identify residents with asymptomatic and presymptomatic SARS-CoV-2 infection to inform mitigation efforts, including cohorting of residents with positive test results and exclusion of infected HCP from the workplace (2,3). During April-June 2020, the Minnesota Department of Health (MDH), with CDC assistance, conducted weekly serial testing at two SNFs experiencing COVID-19 outbreaks. Among 259 tested residents, and 341 tested HCP, 64% and 33%, respectively, had positive reverse transcription-polymerase chain reaction (RT-PCR) SARS-CoV-2 test results. Continued SARS-CoV-2 transmission was potentially facilitated by lapses in infection prevention and control (IPC) practices, up to 12-day delays in receiving HCP test results (53%) at one facility, and incomplete HCP participation (71%). Genetic sequencing demonstrated that SARS-CoV-2 viral genomes from HCP and resident specimens were clustered by facility, suggesting facility-based transmission. Residents and HCP working in SNFs are at risk for infection with SARS-CoV-2. As part of comprehensive COVID-19 preparation and response, including early identification of cases, SNFs should conduct serial testing of residents and HCP, maximize HCP testing participation, ensure availability of personal protective equipment (PPE), and enhance IPC practices(†) (4-5). |
Coronavirus Disease among Persons with Sickle Cell Disease, United States, March 20-May 21, 2020.
Panepinto JA , Brandow A , Mucalo L , Yusuf F , Singh A , Taylor B , Woods K , Payne AB , Peacock G , Schieve LA . Emerg Infect Dis 2020 26 (10) 2473-2476 Sickle cell disease (SCD) disproportionately affects Black or African American persons in the United States and can cause multisystem organ damage and reduced lifespan. Among 178 persons with SCD in the United States who were reported to an SCD-coronavirus disease case registry, 122 (69%) were hospitalized and 13 (7%) died. |
Preventing and Responding to COVID-19 on College Campuses.
Walke HT , Honein MA , Redfield RR . JAMA 2020 324 (17) 1727-1728 The coronavirus disease 2019 (COVID-19) pandemic continues to present public health and societal challenges worldwide. Concerted public health efforts in the US at the local, state, territorial, national, and tribal levels remain paramount to protecting the population, particularly those at greatest risk for severe illness and death. Throughout the summer months, younger people accounted increasingly for confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in all US regions, with highest incidence among young adults aged 20 through 29 years during June to August, and with young adults (20–39 years) contributing to the large regional increases in the southern US during June 2020.1 |
Adapting HIV services for pregnant and breastfeeding women, infants, children, adolescents and families in resource-constrained settings during the COVID-19 pandemic.
Vrazo AC , Golin R , Fernando NB , Killam WP , Sharifi S , Phelps BR , Gleason MM , Wolf HT , Siberry GK , Srivastava M . J Int AIDS Soc 2020 23 (9) e25622 INTRODUCTION: The COVID-19 pandemic has impacted global health service delivery, including provision of HIV services. Countries with high HIV burden are balancing the need to minimize interactions with health facilities to reduce the risk of COVID-19 transmission, while delivering uninterrupted essential HIV prevention, testing and treatment services. Many of these adaptations in resource-constrained settings have not adequately accounted for the needs of pregnant and breastfeeding women, infants, children and adolescents. We propose whole-family, tailored programme adaptations along the HIV clinical continuum to protect the programmatic gains made in services. DISCUSSION: Essential HIV case-finding services for pregnant and breastfeeding women and children should be maintained and include maternal testing, diagnostic testing for infants exposed to HIV, index testing for children whose biological parents or siblings are living with HIV, as well as for children/adolescents presenting with symptoms concerning for HIV and comorbidities. HIV self-testing for children two years of age and older should be supported with caregiver and provider education. Adaptations include bundling services in the same visit and providing testing outside of facilities to the extent possible to reduce exposure risk to COVID-19. Virtual platforms can be used to identify vulnerable children at risk of HIV infection, abuse, harm or violence, and link them to necessary clinical and psychosocial support services. HIV treatment service adaptations for families should focus on family based differentiated service delivery models, including community-based ART initiation and multi-month ART dispensing. Viral load monitoring should not be a barrier to transitioning children and adolescents experiencing treatment failure to more effective ART regimens, and viral load monitoring for pregnant and breastfeeding women and children should be prioritized and bundled with other essential services. CONCLUSIONS: Protecting pregnant and breastfeeding women, infants, children and adolescents from acquiring SARS-CoV-2 while sustaining essential HIV services is an immense global health challenge. Tailored, family friendly programme adaptations for case-finding, ART delivery and viral load monitoring for these populations have the potential to limit SARS-CoV-2 transmission while ensuring the continuity of life-saving HIV case identification and treatment efforts. |
Does Pulmonary Aspergillosis Complicate Coronavirus Disease 2019?
Beer KD , Jackson BR , Chiller T , Verweij PE , Van de Veerdonk FL , Wauters J . Crit Care Explor 2020 2 (9) e0211 OBJECTIVES: Aspergillus coinfection in coronavirus disease 2019 patients has rarely been described but may be occurring among coronavirus disease 2019 patients admitted to ICUs. Previous reports of viral coinfections with Aspergillus, including influenza-associated pulmonary aspergillosis, suggest that coronavirus disease 2019-associated aspergillosis is plausible. This report aims to summarize what is known about coronavirus disease 2019 complicated by Aspergillus, introduces coronavirus disease 2019-associated pulmonary aspergillosis as a possible clinical entity, and describes reasons clinical suspicion of Aspergillus is warranted in the critical care setting. DATA SOURCES: We summarize the available evidence suggesting the existence of Aspergillus coinfection among severe coronavirus disease 2019 patients. This includes published coronavirus disease 2019 patient case series, a case description, and a review of potential biologic mechanisms. STUDY SELECTION: Reports of coronavirus disease 2019 patient attributes were selected if they included clinical, microbiologic, or radiologic signs of invasive fungal infection. DATA EXTRACTION: Data included in summary tables were identified through a literature search for coronavirus disease 2019-associated pulmonary aspergillosis. DATA SYNTHESIS: We present descriptive data extracted from coronavirus disease 2019-associated pulmonary aspergillosis case series current at the time of article submission. DISCUSSION: Pulmonary aspergillosis is known to occur among influenza patients requiring intensive care and is associated with increased mortality. If Aspergillus coinfections are occurring among coronavirus disease 2019 patients, early clinical suspicion and testing are needed to understand the epidemiology of these infections and prevent associated mortality. As the coronavirus disease 2019 pandemic unfolds, reports on the existence of this coinfection are needed, and opportunities to contribute cases of Aspergillus coinfection among coronavirus disease 2019 patients to an ongoing registry are described. |
Characteristics and Maternal and Birth Outcomes of Hospitalized Pregnant Women with Laboratory-Confirmed COVID-19 - COVID-NET, 13 States, March 1-August 22, 2020.
Delahoy MJ , Whitaker M , O'Halloran A , Chai SJ , Kirley PD , Alden N , Kawasaki B , Meek J , Yousey-Hindes K , Anderson EJ , Openo KP , Monroe ML , Ryan PA , Fox K , Kim S , Lynfield R , Siebman S , Davis SS , Sosin DM , Barney G , Muse A , Bennett NM , Felsen CB , Billing LM , Shiltz J , Sutton M , West N , Schaffner W , Talbot HK , George A , Spencer M , Ellington S , Galang RR , Gilboa SM , Tong VT , Piasecki A , Brammer L , Fry AM , Hall AJ , Wortham JM , Kim L , Garg S . MMWR Morb Mortal Wkly Rep 2020 69 (38) 1347-1354 Pregnant women might be at increased risk for severe coronavirus disease 2019 (COVID-19) (1,2). The COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) (3) collects data on hospitalized pregnant women with laboratory-confirmed SARS-CoV-2, the virus that causes COVID-19; to date, such data have been limited. During March 1-August 22, 2020, approximately one in four hospitalized women aged 15-49 years with COVID-19 was pregnant. Among 598 hospitalized pregnant women with COVID-19, 54.5% were asymptomatic at admission. Among 272 pregnant women with COVID-19 who were symptomatic at hospital admission, 16.2% were admitted to an intensive care unit (ICU), and 8.5% required invasive mechanical ventilation. During COVID-19-associated hospitalizations, 448 of 458 (97.8%) completed pregnancies resulted in a live birth and 10 (2.2%) resulted in a pregnancy loss. Testing policies based on the presence of symptoms might miss COVID-19 infections during pregnancy. Surveillance of pregnant women with COVID-19, including those with asymptomatic infections, is important to understand the short- and long-term consequences of COVID-19 for mothers and newborns. Identifying COVID-19 in women during birth hospitalizations is important to guide preventive measures to protect pregnant women, parents, newborns, other patients, and hospital personnel. Pregnant women and health care providers should be made aware of the potential risks for severe COVID-19 illness, adverse pregnancy outcomes, and ways to prevent infection. |
COVID-19 Contact Tracing in Two Counties - North Carolina, June-July 2020.
Lash RR , Donovan CV , Fleischauer AT , Moore ZS , Harris G , Hayes S , Sullivan M , Wilburn A , Ong J , Wright D , Washington R , Pulliam A , Byers B , McLaughlin HP , Dirlikov E , Rose DA , Walke HT , Honein MA , Moonan PK , Oeltmann JE . MMWR Morb Mortal Wkly Rep 2020 69 (38) 1360-1363 Contact tracing is a strategy implemented to minimize the spread of communicable diseases (1,2). Prompt contact tracing, testing, and self-quarantine can reduce the transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (3,4). Community engagement is important to encourage participation in and cooperation with SARS-CoV-2 contact tracing (5). Substantial investments have been made to scale up contact tracing for COVID-19 in the United States. During June 1-July 12, 2020, the incidence of COVID-19 cases in North Carolina increased 183%, from seven to 19 per 100,000 persons per day* (6). To assess local COVID-19 contact tracing implementation, data from two counties in North Carolina were analyzed during a period of high incidence. Health department staff members investigated 5,514 (77%) persons with COVID-19 in Mecklenburg County and 584 (99%) in Randolph Counties. No contacts were reported for 48% of cases in Mecklenburg and for 35% in Randolph. Among contacts provided, 25% in Mecklenburg and 48% in Randolph could not be reached by telephone and were classified as nonresponsive after at least one attempt on 3 consecutive days of failed attempts. The median interval from specimen collection from the index patient to notification of identified contacts was 6 days in both counties. Despite aggressive efforts by health department staff members to perform case investigations and contact tracing, many persons with COVID-19 did not report contacts, and many contacts were not reached. These findings indicate that improved timeliness of contact tracing, community engagement, and increased use of community-wide mitigation are needed to interrupt SARS-CoV-2 transmission. |
Change in Antibodies to SARS-CoV-2 Over 60 Days Among Health Care Personnel in Nashville, Tennessee.
Patel MM , Thornburg NJ , Stubblefield WB , Talbot HK , Coughlin MM , Feldstein LR , Self WH . JAMA 2020 324 (17) 1781-1782 This study examines the duration of antibody response to SARS-CoV-2 in health care personnel over a 60-day period in Nashville, Tennessee. |
Descriptive epidemiology of coronavirus disease 2019 in Nigeria, 27 February-6 June 2020.
Elimian KO , Ochu CL , Ilori E , Oladejo J , Igumbor E , Steinhardt L , Wagai J , Arinze C , Ukponu W , Obiekea C , Aderinola O , Crawford E , Olayinka A , Dan-Nwafor C , Okwor T , Disu Y , Yinka-Ogunleye A , Kanu NE , Olawepo OA , Aruna O , Michael CA , Dunkwu L , Ipadeola O , Naidoo D , Umeokonkwo CD , Matthias A , Okunromade O , Badaru S , Jinadu A , Ogunbode O , Egwuenu A , Jafiya A , Dalhat M , Saleh F , Ebhodaghe GB , Ahumibe A , Yashe RU , Atteh R , Nwachukwu WE , Ezeokafor C , Olaleye D , Habib Z , Abdus-Salam I , Pembi E , John D , Okhuarobo UJ , Assad H , Gandi Y , Muhammad B , Nwagwogu C , Nwadiuto I , Sulaiman K , Iwuji I , Okeji A , Thliza S , Fagbemi S , Usman R , Mohammed AA , Adeola-Musa O , Ishaka M , Aketemo U , Kamaldeen K , Obagha CE , Akinyode AO , Nguku P , Mba N , Ihekweazu C . Epidemiol Infect 2020 148 1-42 The objective of this study was to describe the epidemiology of COVID-19 in Nigeria with a view of generating evidence to enhance planning and response strategies. A national surveillance dataset between 27 February and 6 June 2020 was retrospectively analysed, with confirmatory testing for COVID-19 done by real-time polymerase chain reaction (RT-PCR). The primary outcomes were cumulative incidence (CI) and case fatality (CF). A total of 40 926 persons (67% of total 60 839) had complete records of RT-PCR test across 35 states and the Federal Capital Territory, 12 289 (30.0%) of whom were confirmed COVID-19 cases. Of those confirmed cases, 3467 (28.2%) had complete records of clinical outcome (alive or dead), 342 (9.9%) of which died. The overall CI and CF were 5.6 per 100 000 population and 2.8%, respectively. The highest proportion of COVID-19 cases and deaths were recorded in persons aged 31-40 years (25.5%) and 61-70 years (26.6%), respectively; and males accounted for a higher proportion of confirmed cases (65.8%) and deaths (79.0%). Sixty-six per cent of confirmed COVID-19 cases were asymptomatic at diagnosis. In conclusion, this paper has provided an insight into the early epidemiology of COVID-19 in Nigeria, which could be useful for contextualising public health planning. |
Disparities in COVID-19 Incidence, Hospitalizations, and Testing, by Area-Level Deprivation - Utah, March 3-July 9, 2020.
Lewis NM , Friedrichs M , Wagstaff S , Sage K , LaCross N , Bui D , McCaffrey K , Barbeau B , George A , Rose C , Willardson S , Carter A , Smoot C , Nakashima A , Dunn A . MMWR Morb Mortal Wkly Rep 2020 69 (38) 1369-1373 Coronavirus disease 2019 (COVID-19) has had a substantial impact on racial and ethnic minority populations and essential workers in the United States, but the role of geographic social and economic inequities (i.e., deprivation) in these disparities has not been examined (1,2). As of July 9, 2020, Utah had reported 27,356 confirmed COVID-19 cases. To better understand how area-level deprivation might reinforce ethnic, racial, and workplace-based COVID-19 inequities (3), the Utah Department of Health (UDOH) analyzed confirmed cases of infection with SARS-CoV-2 (the virus that causes COVID-19), COVID-19 hospitalizations, and SARS-CoV-2 testing rates in relation to deprivation as measured by Utah's Health Improvement Index (HII) (4). Age-weighted odds ratios (weighted ORs) were calculated by weighting rates for four age groups (≤24, 25-44, 45-64, and ≥65 years) to a 2000 U.S. Census age-standardized population. Odds of infection increased with level of deprivation and were two times greater in high-deprivation areas (weighted OR = 2.08; 95% confidence interval [CI] = 1.99-2.17) and three times greater (weighted OR = 3.11; 95% CI = 2.98-3.24) in very high-deprivation areas, compared with those in very low-deprivation areas. Odds of hospitalization and testing also increased with deprivation, but to a lesser extent. Local jurisdictions should use measures of deprivation and other social determinants of health to enhance transmission reduction strategies (e.g., increasing availability and accessibility of SARS-CoV-2 testing and distributing prevention guidance) to areas with greatest need. These strategies might include increasing availability and accessibility of SARS-CoV-2 testing, contact tracing, isolation options, preventive care, disease management, and prevention guidance to facilities (e.g., clinics, community centers, and businesses) in areas with high levels of deprivation. |
SARS-CoV-2 Infection Among Hospitalized Pregnant Women: Reasons for Admission and Pregnancy Characteristics - Eight U.S. Health Care Centers, March 1-May 30, 2020.
Panagiotakopoulos L , Myers TR , Gee J , Lipkind HS , Kharbanda EO , Ryan DS , Williams JTB , Naleway AL , Klein NP , Hambidge SJ , Jacobsen SJ , Glanz JM , Jackson LA , Shimabukuro TT , Weintraub ES . MMWR Morb Mortal Wkly Rep 2020 69 (38) 1355-1359 Pregnant women might be at increased risk for severe coronavirus disease 2019 (COVID-19), possibly related to changes in their immune system and respiratory physiology* (1). Further, adverse birth outcomes, such as preterm delivery and stillbirth, might be more common among pregnant women infected with SARS-CoV-2, the virus that causes COVID-19 (2,3). Information about SARS-CoV-2 infection during pregnancy is rapidly growing; however, data on reasons for hospital admission, pregnancy-specific characteristics, and birth outcomes among pregnant women hospitalized with SARS-CoV-2 infections are limited. During March 1-May 30, 2020, as part of Vaccine Safety Datalink (VSD)(†) surveillance of COVID-19 hospitalizations, 105 hospitalized pregnant women with SARS-CoV-2 infection were identified, including 62 (59%) hospitalized for obstetric reasons (i.e., labor and delivery or another pregnancy-related indication) and 43 (41%) hospitalized for COVID-19 illness without an obstetric reason. Overall, 50 (81%) of 62 pregnant women with SARS-CoV-2 infection who were admitted for obstetric reasons were asymptomatic. Among 43 pregnant women hospitalized for COVID-19, 13 (30%) required intensive care unit (ICU) admission, six (14%) required mechanical ventilation, and one died from COVID-19. Prepregnancy obesity was more common (44%) among pregnant women hospitalized for COVID-19 than that among asymptomatic pregnant women hospitalized for obstetric reasons (31%). Likewise, the rate of gestational diabetes (26%) among pregnant women hospitalized for COVID-19 was higher than it was among women hospitalized for obstetric reasons (8%). Preterm delivery occurred in 15% of pregnancies among 93 women who delivered, and stillbirths (fetal death at ≥20 weeks' gestation) occurred in 3%. Antenatal counseling emphasizing preventive measures (e.g., use of masks, frequent hand washing, and social distancing) might help prevent COVID-19 among pregnant women,(§) especially those with prepregnancy obesity and gestational diabetes, which might reduce adverse pregnancy outcomes. |
Update: Characteristics of Health Care Personnel with COVID-19 - United States, February 12-July 16, 2020.
Hughes MM , Groenewold MR , Lessem SE , Xu K , Ussery EN , Wiegand RE , Qin X , Do T , Thomas D , Tsai S , Davidson A , Latash J , Eckel S , Collins J , Ojo M , McHugh L , Li W , Chen J , Chan J , Wortham JM , Reagan-Steiner S , Lee JT , Reddy SC , Kuhar DT , Burrer SL , Stuckey MJ . MMWR Morb Mortal Wkly Rep 2020 69 (38) 1364-1368 As of September 21, 2020, the coronavirus disease 2019 (COVID-19) pandemic had resulted in 6,786,352 cases and 199,024 deaths in the United States.* Health care personnel (HCP) are essential workers at risk for exposure to patients or infectious materials (1). The impact of COVID-19 on U.S. HCP was first described using national case surveillance data in April 2020 (2). Since then, the number of reported HCP with COVID-19 has increased tenfold. This update describes demographic characteristics, underlying medical conditions, hospitalizations, and intensive care unit (ICU) admissions, stratified by vital status, among 100,570 HCP with COVID-19 reported to CDC during February 12-July 16, 2020. HCP occupation type and job setting are newly reported. HCP status was available for 571,708 (22%) of 2,633,585 cases reported to CDC. Most HCP with COVID-19 were female (79%), aged 16-44 years (57%), not hospitalized (92%), and lacked all 10 underlying medical conditions specified on the case report form(†) (56%). Of HCP with COVID-19, 641 died. Compared with nonfatal COVID-19 HCP cases, a higher percentage of fatal cases occurred in males (38% versus 22%), persons aged ≥65 years (44% versus 4%), non-Hispanic Asians (Asians) (20% versus 9%), non-Hispanic Blacks (Blacks) (32% versus 25%), and persons with any of the 10 underlying medical conditions specified on the case report form (92% versus 41%). From a subset of jurisdictions reporting occupation type or job setting for HCP with COVID-19, nurses were the most frequently identified single occupation type (30%), and nursing and residential care facilities were the most common job setting (67%). Ensuring access to personal protective equipment (PPE) and training, and practices such as universal use of face masks at work, wearing masks in the community, and observing social distancing remain critical strategies to protect HCP and those they serve. |
Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection - United Kingdom and United States, March-August 2020.
Morris SB , Schwartz NG , Patel P , Abbo L , Beauchamps L , Balan S , Lee EH , Paneth-Pollak R , Geevarughese A , Lash MK , Dorsinville MS , Ballen V , Eiras DP , Newton-Cheh C , Smith E , Robinson S , Stogsdill P , Lim S , Fox SE , Richardson G , Hand J , Oliver NT , Kofman A , Bryant B , Ende Z , Datta D , Belay E , Godfred-Cato S . MMWR Morb Mortal Wkly Rep 2020 69 (40) 1450-1456 During the course of the coronavirus disease 2019 (COVID-19) pandemic, reports of a new multisystem inflammatory syndrome in children (MIS-C) have been increasing in Europe and the United States (1-3). Clinical features in children have varied but predominantly include shock, cardiac dysfunction, abdominal pain, and elevated inflammatory markers, including C-reactive protein (CRP), ferritin, D-dimer, and interleukin-6 (1). Since June 2020, several case reports have described a similar syndrome in adults; this review describes in detail nine patients reported to CDC, seven from published case reports, and summarizes the findings in 11 patients described in three case series in peer-reviewed journals (4-6). These 27 patients had cardiovascular, gastrointestinal, dermatologic, and neurologic symptoms without severe respiratory illness and concurrently received positive test results for SARS-CoV-2, the virus that causes COVID-19, by polymerase chain reaction (PCR) or antibody assays indicating recent infection. Reports of these patients highlight the recognition of an illness referred to here as multisystem inflammatory syndrome in adults (MIS-A), the heterogeneity of clinical signs and symptoms, and the role for antibody testing in identifying similar cases among adults. Clinicians and health departments should consider MIS-A in adults with compatible signs and symptoms. These patients might not have positive SARS-CoV-2 PCR or antigen test results, and antibody testing might be needed to confirm previous SARS-CoV-2 infection. Because of the temporal association between MIS-A and SARS-CoV-2 infections, interventions that prevent COVID-19 might prevent MIS-A. Further research is needed to understand the pathogenesis and long-term effects of this newly described condition. |
Characteristics Associated with Adults Remembering to Wash Hands in Multiple Situations Before and During the COVID-19 Pandemic - United States, October 2019 and June 2020.
Haston JC , Miller GF , Berendes D , Andújar A , Marshall B , Cope J , Hunter CM , Robinson BM , Hill VR , Garcia-Williams AG . MMWR Morb Mortal Wkly Rep 2020 69 (40) 1443-1449 Washing hands often, especially during times when one is likely to acquire and spread pathogens,* is one important measure to help prevent the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), as well as other pathogens spread by respiratory or fecal-oral transmission (1,2). Studies have reported moderate to high levels of self-reported handwashing among adults worldwide during the COVID-19 pandemic (3-5)(†); however, little is known about how handwashing behavior among U.S. adults has changed since the start of the pandemic. For this study, survey data from October 2019 (prepandemic) and June 2020 (during pandemic) were compared to assess changes in adults' remembering to wash their hands in six situations.(§) Statistically significant increases in reported handwashing were seen in June 2020 compared with October 2019 in four of the six situations; the odds of remembering to wash hands was 2.3 times higher among respondents after coughing, sneezing, or blowing their nose, 2.0 times higher before eating at a restaurant, and 1.7 times higher before eating at home. Men, young adults aged 18-24 years, and non-Hispanic White (White) adults were less likely to remember to wash hands in multiple situations. Strategies to help persons remember to wash their hands frequently and at important times should be identified and implemented, especially among groups reporting low prevalence of remembering to wash their hands. |
Adolescent with COVID-19 as the Source of an Outbreak at a 3-Week Family Gathering - Four States, June-July 2020.
Schwartz NG , Moorman AC , Makaretz A , Chang KT , Chu VT , Szablewski CM , Yousaf AR , Brown MM , Clyne A , DellaGrotta A , Drobeniuc J , Korpics J , Muir A , Drenzek C , Bandy U , Kirking HL , Tate JE , Hall AJ , Lanzieri TM , Stewart RJ . MMWR Morb Mortal Wkly Rep 2020 69 (40) 1457-1459 There is increasing evidence that children and adolescents can efficiently transmit SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1-3). During July-August 2020, four state health departments and CDC investigated a COVID-19 outbreak that occurred during a 3-week family gathering of five households in which an adolescent aged 13 years was the index and suspected primary patient; 11 subsequent cases occurred. |
Trends in COVID-19 Incidence After Implementation of Mitigation Measures - Arizona, January 22-August 7, 2020.
Gallaway MS , Rigler J , Robinson S , Herrick K , Livar E , Komatsu KK , Brady S , Cunico J , Christ CM . MMWR Morb Mortal Wkly Rep 2020 69 (40) 1460-1463 Mitigating the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), requires individual, community, and state public health actions to prevent person-to-person transmission. Community mitigation measures can help slow the spread of COVID-19; these measures include wearing masks, social distancing, reducing the number and size of large gatherings, pausing operation of businesses where maintaining social distancing is challenging, working from or staying at home, and implementing certain workplace and educational institution controls (1-4). The Arizona Department of Health Services' (ADHS) recommendations for mitigating exposure to SARS-CoV-2 were informed by continual monitoring of patient demographics, SARS-CoV-2 community spread, and the pandemic's impacts on hospitals. To assess the effect of mitigation strategies in Arizona, the numbers of daily COVID-19 cases and 7-day moving averages during January 22-August 7, 2020, relative to implementation of enhanced community mitigation measures, were examined. The average number of daily cases increased approximately 151%, from 808 on June 1, 2020 to 2,026 on June 15, 2020 (after stay-at-home order lifted), necessitating increased preventive measures. On June 17, local officials began implementing and enforcing mask wearing (via county and city mandates),* affecting approximately 85% of the state population. Statewide mitigation measures included limitation of public events; closures of bars, gyms, movie theaters, and water parks; reduced restaurant dine-in capacity; and voluntary resident action to stay at home and wear masks (when and where not mandated). The number of COVID-19 cases in Arizona peaked during June 29-July 2, stabilized during July 3-July 12, and further declined by approximately 75% during July 13-August 7. Widespread implementation and enforcement of sustained community mitigation measures informed by state and local officials' continual data monitoring and collaboration can help prevent transmission of SARS-CoV-2 and decrease the numbers of COVID-19 cases. |
Public awareness of invasive fungal diseases - United States, 2019
Benedict K , Molinari NAM , Jackson BR . MMWR Morb Mortal Wkly Rep 2020 69 (38) 1343-1346 Fungal diseases range from minor skin and mucous membrane infections to life-threatening disseminated disease. The estimated yearly direct health care costs of fungal diseases exceed $7.2 billion (1). These diseases are likely widely underdiagnosed (1,2), and improved recognition among health care providers and members of the public is essential to reduce delays in diagnoses and treatment. However, information about public awareness of fungal diseases is limited. To guide public health educational efforts, a nationally representative online survey was conducted to assess whether participants had ever heard of six invasive fungal diseases. Awareness was low and varied by disease, from 4.1% for blastomycosis to 24.6% for candidiasis. More than two thirds (68.9%) of respondents had never heard of any of the diseases. Female sex, higher education, and increased number of prescription medications were associated with awareness. These findings can serve as a baseline to compare with future surveys; they also indicate that continued strategies to increase public awareness about fungal diseases are needed. |
Oseltamivir provides up to 3 days earlier time to recovery over usual care
Campbell AP , Uyeki TM . J Pediatr 2020 220 264-267 Question | Among patients with influenza, what is the therapeutic efficacy of oseltamivir, compared with usual care, in time to recovery? | | Design | Block randomized, stratified (<12, 12 to <65, and ≥65 years), controlled, unblinded, pragmatic trial. | | Setting | 15 European countries. | | Participants | 3259 patients, 448 children. | | Intervention | Oseltamivir versus usual care. | | Outcomes | Time to recovery. | | Main Results | Compared with usual care, the time to recovery with oseltamivir was 0·70 days earlier (95% Bayesian Credible Interval, 0.30–1.20) in patients younger than 12 years and/or with milder illness to 3.20 days (95% BCrI 1·00–5·50) in patients aged 65 years or older and/or with more severe illness. | | Conclusions | Oseltamivir provided an overall time to recovery benefit of 1 day, with older/sicker patients deriving more benefit. |
Global seasonal influenza mortality estimates: a comparison of three different approaches
Cozza V , Campbell H , Chang HH , Iuliano AD , Paget J , Patel NN , Reiner RC , Troeger C , Viboud C , Bresee JS , Fitzner J . Am J Epidemiol 2020 190 (5) 718-727 Prior to updating global influenza-associated mortality estimates, the World Health Organization convened a consultation in July 2017 to understand differences in methodology and implications on results of three influenza mortality projects from the United States Centers for Disease Control and Prevention (CDC), the Netherlands Institute for Health Service Research (GLaMOR), and the Institute for Health Metrics and Evaluation (IHME). The expert panel reviewed estimates and discussed differences in data sources, analysis, and modeling assumptions. We performed a comparison analysis of the estimates. Influenza-associated respiratory death counts were comparable between CDC and GLaMOR; IHME estimate was considerably lower. The greatest country-specific influenza-associated mortality rate fold differences between CDC/IHME and between GLaMOR/IHME estimates were among countries in South-East Asia and Eastern Mediterranean region. The data envelope used for the calculation was one of the major differences (CDC and GLaMOR: all respiratory deaths; IHME: low respiratory infection deaths). With the assumption that there is only one cause of death for each death, IHME estimates a fraction of the full influenza-associated respiratory mortality that is measured by the other two groups. Wide variability of parameters was observed. Continued coordination between groups could assist with better understanding of methodological differences and new approaches to estimating influenza deaths globally. |
Barriers to antiretroviral therapy adherence among HIV-positive Hispanic and Latino men who have sex with men -United States, 2015-2019
Crim SM , Tie Y , Beer L , Weiser J , Dasgupta S . MMWR Morb Mortal Wkly Rep 2020 69 (40) 1437-1442 During 2018, estimated incidence of human immunodeficiency virus (HIV) infection among Hispanic and Latino (Hispanic/Latino) persons in the United States was four times that of non-Hispanic White persons (1). Hispanic/Latino men who have sex with men (MSM) accounted for 24% (138,023) of U.S. MSM living with diagnosed HIV infection at the end of 2018 (1). Antiretroviral therapy (ART) adherence is crucial for viral suppression, which improves health outcomes and prevents HIV transmission (2). Barriers to ART adherence among Hispanic/Latino MSM have been explored in limited contexts (3); however, nationally representative analyses are lacking. The Medical Monitoring Project reports nationally representative estimates of behavioral and clinical experiences of U.S. adults with diagnosed HIV infection. This analysis used Medical Monitoring Project data collected during 2015-2019 to examine ART adherence and reasons for missing ART doses among HIV-positive Hispanic/Latino MSM (1,673). On a three-item ART adherence scale with 100 being perfect adherence, 77.3% had a score of ≥85. Younger age, poverty, recent drug use, depression, and unmet needs for ancillary services were predictors of lower ART adherence. The most common reason for missing an ART dose was forgetting; 63.9% of persons who missed ≥1 dose reported more than one reason. Interventions that support ART adherence and access to ancillary services among Hispanic/Latino MSM might help improve clinical outcomes and reduce transmission. |
HIV-positive persons who inject drugs experience poor health outcomes and unmet needs for care services
Dasgupta S , Tie Y , Lemons-Lyn A , Broz D , Buchacz K , Shouse RL . AIDS Care 2020 33 (9) 1-9 Comparison of social determinants of health and clinical outcomes between HIV-positive persons who inject drugs (PWID) and HIV-positive persons who do not inject drugs is essential to understanding disparities and informing HIV prevention and care efforts; however, nationally representative estimates are lacking. Interview and medical record data were collected for the Medical Monitoring Project during 2015-2018 among U.S. adults with diagnosed HIV. Among HIV-positive PWID (N=340) and HIV-positive persons who do not inject drugs (N=11,475), we reported weighted percentages and prevalence ratios with predicted marginal means to compare differences between groups (P<.05). Associations with clinical outcomes were adjusted for age, race/ethnicity, and gender. HIV-positive PWID were more likely to be homeless (29.1% vs. 8.1%) and incarcerated (18.3% vs. 4.9%). HIV-positive PWID were less likely to be retained in HIV care (aPR: 0.85 [95% CI: 0.77-0.94]), and were more likely to have poor HIV outcomes, have unmet needs for care services (aPR: 1.50 [1.39-1.61]), seek non-routine care, and experience healthcare discrimination (aPR: 1.42 [1.17-1.73]). Strengthening interventions supporting (1) continuity of care given high levels of incarceration and housing instability, (2) early ART initiation and adherence support, and (3) drug treatment and harm reduction programs to limit transmission risk may improve outcomes among HIV-positive PWID. |
Why are rates of reported chlamydia changing in the United States: Insights from the National Job Training Program
Diesel J , Kreisel K , Learner E , Torrone E , Peterman T . Sex Transm Dis 2020 48 (3) 152-160 BACKGROUND: During 2010-2017, rates of reported chlamydia decreased among young Black women but increased for White women and all men. Since chlamydia case rates can be influenced by changes in prevalence, screening, and other factors, we compared chlamydia prevalence trends in a sentinel population to national case rate trends to understand potential drivers of case rate trends. METHODS: Chlamydia prevalence was calculated annually among 16-24 year old entrants to the National Job Training Program (NJTP) during 2010-2017. An expectation-maximization-based maximum likelihood approach was used to adjust for misclassification due to imperfect test sensitivity and specificity. Models were stratified by sex, age, and race/ethnicity. A statistically significant trend in prevalence was defined as non-overlapping 95% confidence intervals comparing 2010 and 2017. Trends in chlamydia prevalence were compared to trends in case rates using percentage change over time; relative changes ≥10% were considered meaningful. RESULTS: Among NJTP entrants during 2010-2017, chlamydia prevalence was stable for all Black women, while case rates decreased for adolescents (-12%) and were stable for 20-24 year-olds (-4%). Among adolescent White women, prevalence was stable while case rates increased (+30%). For White women aged 20-24 years, prevalence increased +62% and case rates increased +43%. Trends in prevalence differed from trends in case rates for all subgroups of men. CONCLUSIONS: Prevalence trends in this sentinel population differed from national case rate trends for Black women, White women, and men, suggesting potential decreased screening among Black women 16-19, increased prevalence among White women 20-24, and increased screening among men. |
Impact of breastfeeding, maternal antiretroviral treatment and health service factors on 18-month vertical transmission of HIV and HIV-free survival: results from a nationally representative HIV-exposed infant cohort, South Africa
Goga AE , Lombard C , Jackson D , Ramokolo V , Ngandu NK , Sherman G , Puren A , Chirinda W , Bhardwaj S , Makhari N , Ramraj T , Magasana V , Singh Y , Pillay Y , Dinh TH . J Epidemiol Community Health 2020 74 (12) 1069-1077 BACKGROUND: We analysed the impact of breastfeeding, antiretroviral drugs and health service factors on cumulative (6 weeks to 18 months) vertical transmission of HIV (MTCT) and 'MTCT-or-death', in South Africa, and compared estimates with global impact criteria to validate MTCT elimination: (1) <5% final MTCT and (2) case rate ≤50 (new paediatric HIV infections/100 000 live births). METHODS: 9120 infants aged 6 weeks were enrolled in a nationally representative survey. Of 2811 HIV-exposed uninfected infants (HEU), 2644 enrolled into follow-up (at 3, 6, 9, 12, 15 and 18 months). Using Kaplan-Meier analysis and weighted survey domain-based Cox proportional hazards models, we estimated cumulative risk of MTCT and 'MTCT or death' and risk factors for time-to-event outcomes, adjusting for study design and loss-to-follow-up. RESULTS: Cumulative (final) MTCT was 4.3% (95% CI 3.7% to 5.0%); case rate was 1290. Postnatal MTCT (>6 weeks to 18 months) was 1.7% (95% CI 1.2% to 2.4%). Cumulative 'MTCT-or-death' was 6.3% (95% CI 5.5% to 7.3%); 81% and 62% of cumulative MTCT and 'MTCT-or-death', respectively, occurred by 6 months. Postnatal MTCT increased with unknown maternal CD4-cell-count (adjusted HR (aHR 2.66 (1.5-5.6)), undocumented maternal HIV status (aHR 2.21 (1.0-4.7)) and exclusive (aHR 2.3 (1.0-5.2)) or mixed (aHR 3.7 (1.2-11.4)) breastfeeding. Cumulative 'MTCT-or death' increased in households with 'no refrigerator' (aHR 1.7 (1.1-2.9)) and decreased if infants used nevirapine at 6 weeks (aHR 0.4 (0.2-0.9)). CONCLUSIONS: While the <5% final MTCT target was met, the case rate was 25-times above target. Systems are needed in the first 6 months post-delivery to optimise HEU health and fast-track ART initiation in newly diagnosed mothers. |
High HIV and syphilis prevalence among female sex workers in Juba, South Sudan
Hakim AJ , Bolo A , Werner M , Achut V , Katoro J , Caesar G , Lako R , Taban AI , Wesson J , Okiria AG . PLoS One 2020 15 (9) e0239543 HIV prevalence is estimated to be 2.7% in South Sudan; however, little is known about the young country's epidemic. We conducted a respondent-driven sampling biobehavioral survey in Juba of female sex workers (FSW) aged ≥15 years who sold or exchanged sex in the last 6 months to learn more about this population. We enrolled 838 FSW from November 2015 to March 2016 and estimated HIV prevalence to be 37.8%. Prevalence of active syphilis was 7.3%. FSW were from South Sudan and most neighboring countries. Comprehensive knowledge of HIV was 11.1% and 64.2% of FSW had never spoken with an outreach worker. In multivariable analysis, HIV was associated with being from Uganda (aOR: 3.3, 95% CI: 1.7-6.1) or Kenya (aOR: 4.3, 95% CI: 1.5-13.0) versus from South Sudan. Our survey suggests that FSW may play a critical role in South Sudan's HIV epidemic and highlights the importance of tailoring services to the unique needs of FSW of all nationalities in Juba. |
High prevalence of chlamydia and gonorrhea and the need for STI testing among men who have sex with men and transgender women in Papua New Guinea
Hakim AJ , Iwamoto C , Badman SG , Willie B , Pekon S , Aeno H , Neo-Boli R , Ase S , Weikum D , Vallely AJ , Kelly-Hanku A . Sex Transm Dis 2020 48 (2) 109-117 BACKGROUND: Papua New Guinea (PNG) has among the highest prevalence of sexually transmitted infections in the world but no estimates of Chlamydia trachomatis, Neisseria gonorrhoeae, or hepatitis B virus (HBV) are available among men who have sex with men (MSM) or transgender women (TGW). METHODS: We conducted respondent-driven sampling surveys among MSM and TGW in Port Moresby, Lae, and Mt. Hagen (2016-2017) to characterize prevalence of these infections. Eligibility criteria: aged>12 years, born male, could speak English or Tok Pisin and had oral or anal sex with another person born male in the past 6 months. Participants were surveyed face-to-face and offered testing for anorectal and genital chlamydia and gonorrhea, syphilis, HIV, and HBV. All results are RDS-weighted. RESULTS: We enrolled 400 participants in Port Moresby, 352 in Lae, and 111 in Mt. Hagen. Chlamydia prevalence in the three cities regardless of anatomical site was 19.9%, 19.2%, and 24.3%, respectively. Gonorrhea prevalence regardless of anatomical site was 10.3%, 9.4%, and 9.6%, respectively. HBV prevalence was 11.7%, 13.8%, and 13.6%, respectively. In multivariable analysis, syphilis was associated with having either chlamydia or gonorrhea in Port Moresby (adjusted odds ratio [aOR]: 4.0, 95% CI: 2.0-7.9) and Lae (aOR: 2.4, 95% CI: 1.2-5.0). CONCLUSIONS: There is a large unmet need among MSM and TGW in PNG for chlamydia and gonorrhea detection and treatment. The high prevalence of HBV reinforces the importance of ensuring introduction and scale up of HBV treatment and immunization. Urgent efforts are needed to introduce laboratory-based diagnosis for chlamydia and gonorrhea to ensure these populations have access to much needed treatment services. |
Uptake of online HIV-related continuing medical education training among primary care providers in Southeast United States, 2017-2018
Henny KD , Duke CC , Sutton MY . AIDS Care 2020 33 (12) 1-10 Primary care providers play a vital role for HIV prevention and care in high burden areas of the Southeast United States. Studies reveal that only a third of these providers had previous HIV-related training. We evaluated the effects of targeted online continuing medical education training on HIV-related knowledge, attitudes and practices among providers in the Southeast. During April 2017-February 2018, we administered baseline and six-month follow-up surveys to assess changes attributed to online training among a representative sample of providers from six Southeast locations. Data were analyzed using logistic regression analysis (p < 0.05). Baseline and follow-up surveys were completed by 349 participants (61.2% female, 64.6% white, 69.6% physicians, and 27.5% aged 40 years or less); 18% (n = 63) of whom visited online training websites sent following the baseline survey. Comparing baseline versus follow-up responses, providers who completed online training were half as likely to identify "patients' age" (30% vs. 15%) and "patients' race" (3% vs. 1.4%) as barriers to discussing sex with clients; survey responses by participants who declined training remained unchanged. Based on baseline versus follow-up responses, providers who visited online training websites were more likely to become familiar with preexposure prophylaxis (PrEP) (38% vs. 58%); participants who declined training remained unchanged at 45%. No impact on clinical practices such as PrEP prescriptions was identified. Targeted online training can enhance HIV readiness and should be explored for providers in the Southeast, particularly for enhancing PrEP service delivery. |
Provider adherence to syphilis testing guidelines among stillbirth cases
Ho YA , Allen K , Tao G , Patel CG , Arno JN , Broyles AA , Dixon BE . Sex Transm Dis 2020 47 (10) 686-690 BACKGROUND: The Centers for Disease Control and Prevention (CDC) recommends that all women with a stillbirth have a syphilis test after delivery. Our study seeks to evaluate adherence to CDC guidelines for syphilis screening among women with a stillbirth delivery. METHODS: We used data recorded in electronic health records for women who gave birth between January 1, 2014, and December 31, 2016. Patients were included if they were 18 to 44 years old and possessed an International Classification of Diseases, Ninth Revision or Tenth Revision, Clinical Modification diagnosis of stillbirth. Stillbirth diagnoses were confirmed through a random sample of medical chart reviews. To evaluate syphilis screening, we estimated the proportion of women who received syphilis testing within 300 days before stillbirth, women who received syphilis testing within 30 days after a stillbirth delivery, and women who received syphilis testing both before and after stillbirth delivery. RESULTS: We identified 1111 stillbirths among a population of 865,429 unique women with encounter data available from electronic health records. Among a sample of 127 chart-reviewed cases, only 35 (27.6%) were confirmed stillbirth cases, 45 (35.4%) possible stillbirth cases, 39 (30.7%) cases of miscarriage, and 8 (6.3%) cases of live births. Among confirmed stillbirth cases, 51.4% had any syphilis testing conducted, 31.4% had testing before their stillbirth delivery, 42.9% had testing after the delivery, and only 22.9% had testing before and after delivery. CONCLUSIONS: A majority of women with a stillbirth delivery do not receive syphilis screening adherent to CDC guidelines. Stillbirth International Classification of Diseases codes do not accurately identify cases of stillbirth. |
An evaluation of 6-month versus continuous isoniazid preventive therapy for M. tuberculosis in adults living with HIV/AIDS in Malawi
Hsieh YL , Jahn A , Menzies NA , Yaesoubi R , Salomon JA , Girma B , Gunde L , Eaton JW , Auld A , Odo M , Kiyiika CN , Kalua T , Chiwandira B , Mpunga JU , Mbendra K , Corbett L , Hosseinipour MC , Cohen T , Kunkel A . J Acquir Immune Defic Syndr 2020 85 (5) 643-650 BACKGROUND: To assist the Malawi Ministry of Health to evaluate two competing strategies for scale-up of isoniazid preventive therapy (IPT) among HIV-positive adults receiving ART. SETTING: Malawi. METHODS: We used a multi-district, compartmental model of the Malawi TB/HIV epidemic to compare the anticipated health impacts of 6-month versus continuous IPT programs over a 12-year horizon, while respecting a US$10.8 million constraint on drug costs in the first three years. RESULTS: The 6-month IPT program could be implemented nationwide while the continuous IPT alternative could be introduced in 14 (out of 27) districts. By the end of year 12, the continuous IPT strategy was predicted to avert more TB cases than the 6-month alternative, although not statistically significantly (2368 additional cases averted; 95%PI, -1459, 5023). The 6-month strategy required fewer person-years of IPT to avert a case of TB or death than the continuous strategy. For both programs, the mean reductions in TB incidence among PLHIV by year 12 were expected to be <10%, and the cumulative numbers of IPT-related hepatotoxicity to exceed the number of all-cause deaths averted in the first three years. CONCLUSION: With the given budgetary constraint, nationwide implementation of 6-month IPT would be more efficient and yield comparable health benefits than implementing continuous IPT program in fewer districts. The anticipated health effects associated with both IPT strategies suggested a combination of different TB intervention strategies would likely be required to yield greater impact on TB control in settings like Malawi, where ART coverage is relatively high. |
Trends in diagnosis of HIV infection, linkage to medical care, and viral suppression among men who have sex with men, by race/ethnicity and age - 33 jurisdictions, United States, 2014-2018
Jeffries WL 4th , Dailey AF , Jin C , Carter JW Jr , Scales L . MMWR Morb Mortal Wkly Rep 2020 69 (38) 1337-1342 During 2018, gay, bisexual, and other men who have sex with men (MSM) accounted for 69.4% of all diagnoses of human immunodeficiency virus (HIV) infection in the United States (1). Moreover, in all 42 jurisdictions with complete laboratory reporting of CD4 and viral load results,* percentages of MSM linked to care within 1 month (80.8%) and virally suppressed (viral load <200 copies of HIV RNA/mL or interpreted as undetected) within 6 months (68.3%) of diagnosis were below target during 2018 (2). African American/Black (Black), Hispanic/Latino (Hispanic), and younger MSM disproportionately experience HIV diagnosis, not being linked to care, and not being virally suppressed. To characterize trends in these outcomes, CDC analyzed National HIV Surveillance System(†) data from 2014 to 2018. The number of diagnoses of HIV infection among all MSM decreased 2.3% per year (95% confidence interval [CI] = 1.9-2.8). However, diagnoses did not significantly change among either Hispanic MSM or any MSM aged 13-19 years; increased 2.2% (95% CI = 1.0-3.4) and 2.0% (95% CI = 0.6-3.3) per year among Black and Hispanic MSM aged 25-34 years, respectively; and were highest in absolute count among Black MSM. Annual percentages of linkage to care within 1 month and viral suppression within 6 months of diagnosis among all MSM increased (2.9% [95% CI = 2.4-3.5] and 6.8% [95% CI = 6.2-7.4] per year, respectively). These findings, albeit promising, warrant intensified prevention efforts for Black, Hispanic, and younger MSM. |
Modeling an integrated HIV prevention and care continuum to achieve the ending the HIV epidemic goals
Jenness SM , Johnson JA , Hoover KW , Smith DK , Delaney KP . AIDS 2020 34 (14) 2103-2113 OBJECTIVE: We sought to evaluate which combinations of HIV prevention and care activities would have the greatest impact towards reaching the US Ending the HIV Epidemic (EHE) plan goals of HIV incidence reduction. DESIGN: A stochastic network-based HIV transmission model for men who have sex with men (MSM), calibrated to surveillance estimates in the Atlanta area, a focal EHE jurisdiction. METHODS: Model scenarios varied HIV screening rates under different assumptions of how HIV-negative MSM would be linked to PrEP initiation, and rates of HIV care linkage and retention for those screening positive. RESULTS: A 10-fold relative increase in HIV screening rates (to approximately biannual screening for black and Hispanic MSM and quarterly for white MSM) would lead to 43% of infections averted if integrated with PrEP initiation. Improvements focused only on black MSM would achieve nearly the same outcome (37% of infections averted). Improvements to HIV care retention would avert 41% of infections if retention rates were improved 10-fold. If both screening and retention were jointly improved 10-fold, up to 74% of cumulative infections would be averted. Under this scenario, it would take 4 years to meet the 75% EHE goal and 12 years to meet the 90% goal for Atlanta MSM. CONCLUSIONS: Reaching the EHE 75% incidence reduction goals by their target dates will require immediate and substantial improvements in HIV screening, PrEP, and ART care retention. Meeting these EHE goals in target jurisdictions like Atlanta will be possible only by addressing the HIV service needs of black MSM. |
HIV prevalence, risk factors for infection, and uptake of prevention, testing, and treatment among female sex workers in Namibia
Jonas A , Patel SV , Katuta F , Maher AD , Banda KM , Gerndt K , Pietersen I , Menezes de Prata N , Mutenda N , Nakanyala T , Kisting E , Kawana B , Nietschke AM , Prybylski D , McFarland W , Lowrance DW . J Epidemiol Glob Health 2020 10 (4) 351-358 BACKGROUND: In most settings, Female Sex Workers (FSW) bear a disproportionate burden of Human Immunodeficiency Virus (HIV) disease worldwide. Representative data to inform the development of behavioral and biomedical interventions for FSW in Namibia have not been published. OBJECTIVES: Our objectives were to measure HIV prevalence, identify risk factors for infection, and describe uptake of prevention, testing, and treatment among FSW in Namibia. METHODS: We conducted cross-sectional surveys using Respondent-driven Sampling (RDS) in the Namibian cities of Katima Mulilo, Oshikango, Swakopmund/Walvis Bay, and Windhoek. Participating FSW completed behavioral questionnaires and rapid HIV testing. RESULTS: City-specific ranges of key indicators were: HIV prevalence (31.0-52.3%), reached by prevention programs in the past 12 months (46.9-73.6%), condom use at last sex with commercial (82.1-91.1%) and non-commercial (87.0-94.2%) partners, and tested for HIV within past 12 months or already aware of HIV-positive serostatus (56.9-82.1%). Factors associated with HIV infection varied by site and included: older age, having multiple commercial or non-commercial sex partners, unemployment, being currently out of school, and lower education level. Among HIV-positive FSW, 57.1% were aware of their HIV-positive serostatus and 33.7% were on antiretroviral treatment. DISCUSSION: Our results indicate extremely high HIV prevalence and low levels of case identification and treatment among FSW in Namibia. Our results, which are the first representative community-based estimates among FSW in Namibia, can inform the scale-up of interventions to reduce the risk for HIV acquisition and onward transmission, including treatment as prevention and pre-exposure prophylaxis. |
Enrolment characteristics associated with retention among HIV negative Kenyan gay, bisexual and other men who have sex with men enrolled in the Anza Mapema cohort study
Kunzweiler C , Bailey RC , Okall DO , Graham SM , Mehta SD , Otieno-Nyunya B , Djomand G , Otieno FO . J Int AIDS Soc 2020 23 Suppl 6 e25598 INTRODUCTION: Most gay, bisexual and other men who have sex with men (GBMSM) live in rights-constrained environments making retaining them in research to be as hard as recruiting them. To evaluate Anza Mapema, an HIV risk-reduction programme in Kisumu, Kenya, we examined the enrolment sociodemographic, behavioural, psychosocial and clinical factors associated with missing two or more follow-up visits for GBMSM participating in Anza Mapema. METHODS: Between August 2015 and November 2017, GBMSM were enrolled and followed in a prospective cohort study with quarterly visits over 12 months. At enrolment, men were tested for HIV and sexually transmitted infections and completed questionnaires via audio computer-assisted self-interview. Because the Kenya Ministry of Health recommends HIV testing every three to six months for GBMSM, the retention outcome in this cross sectional analysis was defined as missing two consecutive follow-up visits (vs. not missing two or more consecutive visits). Multivariable logistic regression estimated the adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the associations of the enrolment characteristics with the binary outcome of retention. RESULTS AND DISCUSSION: Among 609 enrolled HIV-negative GBMSM, the median age was 23 years (interquartile range, 21 to 28 years), 19.0% had completed ≤8 years of education and 4.1% had resided in the study area <1 year at enrolment. After enrolment, 19.7% missed two consecutive follow-up visits. In the final multivariable model, the odds of missing two consecutive follow-up visits were higher for men who: resided in the study area <1 year at enrolment (aOR, 4.14; 95% CI: 1.77 to 9.68), were not living with a male sexual partner (aOR, 1.59; 95% CI: 1.01 to 2.50), and engaged in transactional sex during the last three months (aOR, 1.70; 95% CI: 1.08 to 2.67). CONCLUSIONS: One in five men missed two consecutive follow-up visits during this HIV prevention study despite intensive retention efforts and compensation for travel and participation. Participants with recent community arrival may require special support to optimize their retention in HIV prevention activities. Live-in partners of participants may be enlisted to support greater engagement in prevention programmes, and men who engage in transactional sex will need enhanced counselling and support to stay in longitudinal studies. |
HIV pre-exposure prophylaxis medication sharing among HIV-negative men who have sex with men
Mansergh G , Mayer K , Hirshfield S , Stephenson R , Sullivan P . JAMA Netw Open 2020 3 (9) e2016256 This cross-sectional study used data from the M-Cubed randomized clinical trial to assess the prevalence of pre-exposure prophylaxis (PrEP) medication sharing among HIV-negative men who have sex with men. |
Changes in racial and ethnic disparities in estimated diagnosis rates of heterosexually-acquired HIV infection among heterosexual males in the United States, 2014-2018
McCree DH , Chesson HW , Eppink ST , Beer L , Henny KD . J Acquir Immune Defic Syndr 2020 85 (5) 588-592 BACKGROUND: Diagnoses of HIV infection among male adults and adolescents >13 years with infection attributed to heterosexual contact decreased 2014 through 2018. Racial disparities exist; HIV diagnoses are higher among Black/African American men compared to men of other races/ethnicities. In 2018, Black/African American males accounted for 61% of diagnosed HIV infections attributed to heterosexual contact among males. SETTING: We used national HIV surveillance data from Atlas Plus to obtain the annual case counts of new HIV diagnoses in males with infection attributed to heterosexual contact and population size for years 2014 through 2018 for males (United States excluding territories) by racial/ethnic group. METHODS: We used an adjusted population denominator to calculate rates of diagnoses of HIV infection acquired through heterosexual contact per 100,000 males and twelve absolute and relative measures of disparity to calculate racial/ethnic disparity changes from 2014 to 2018. RESULTS: Results from all disparity measures indicate that disparities decreased in 2018, compared to 2014. The decreases ranged from 18.8% to 34.6% among the four absolute disparity measures and from 5.3% to 22.7% among the eight relative disparity measures. CONCLUSION: Despite the decrease, disparities remain. Tailored, effective strategies and interventions are needed to address the social and structural factors associated with HIV risk among heterosexual Black men and to promote continued progress towards reducing disparities. |
Gonorrhea testing, morbidity, and reporting using an integrated sexually transmitted disease registry in Indiana: 2004-2016
Ojo OC , Arno JN , Tao G , Patel CG , Zhang Z , Wang J , Holderman J , Dixon BE . Int J STD AIDS 2020 32 (1) 30-37 Surveillance of gonorrhea (GC), the second most common notifiable disease in the United States, depends on case reports. Population-level data that contain the number of individuals tested in addition to morbidity are lacking. We performed a cross-sectional analysis of data obtained from individuals tested for GC recorded in a sexually transmitted disease (STD) registry in the state of Indiana. Descriptive statistics were performed, and a Poisson generalized linear model was used to evaluate the number of individuals tested for GC and the positivity rate. GC cases from a subset of the registry were compared to CDC counts to determine the completeness of the registry. A total of 1,870,811 GC tests were linked to 627,870 unique individuals. Individuals tested for GC increased from 54,334 in 2004 to 269,701 in 2016; likewise, GC cases increased from 2,039 to 5,997. However, positivity rate decreased from 3.75% in 2004 to 2.22% in 2016. The difference in the number of GC cases captured by the registry and those reported to the CDC was not statistically significant (P = 0.0665). Population-level data from an STD registry combining electronic medical records and public health case data may inform STD control efforts. In Indiana, increased testing rates appeared to correlate with increased GC morbidity. |
Binge drinking, non-injection drug use, and sexual risk behaviors among adolescent sexual minority males, 3 US cities, 2015
Robbins T , Wejnert C , Balaji AB , Hoots B , Paz-Bailey G , Bradley H . J Urban Health 2020 97 (5) 739-748 In 2016, more than 90% of HIV diagnoses among young men aged 13-19 years were attributed to male-male sexual contact. Little is known about how binge drinking and non-injection drug use may be associated with risky sexual behavior among adolescent sexual minority males (ASMM). Using data from the National HIV Behavioral Surveillance, we examined how binge drinking and non-injection drug use may be associated with sexual risk among ASMM. ASMM were recruited for interviews in 3 cities: Chicago, New York City, and Philadelphia. Among 16-18-year-olds (N = 488), we evaluated the association between binge drinking (≥ 5 drinks in one sitting in the past 30 days), non-injection drug use (past 12-month use of methamphetamines, powder cocaine, downers, painkillers, ecstasy, poppers, and "other"), and two past 12-month sexual risk outcomes: condomless anal intercourse with a casual partner and having multiple sex partners. We used log-linked Poisson regression models with robust standard errors to estimate prevalence ratios (PR) and 95% confidence intervals (CI). Overall, 26% of 16-18-year-old ASMM binge drank, and 21% reported non-injection drug use. Among ASMM who binge drank, 34% reported condomless anal intercourse with a casual partner compared with 22% of those who did not (PR: 1.53, 95% CI: 1.04-2.26). Similarly, 84% of ASMM who binge drank reported having multiple partners compared with 61% of those who did not (PR: 1.38, 95% CI: 1.09-1.76). Among ASMM who used non-injection drugs, 37% reported condomless anal intercourse compared with 22% of those who did not (PR: 1.70, 95% CI 1.09-2.50), while 86% of those who used non-injection drugs had multiple partners compared with 62% of those who did not (PR: 1.40, 95% CI: 1.06-1.80). Our findings suggest that the prevalence of substance misuse is high among sexual minority youth and is associated with sexual risk in this population. Our findings highlight the need for high-quality HIV prevention programs for ASMM especially as HIV prevention programs for this population are scarce. |
Estimated population-level impact of using a six-week regimen of daily rifapentine to treat latent tuberculosis infection in the United States
Shrestha S , Parriott A , Menzies NA , Shete PB , Hill AN , Marks SM , Dowdy DW . Ann Am Thorac Soc 2020 17 (12) 1639-1642 The Centers for Disease Control and Prevention attributes only 13% of incident tuberculosis (TB) disease in the United States to recent (≤2 yr) transmission; nearly all of the remaining incident cases of TB disease are believed to occur via reactivation of latent TB infection (LTBI) acquired by individuals earlier in their lives (1). It is estimated that up to 13 million people would test positive on the tuberculin skin test, and 9 (6–15) million people have untreated LTBI in the United States (2, 3). As such, treatment of LTBI is central to the current U.S. TB elimination strategy (4). Treatment regimens such as 3 months of isoniazid and rifapentine (3HP), 4 months of rifampin (4R), and 6–9 months of isoniazid are efficacious in preventing TB disease (5–8), but effectiveness of any LTBI regimen in general populations may be limited by suboptimal levels of treatment initiation and completion (8, 9) and by discontinuation because of adverse effects (AEs) (7, 9). Novel regimens with shorter duration of therapy, such as 6 weeks of daily 600-mg doses of rifapentine (6wP), which is currently being evaluated in a phase III clinical trial, may have important benefits, particularly if determined to be noninferior to 3HP and 9 months of isoniazid with lower discontinuation rates (10). |
Estimating recommended gonorrhea and chlamydia treatment rate using linked medical claims, prescription and laboratory data in US private settings
Tao G , Workowski K , Bowden KE , Pearson WS , Sullivan JM , Henk HJ , Gift TL . Sex Transm Dis 2020 48 (3) 167-173 BACKGROUND: The Centers for Disease Control and Prevention (CDC) recommends specific regimens for chlamydia and dual therapy for gonorrhea to mitigate antimicrobial resistant gonorrhea in the CDC 2015 STD Treatment Guidelines. Only limited studies examining adherence to these recommendations have been conducted at private practices in the United States. METHODS: We used the OptumLabs® Data Warehouse (OLDW), a comprehensive, longitudinal data asset with de-identified persons with linked commercial insurance claims and clinical information, to identify persons aged 15-60 years who had valid nucleic acid amplification testing results demonstrating urogenital or extragenital gonorrhea or chlamydia in 2016-2018. We defined valid lab results as positive or negative. We then assessed the time of their first positive test and the type of treatment within 30 days to determine if there was evidence in the claims record that the CDC-recommended treatment was provided. We defined presumed treatment if the date of treatment was before the date of the positive test within 30 days. RESULTS: Among 6,476 patients with positive gonorrhea tests and 26,847 patients with positive chlamydia tests only, 34.8% and 64.2% had evidence of receiving the CDC-recommended therapy, respectively. About 11.6% of patients with positive gonorrhea tests with recommended dual treatment and 7.1% of patients with positive chlamydia tests only with recommended chlamydia treatment were presumptively treated. CONCLUSION: Analysis of treatment claims and medical records from private settings indicated low rates of recommended gonorrhea and chlamydia treatment. Validation of treatment claims is needed to support further quality of care interventions based on these data. |
Increasing HIV prevalence and injection drug use among men who have sex with men in Ho Chi Minh City, Vietnam
Tuan NA , Johnston LG , Thanh DC , Le LN , Hoang TV , Quang TD , Quoc NC , Nadol P , Hien NT , Abdul-Quader A . Int J STD AIDS 2020 31 (13) 1247-1254 Vietnam has been conducting HIV/sexually transmitted infection (STI) integrated bio-behavioral surveillance surveys on men who have sex with men (MSM) as well as other key populations since 2005. Although HIV prevalence in the Vietnamese general population remains below 1%, it is expected to be much higher among MSM.Data on HIV prevalence and sexual and drug use behaviors were collected from MSM in Ho Chi Minh City (HCMC) in 2006 (n = 397), 2009 (n = 399) and 2013 (n = 350) using respondent-driven sampling. Eligible participants were males, aged ≥15 years who reported having manual, oral, or anal sexual activity with males in the past year and lived, worked or socialized in HCMC.HIV seroprevalence among MSM was 5.8% in 2006, 16.1% in 2009 and 12.1% in 2013 and prevalence of at least one STI (syphilis, gonorrhea and/or chlamydia infection) was 11.4% in 2006 and 15.6% in 2009 (no data for 2013). Significant, but small, increasing trends were found for MSM who reported ever testing and receiving results for HIV and for HIV prevalence. No significant changes for condom use, injecting and non-injecting drug use, or and receipt of free condoms were observed.Although a small percentage of MSM reported injecting drugs, HIV was positively associated with ever injecting drugs. Programs targeting MSM should include screening and treatment for injection drug use to most effectively control the HIV/AIDS epidemic among MSM in HCMC. |
Exploring how epidemic context influences syphilis screening impact: a mathematical modeling study
Tuite AR , Testa C , Rönn M , Bellerose M , Gift T , Fridge J , Molotnikov L , Desmarais C , Berruti A , Menzies N , Malyuta Y , Hsu K , Salomon JA . Sex Transm Dis 2020 47 (12) 798-810 BACKGROUND: The current syphilis epidemic in the United States is concentrated in gay, bisexual, and other men who have sex with men (MSM), but substantial heterosexual transmission is reported in some parts of the country. Using the U.S. states of Louisiana and Massachusetts as case studies, we investigated how epidemic context influences the impact of population screening approaches for syphilis control. METHODS: We constructed a compartmental metapopulation model parameterized to describe observed patterns of syphilis transmission. We estimated the impact of different approaches to screening, including perfect adherence to current U.S. screening guidelines in MSM. RESULTS: In Louisiana, where syphilis cases are more evenly distributed among MSM and heterosexual populations, we projected that screening according to guidelines would contribute to no change or an increase in syphilis burden, compared to burden with current estimated screening coverage. In Massachusetts, which has a more MSM-focused outbreak, we projected that screening according to guidelines would be as or more effective than current screening coverage in most population groups. CONCLUSIONS: MSM-focused approaches to screening may be insufficient for control when there is substantial transmission in heterosexual populations. Epidemic characteristics may be useful when identifying at-risk groups for syphilis screening. |
Furthering discussion of ethical implementation of HIV cluster detection and response
Watson M , Sweeney P . Am J Bioeth 2020 20 (10) 24-26 Molldrem and Smith’s (2020) “Reassessing the Ethics of Molecular HIV Surveillance in the Era of Cluster Detection and Response: Toward HIV Data Justice,” outlines important considerations toward more ethical use of HIV data collected and used for public health. As both the HIV and coronavirus disease 2019 (COVID-19) pandemics have demonstrated, social justice concerns and historical struggles against inequality and oppression cannot be separated from public health (Bailey et al. 2017). Public health efforts aimed at reducing transmission of infectious disease often succeed in protecting relatively privileged groups, while allowing persons from oppressed groups to experience disproportionate harms (Jeffries and Henny 2019). Documenting these disproportionate harms is necessary, but not sufficient, to address ongoing HIV disparities. |
Distance matters: The association of proximity to syringe services programs with sharing of syringes and injecting equipment - 17 U.S. cities, 2015
Whiteman A , Burnett J , Handanagic S , Wejnert C , Broz D . Int J Drug Policy 2020 85 102923 BACKGROUND: Syringe services programs (SSPs) have effectively limited the spread of HIV and hepatitis C (HCV) among people who inject drugs (PWID). Access to SSPs has been shown to reduce injection risk behaviors but the relationship between distance to an SSP and likelihood of sharing injection equipment is not well known. METHODS: We analyzed a sample of 8,392 PWID from 17 U.S. cities recruited through the National HIV Behavioral Surveillance (NHBS) system in 2015. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were estimated from log-linked Poisson regression to explore associations between injecting equipment sharing in the past 12 months and distance to the nearest SSP. RESULTS: Regardless of SSP use, respondents who lived in zip codes further than the city-specific mean distance to nearest SSP were more likely to report sharing behavior. Among PWID who had not reported using an SSP in the previous 12 months, distributive sharing (aPR=1.13 95% CI=1.05, 1.21), receptive sharing (aPR=1.15, 95% CI=1.06, 1.24), and injection equipment sharing (aPR=1.08, 95% CI=1.03, 1.13) were more prevalent among residents who resided further than the average distance to the nearest SSP. CONCLUSIONS: Greater distance to an SSP was associated with increased sharing behaviors. Improved access to an SSP and subsequent decreases in sharing behaviors could reduce transmission of HIV and HCV among PWID. Accessibility should be taken into account when planning provision of SSPs. |
Performance of a short, self-report adherence scale in a probability sample of persons using HIV antiretroviral therapy in the United States
Wilson IB , Tie Y , Padilla M , Rogers WH , Beer L . AIDS 2020 34 (15) 2239-2247 BACKGROUND: Excellent adherence to HIV antiretroviral therapy (ART) remains a cornerstone of HIV care. A three-item adherence self-report scale was recently developed and validated, but the scale has not been previously tested in a nationally representative sample. DESIGN: We administered the adherence scale to participants in the CDC's Medical Monitoring Project (MMP), which is a probability sample of U.S. adults with diagnosed HIV. METHODS: We combined sociodemographic and clinical participant data from three consecutive cycles of the Medical Monitoring Project (6/2015-5/2018). We used medical record reviews to determine most recent viral load, and whether viral loads were suppressed at all measurement points in the past 12 months. We describe the relationship between adherence scale score and two measures of viral load suppression (most recent and sustained), and estimate linear regression models using sampling weights to determine independent predictors of ART adherence scores. RESULTS: Of those using ART, the median adherence score was 93 (100 = perfect adherence), and the standardized Cronbach's alpha was 0.83. For both measures of viral load suppression, the relationship with the adherence score was generally linear; there was no "cutoff" point indicating good vs. poor adherence. In the multivariable model, younger age, non-white race, poverty, homelessness, depression, binge-drinking, and both non-injection and injection drug use were independently associated with lower adherence. CONCLUSIONS: The adherence measure had good psychometric qualities and a linear relationship with viral load, supporting its use in both clinical care and research. Adherence interventions should focus on persons with the highest risk of poor adherence. |
Heartland Virus in Lone Star Ticks, Alabama, USA.
Newman BC , Sutton WB , Moncayo AC , Hughes HR , Taheri A , Moore TC , Schweitzer CJ , Wang Y . Emerg Infect Dis 2020 26 (8) 1954-1956 We detected Heartland virus (HRTV) in lone star nymphs collected in 2018 in northern Alabama, USA. Real-time reverse transcription PCR selective for the small segment of the HRTV genome and confirmatory sequencing of positive samples showed high identity with HRTV strains sequenced from Tennessee and Missouri. |
Diagnostic evaluation of fatal Balamuthia mandrillaris meningoencephalitis in a captive Bornean orangutan (Pongo pygmaeus) with identification of potential environmental source and evidence of chronic exposure
Hawkins SJ , Struthers JD , Phair K , Ali IKM , Roy S , Mull B , West G . Primates 2020 62 (1) 51-61 A female Bornean orangutan (Pongo pygmaeus) aged 11 years and 6 months was examined by veterinarians after caretakers observed lethargy and facial grimacing. Within 72 h the primate had left-sided hemiparesis that worsened over the next week. An MRI revealed a focal right-sided cerebral mass suspected to be a neoplasm. Ten days after onset of clinical signs, the orangutan died. On postmortem exam, the medial right parietal lobe was replaced by a 7 × 4 × 3.5 cm focus of neuromalacia and hemorrhage that displaced the lateral ventricle and abutted the corpus callosum. Histopathology of the cerebral lesion revealed pyogranulomatous meningoencephalitis with intralesional amoeba trophozoites and rare cysts. Fresh parietal lobe was submitted to the Centers for Disease Control and Prevention lab for multiplex free-living amoebae real-time PCR and detected Balamuthia mandrillaris DNA at a high burden. Mitochondrial DNA was sequenced, and a 760-bp locus 19443F/20251R was compared to several human infections of B. mandrillaris and shown to be identical to the isolates from four human cases of encephalitis: 1998 in Australia, 1999 in California, 2000 in New York, and 2010 in Arizona. Indirect immunofluorescent antibody testing of stored serum samples indicated exposure to B. mandrillaris for at least 2 years prior to death. Within 1 week of the orangutan's death, water from the exhibit was analyzed and identified the presence of B. mandrillaris DNA, elucidating a possible source of exposure. B. mandrillaris, first reported in a mandrill in 1986, has since occurred in humans and animals and is now considered an important emerging pathogen. |
Rabies in a dog imported from egypt - Kansas, 2019
Raybern C , Zaldivar A , Tubach S , Ahmed FS , Moore S , Kintner C , Wallace RM , Mandra AM , Stauffer K , Condori RE , Garrison I . MMWR Morb Mortal Wkly Rep 2020 69 (38) 1374-1377 Although canine rabies virus variant (CRVV) was successfully eliminated from the United States after approximately 6 decades of vaccination campaigns, licensing requirements, and stray animal control, dogs remain the principal source of human rabies infections worldwide. A rabies vaccination certificate is required for dogs entering the United States from approximately 100 countries with endemic CRVV, including Egypt (1). On February 25, 2019, rabies was diagnosed in a dog imported from Egypt, representing the third canine rabies case imported from Egypt in 4 years (2,3). This dog and 25 others were imported by a pet rescue organization in the Kansas City metropolitan area on January 29. Upon entry into the United States, all 26 dogs had certificates of veterinary inspection, rabies vaccination certificates, and documentation of serologic conversion from a government-affiliated rabies laboratory in Egypt. CDC confirmed that the dog was infected with a CRVV that circulates in Egypt, underscoring the continued risk for CRVV reintroduction and concern regarding the legitimacy of vaccine documentation of dogs imported from countries considered at high risk for CRVV. Vaccination documentation of dogs imported from these countries should be critically evaluated before entry into the United States is permitted, and public health should be consulted upon suspicion of questionable documents. |
Uncovering environmental health needs and opportunities
Byrne MK , Kayleigh Hall S , Dejarnett N , Tariq R , Gustafson M . J Environ Health 2020 83 (1) 34-37 Health departments represent the frontline of public health but how much do we really know about the professionals working there? Profiles of state and local health departments provide helpful information about health department services and programs. Detailed information about the environmental health profession, however, is beyond the scope of those assessments. | | To better understand environmental health professionals and the programs they lead, the Centers for Disease Control and Prevention's (CDC) National Center for Environmental Health, the National Environmental Health Association (NEHA), and Baylor University partnered to conduct a first of its kind assessment of this critical group within governmental health departments. The initiative became known as Understanding the Needs, Challenges, Opportunities, Vision, and Emerging Roles in Environmental Health (UNCOVER EH). Overall, the final results included responses from 1,700 environmental health professionals from governmental public health programs at state, tribal, local, and territorial levels. | | This month's column provides key takeaways from the UNCOVER EH initiative and recommendations to strengthen environmental health programs and address challenges facing the profession. |
Maternal urinary concentrations of organophosphate ester metabolites: associations with gestational weight gain, early life anthropometry, and infant eating behaviors among mothers-infant pairs in Rhode Island
Crawford KA , Hawley N , Calafat AM , Jayatilaka NK , Froehlich RJ , Has P , Gallagher LG , Savitz DA , Braun JM , Werner EF , Romano ME . Environ Health 2020 19 (1) 97 BACKGROUND: Organophosphate esters (OPEs)-used as flame retardants and plasticizers-are associated with adverse pregnancy outcomes such as reduced fecundity and live births and increased preterm delivery. OPEs may interfere with growth and metabolism via endocrine-disruption, but few studies have investigated endocrine-related outcomes. The objective of this pilot study (n = 56 mother-infant pairs) was to evaluate associations of OPEs with gestational weight gain (GWG), gestational age at delivery, infant anthropometry, and infant feeding behaviors. METHODS: We quantified OPE metabolites (bis-2-chloroethyl phosphate [BCEP], bis (1,3-dichloro-2-propyl) phosphate [BDCPP], diphenyl phosphate [DPHP]) in pooled maternal spot urine collected throughout pregnancy (~ 12, 28, and 35 weeks' gestation). We obtained maternal sociodemographic characteristics from questionnaires administered at enrollment and perinatal characteristics from medical record abstraction. Trained research assistants measured infant weight, length, head and abdominal circumferences, and skinfold thicknesses at birth and 6 weeks postpartum. Mothers reported infant feeding behavior via the Baby Eating Behavior Questionnaire (BEBQ). Using multiple linear regression, we assessed associations of log(2)-transformed maternal urinary OPE metabolites with GWG, gestational age at delivery, infant anthropometry at birth, weekly growth rate, and BEBQ scores at 6 weeks postpartum. We used linear mixed effects (LME) models to analyze overall infant anthropometry during the first 6 weeks of life. Additionally, we considered effect modification by infant sex. RESULTS: We observed weak positive associations between all OPE metabolites and GWG. In LME models, BDCPP was associated with increased infant length (β = 0.44 cm, 95%CI = 0.01, 0.87) and weight in males (β = 0.14 kg, 95%CI = 0.03, 0.24). BDCPP was also associated with increased food responsiveness (β = 0.23, 95%CI = 0.06, 0.40). DPHP was inversely associated with infant abdominal circumference (β = - 0.50 cm, 95%CI = - 0.86, - 0.14) and female weight (β = - 0.19 kg, 95%CI = - 0.36, - 0.02), but positively associated with weekly growth in iliac skinfold thickness (β = 0.10 mm/wk., 95%CI = 0.02, 0.19). Further, DPHP was weakly associated with increased feeding speed. BCEP was associated with greater infant thigh skinfold thickness (β = 0.34 mm, 95%CI = 0.16, 0.52) and subscapular skinfold thickness in males (β = 0.14 mm, 95%CI = 0.002, 0.28). CONCLUSIONS: Collectively, these findings suggest that select OPEs may affect infant anthropometry and feeding behavior, with the most compelling evidence for BDCPP and DPHP. |
Empowered by tracking: Using data to solve public health problems
Curtiss C , Ussery-Hall A . J Environ Health 2020 83 (3) 28-30 The authors discuss the use of the Environmental Public Health Tracking Program of the U.S. Centers for Disease Control and Prevention to solve public health problems. Topics mentioned include the aim of the program to help address the public health data gaps that practitioners encounter, an example of data explorer side-by-side data maps, and how professionals are using the program. |
The Anniston Community Health Survey
Cusack C , Pavuk M , Dutton N , Yang E , Serio T . J Environ Health 2020 83 (2) 38-41 The article discusses the Anniston Community Health Survey (ACHS) I and ACHS Follow-Up and Dioxin Analyses (ACHSII) that were conducted by the Anniston Environmental Health Research Consortium in 2005-2007 and in 2014, respectively, to determine effects of polychlorinated biphenyl exposure (PCB) on the health of residents in Anniston, Alabama. Also mentioned is the use of age and race as essential determinants of PCB exposure and contamination among residents. |
Outdoor air quality awareness, perceptions, and behaviors among U.S. children aged 12-17years, 2015-2018
Lynch KM , Mirabelli MC . J Adolesc Health 2020 68 (5) 882-887 PURPOSE: This study aimed to assess U.S. adolescents' perceptions and knowledge about air quality and their behaviors aimed to reduce air pollution exposure and whether they vary by demographic characteristics. METHODS: We analyzed data from the Porter Novelli Public Services YouthStyles survey, a nationally representative survey of U.S. adolescents aged 12-17 years. In survey years 2015-2018, a total of 3,547 adolescents self-reported awareness, perceptions, and behaviors related to air pollution. We calculated weighted percentages of respondents reporting each aspect of air quality awareness, perception, and behaviors overall and by categories of age, gender, parental education, metropolitan status, region, and survey year. RESULTS: Overall, an estimated 81% of U.S. adolescents thought outdoor air pollution could impact health, 52% thought there were things they could do to limit their or their family's exposure, 19% were aware of air quality alerts, 46% of those who thought or were informed air quality was bad did something differently, and 19% always or usually avoided busy roads to reduce air pollution exposure; differences were reported by some demographic variables. CONCLUSIONS: Among U.S. adolescents, awareness that air pollution could impact health was relatively high. However, gaps were found in the awareness of the potential impacts and other aspects of awareness and perceptions related to air pollution and the engagement in behaviors to reduce exposure, some of which varied by demographic characteristics. These results can be used to inform interventions that increase awareness and behaviors to reduce air pollution exposures among U.S. adolescents. |
Per- and polyfluoroalkyl substance exposure, gestational weight gain, and postpartum weight changes in Project Viva
Mitro SD , Sagiv SK , Rifas-Shiman SL , Calafat AM , Fleisch AF , Jaacks LM , Williams PL , Oken E , James-Todd TM . Obesity (Silver Spring) 2020 28 (10) 1984-1992 OBJECTIVE: The purpose of this study was to test the extent to which pregnancy per- and polyfluoroalkyl substance (PFAS) concentrations were associated with gestational weight gain and postpartum weight changes. METHODS: This study was composed of 1,614 women recruited between 1999 and 2002 via the Project Viva cohort with pregnancy plasma concentrations of six PFAS, including perfluorooctanesulfonic acid, perfluorooctanoic acid (PFOA), and 2-(N-ethyl-perfluorooctane sulfonamido) acetic acid. Gestational weight gain was defined as the difference between last pregnancy weight and prepregnancy weight, 1-year postpartum weight retention as the difference between 1-year postpartum weight and prepregnancy weight, and 3-year postpartum weight change as the difference between 3-year postpartum weight and prepregnancy weight. RESULTS: During pregnancy, women gained 0.37 kg (95% CI: 0.11-0.62) more weight per doubling of 2-(N-ethyl-perfluorooctane sulfonamido) acetic acid. At 1 year post partum, women retained 0.55 kg (95% CI: 0.07-1.04) more weight per doubling of PFOA. At 3 years post partum, women gained 0.91 kg (95% CI: 0.25-1.56) more weight per doubling in PFOA. Findings were similar after adjustment for all PFAS. Other PFAS were not associated with weight changes. Postpartum associations were stronger among women with higher prepregnancy BMI. Models were adjusted for demographics. CONCLUSIONS: Pregnancy PFAS were associated with greater gestational weight gain, weight retention, and weight gain years after pregnancy. |
Temporal trends of exposure to phthalates and phthalate alternatives in California pregnant women during 2007-2013: Comparison with other populations
Shin HM , Dhar U , Calafat AM , Nguyen V , Schmidt RJ , Hertz-Picciotto I . Environ Sci Technol 2020 54 (20) 13157-13166 Phthalates with potential adverse health effects are being replaced by other phthalates or phthalate alternatives. Little is known about temporal trends of phthalate exposure in pregnant women in the United States. We quantified 16 metabolites of eight phthalates and di(isononyl) cyclohexane-1,2-dicarboxylate (DINCH) in 656 urine samples collected from 192 California pregnant women in 2007-2013 during their second and third trimesters of pregnancy who participated in the MARBLES (Markers of Autism Risk in Babies-Learning Early Signs) study. We used multiple regression to estimate least squares geometric means of phthalate biomarker concentrations and annual percent changes over the study period. Biomarker concentrations of diethyl phthalate (DEP) and three phthalates with known toxicity and adverse health effects (i.e., butyl benzyl phthalate [BBzP], dibutyl phthalate [DBP], di(2-ethylhexyl) phthalate [DEHP]) decreased, while those of di-isobutyl phthalate [DiBP], di-isononyl phthalate [DiNP], and di-n-octyl phthalate [DOP] increased in California pregnant women during our study period. To understand broad social forces that may influence temporal trends and geographic variations in phthalate exposure across countries, we compared our phthalate biomarker concentrations with those of other populations. We observed over a factor of 2 differences in exposure across countries for some phthalate biomarkers and between pregnant and nonpregnant women for DEP. |
Correlates of urinary concentrations of phthalate and phthalate alternative metabolites among reproductive-aged Black women from Detroit, Michigan
Wesselink AK , Fruh V , Hauser R , Weuve J , Taylor KW , Orta OR , Claus Henn B , Bethea TN , McClean MD , Williams PL , Calafat AM , Baird DD , Wise LA . J Expo Sci Environ Epidemiol 2020 31 (3) 461-475 BACKGROUND: Phthalates are endocrine-disrupting chemicals that are widely present in consumer products. In the United States, Black women are more highly exposed to phthalates than other racial/ethnic groups, yet information on predictors of phthalate exposure among Black women is limited. OBJECTIVE: We evaluated the association of demographics, lifestyle, reproductive history, and personal care product use with urinary concentrations of phthalate and phthalate alternative metabolites, using cross-sectional data from a study of 754 Black women from Detroit, Michigan (2010-2012). METHODS: Women completed questionnaires and provided urine specimens which were analyzed for 16 phthalate and phthalate alternative metabolites. We used linear regression models to estimate mean percentage differences and 95% confidence intervals (CIs) in concentrations across levels of correlates. RESULTS: Monoethyl phthalate (MEP) and MBP concentrations were positively associated with personal care product use, particularly nail products. Educational attainment was positively associated with high molecular weight phthalate concentrations but inversely associated with monobenzyl phthalate (MBzP) concentrations. Parity was positively associated with MBzP concentrations and inversely associated with concentrations of MEP and high molecular weight phthalates. SIGNIFICANCE: We found that sociodemographics, reproductive characteristics, and use of certain personal care products were associated with urinary phthalate concentrations among Black women. Our results emphasize the importance of examining exposure determinants among multiply marginalized populations. |
25 years: GeoSentinel's impact on travel-related surveillance and its vision for the future
Angelo KM . J Travel Med 2020 27 (7) GeoSentinel (https://www.istm.org/geosentinel) is an international network of healthcare sites and providers dedicated to the surveillance of infectious and selected non-infectious travel-related health issues among travelers and migrants. Sites provide routine clinical care to ill travelers and contribute demographic, travel and clinical surveillance data to a central electronic database. The GeoSentinel Network tracks travel-related diseases of potential global impact and helps advance the field of travel medicine, by keeping clinicians and public health practitioners up-to-date on the epidemiology and clinical presentation of key travel-related illnesses, thus improving the understanding of the spread of these illnesses across international borders. |
Estimating undercoverage bias of internet users
Hsia J , Zhao G , Town M . Prev Chronic Dis 2020 17 E104 INTRODUCTION: In the last decade, response rates to the Behavioral Risk Factor Surveillance System (BRFSS) surveys have been declining. Attention has turned to the possibility of using web surveys to complement or replace BRFSS, but web surveys can introduce coverage bias as a result of excluding noninternet users. The objective of this study was to describe undercoverage bias of internet use. METHODS: We used data from 402,578 respondents who completed BRFSS questions in 2017 on internet use, self-reported health, current smoking, and binge drinking. We examined undercoverage bias of internet use by partitioning it into a product of 2 components: proportion of noninternet use and difference in the prevalences of interest (self-reported health, current smoking, and binge drinking) between internet users and noninternet users. RESULTS: Overall, the weighted proportion of noninternet use overall was 15.0%; the proportion increased with an increase in age and a decrease in education and, by race/ethnicity, was lowest among non-Hispanic white respondents. The overall relative bias was -19.2% for self-reported health, -4.0% for current cigarette smoking, and 8.4% for binge drinking. For all 3 variables of interest, we found large biases and relative biases in some demographic subgroups. CONCLUSION: Undercoverage bias of internet use existed in the 3 studied variables. Both proportion of noninternet users and difference in prevalences of studied variables between internet users and noninternet users contributed to the bias to different degrees. These findings have implications on helping health-related behavioral risk factor surveys transition to more cost-effective survey modes than telephone only. |
Evaluation of the WHO global database on blood safety
Kanagasabai U , Selenic D , Chevalier MS , Drammeh B , Qualls M , Shiraishi RW , Bock N , Benech I , Mili FD . Vox Sang 2020 116 (2) 197-206 OBJECTIVE: While the Global Database on Blood Safety (GDBS) helps to monitor the status of adequate and safe blood availability, its presence alone does not serve as a solution to existing challenges. The objective of this evaluation was to determine the GDBS usefulness in improving the availability of adequate safe blood and its ability to function as a surveillance system. METHODS: The GDBS was evaluated using methods set out by the Centers for Disease Control and Prevention (CDC) Guidelines for assessing surveillance systems. Six recommended tasks were used to evaluate if the GDBS met the requirements of a surveillance system in a public health context. RESULTS: The majority of stakeholders engaged with GDBS found it was unique and useful. The GDBS answered all six questions essential for determining a blood safety surveillance system's usefulness. The GDBS fully met the needs to six of the eleven attributes used for evaluating the usefulness of a surveillance system. CONCLUSION: The GDBS is a unique global activity that provides vital data on safety of blood transfusion services across countries and regions. However, aspects of the GDBS such as timeliness of reporting and improvement of WHO Member States national blood information systems could enhance its effectiveness and potential to serve as a global surveillance system for blood safety. |
Modernizing the foodborne outbreak contributing factors: The key to prevention
Wittry B , Nicholas D . J Environ Health 2020 83 (2) 42-46 The article describes the revisions to the list of foodborne outbreak contributing factors (CF) that can be used to prevent future outbreaks and to improve food safety in the U.S. Topics mentioned include the categories of CF including poor personal hygiene and contaminated equipment, the proliferation factors that were added including the improper cooling of food, and the survival factors that were identified including the inadequate nontemperature dependent process like fermentation. |
Implementing Cancer Genomics in State Health Agencies: Mapping Activities to an Implementation Science Outcome Framework.
Green RF , Kumerow MT , Rodriguez JL , Addie S , Beachy SH , Senier L . Public Health Genomics 2020 23 1-12 OBJECTIVE: To show how state health agencies can plan and evaluate activities to strengthen the evidence base for public health genomics, we mapped state cancer genomics activities to the Doyle et al. [Genet Med. 2018;20(9):995-1003] implementation science outcome framework. METHODS: We identified state health agency activities addressing hereditary breast and ovarian cancer and Lynch syndrome by reviewing project narratives from Centers for Disease Control and Prevention Cancer Genomics Program funding recipients, leading discussions with state health agencies, and conducting an environmental scan. RESULTS: State health agencies' cancer genomics activities included developing or adding to state surveillance systems, developing educational materials, bidirectional reporting, promoting health plan policy change, training providers, and promoting recommendations and standards. To address health disparities, programs have tracked group differences, developed culturally appropriate educational materials, and promoted access to services for underserved populations. CONCLUSION: State health agencies can use the Doyle et al. [Genet Med. 2018;20(9):995-1003] performance objectives and outcome measures to evaluate proposed and ongoing activities. By demonstrating whether activities result in improved outcomes, state health agencies can build the evidence for the implementation of cancer genomics activities. |
Azithromycin susceptibility of Neisseria gonorrhoeae in the USA in 2017: a genomic analysis of surveillance data.
Gernert KM , Seby S , Schmerer MW , Thomas JCth , Pham CD , Cyr SS , Schlanger K , Weinstock H , Shafer WM , Raphael BH , Kersh EN . Lancet Microbe 2020 1 (4) e154-e164 BACKGROUND: The number of cases of gonorrhoea in the USA and worldwide caused by Neisseria gonorrhoeae is increasing (555 608 reported US cases in 2017, and 87 million cases worldwide in 2016). Many countries report declining in vitro susceptibility of azithromycin, which is a concern because azithromycin and ceftriaxone are the recommended dual treatment in many countries. We aimed to identify strain types associated with decreased susceptibility to azithromycin. METHODS: We did a genomic analysis of N gonorrhoeae isolates obtained by the US Gonococcal Isolate Surveillance Project. Isolates were whole-genome sequenced based on decreased susceptibility to azithromycin (minimal inhibitory concentration [MIC] ≥2 μg/mL, using agar dilution antibiotic susceptibility testing) and geographical representation. Bioinformatic analyses established genomic diversity, strain population dynamics, and antimicrobial resistance profiles. FINDINGS: 410 isolates were sorted into more than 20 unique phylogenetic clades. One predominant persistent clade (consisting of 97 isolates) included the most isolates with azithromycin MICs of 2 μg/mL or higher (61 of 97 [63%] vs 59 of 311 [19%]; p<0·0001) and carried a mosaic mtr (multiple transferable resistance) locus (68 of 97 [70%] vs two of 313 [1%]; p<0·0001). Of the remaining 313 isolates, 57 (18%) had decreased susceptibility to azithromycin (MIC ≥4 μg/mL), which was attributed to 23S rRNA variants (56 of 57 [98%]) and formed phylogenetically diverse clades, showing various levels of clonal expansion. INTERPRETATION: Reduced azithromycin susceptibility was associated with expanding and persistent clades harbouring two well described resistance mechanisms, mosaic mtr locus and 23S rRNA variants. Understanding the role of recombination, particularly within the mtr locus, on the fitness and expansion of strains with decreased susceptibility has important implications for the public health response to minimise gonorrhoea transmission. FUNDING: US Centers for Disease Control and Prevention (CDC), CDC Combating Antibiotic Resistant Bacteria initiative, Oak Ridge Institute for Science Education, US Department of Energy/CDC/Emory University, National Institutes of Health, and Biomedical Laboratory Research and Development Service of the US Department of Veterans Affairs. |
Signatures of somatic mutations and gene expression from p16INK4A positive head and neck squamous cell carcinomas (HNSCC).
Saba NF , Dinasarapu AR , Magliocca KR , Dwivedi B , Seby S , Qin ZS , Patel M , Griffith CC , Wang X , El-Deiry M , Steuer CE , Kowalski J , Shin DM , Zwick ME , Chen ZG . PLoS One 2020 15 (9) e0238497 Human papilloma virus (HPV) causes a subset of head and neck squamous cell carcinomas (HNSCC) of the oropharynx. We combined targeted DNA- and genome-wide RNA-sequencing to identify genetic variants and gene expression signatures respectively from patients with HNSCC including oropharyngeal squamous cell carcinomas (OPSCC). DNA and RNA were purified from 35- formalin fixed and paraffin embedded (FFPE) HNSCC tumor samples. Immuno-histochemical evaluation of tumors was performed to determine the expression levels of p16INK4A and classified tumor samples either p16+ or p16-. Using ClearSeq Comprehensive Cancer panel, we examined the distribution of somatic mutations. Somatic single-nucleotide variants (SNV) were called using GATK-Mutect2 ("tumor-only" mode) approach. Using RNA-seq, we identified a catalog of 1,044 and 8 genes as significantly expressed between p16+ and p16-, respectively at FDR 0.05 (5%) and 0.1 (10%). The clinicopathological characteristics of the patients including anatomical site, smoking and survival were analyzed when comparing p16+ and p16- tumors. The majority of tumors (65%) were p16+. Population sequence variant databases, including gnomAD, ExAC, COSMIC and dbSNP, were used to identify the mutational landscape of somatic sequence variants within sequenced genes. Hierarchical clustering of The Cancer Genome Atlas (TCGA) samples based on HPV-status was observed using differentially expressed genes. Using RNA-seq in parallel with targeted DNA-seq, we identified mutational and gene expression signatures characteristic of p16+ and p16- HNSCC. Our gene signatures are consistent with previously published data including TCGA and support the need to further explore the biologic relevance of these alterations in HNSCC. |
Rapid, Sensitive, Full-Genome Sequencing of Severe Acute Respiratory Syndrome Coronavirus 2.
Paden CR , Tao Y , Queen K , Zhang J , Li Y , Uehara A , Tong S . Emerg Infect Dis 2020 26 (10) 2401-2405 We describe validated protocols for generating high-quality, full-length severe acute respiratory syndrome coronavirus 2 genomes from primary samples. One protocol uses multiplex reverse transcription PCR, followed by MinION or MiSeq sequencing; the other uses singleplex, nested reverse transcription PCR and Sanger sequencing. These protocols enable sensitive virus sequencing in different laboratory environments. |
Impact of Abstract Versus Concrete Conceptualization of Genetic Modification (GM) Technology on Public Perceptions.
Tallapragada M , Hardy BW , Lybrand E , Hallman WK . Risk Anal 2020 41 (6) 976-991 Based on the scholarship of abstract/concrete cognition, mental schema, and the integrated model of behavior change, this study found that using concrete over abstract language increased support for specific genetically modified (GM) applications and GM in general, and improved intentions to purchase products containing genetically modified organisms (GMOs). An online survey with an embedded 3 × 2 experiment was conducted using a national sample of U.S. adults (N = 1,470). Participants were randomly assigned to conditions that varied in abstract/concrete conceptualization of GMOs and were prompted to assess GM risk and benefit perceptions with respect to human health and the environment. Regardless of whether they assessed risks or benefits, participants who assessed GMOs through concrete terms compared to abstract terms showed an increase in positive emotions, which in turn increased their support for specific GM applications and GM in general, and their intentions to buy products with GMOs. |
Administrative data identify sickle cell disease: A critical review of approaches in U.S. health services research
Grosse SD , Green NS , Reeves SL . Pediatr Blood Cancer 2020 67 (12) e28703 To identify people living with sickle cell disease (SCD) and study their healthcare utilization, researchers can either use clinical records linked to administrative data or use billing diagnosis codes in stand-alone administrative databases. Correct identification of individuals clinically managed for SCD using diagnosis codes in claims databases is limited by the accuracy of billing codes in outpatient encounters. In this critical review, we assess the strengths and limitations of claims-based SCD case-finding algorithms in stand-alone administrative databases that contain both inpatient and outpatient records. Validation studies conducted using clinical records and newborn screening for confirmation of SCD case status have found that algorithms that require three or more nonpharmacy claims or one inpatient claim plus two or more outpatient claims with SCD codes show acceptable accuracy (positive predictive value and sensitivity) in children and adolescents. Future studies might seek to assess the accuracy of case-finding algorithms over the lifespan. |
Inpatient admissions and costs for adolescents and young adults with congenital heart defects in New York, 2009-2013
Hsu WH , Sommerhalter KM , McGarry CE , Farr SL , Downing KF , Lui GK , Zaidi AN , Hsu DT , Van Zutphen AR . Birth Defects Res 2020 113 (2) 173-188 OBJECTIVES: Most individuals born with congenital heart defects (CHDs) survive to adulthood, but healthcare utilization patterns for adolescents and adults with CHDs have not been well described. We sought to characterize the healthcare utilization patterns and associated costs for adolescents and young adults with CHDs. METHODS: We examined 2009-2013 New York State inpatient admissions of individuals ages 11-30 years with ≥1 CHD diagnosis codes recorded during any admission. We conducted multivariate linear regression using generalized estimating equations to examine associations between inpatient costs and sociodemographic and clinical variables. RESULTS: We identified 5,100 unique individuals with 9,593 corresponding hospitalizations over the study period. Median inpatient cost and length of stay (LOS) were $10,720 and 3.0 days per admission, respectively; 55.1% were emergency admissions. Admission volume increased 48.7% from 2009 (1,538 admissions) to 2013 (2,287 admissions), while total inpatient costs increased 91.8% from 2009 ($27.2 million) to 2013 ($52.2 million). Inpatient admissions and costs rose more sharply over the study period for those with nonsevere CHDs compared to severe CHDs. Characteristics associated with higher costs were longer LOS, severe CHD, cardiac/vascular hospitalization classification, surgical procedures, greater severity of illness, and admission in New York City. CONCLUSION: This study provides an informative baseline of health care utilization patterns and associated costs among adolescents and young adults with CHDs in New York State. Structured transition programs may aid in keeping this population in appropriate cardiac care as they move to adulthood. |
The cost-effectiveness of hypertension management in low-income and middle-income countries: a review
Kostova D , Spencer G , Moran AE , Cobb LK , Husain MJ , Datta BK , Matsushita K , Nugent R . BMJ Glob Health 2020 5 (9) Hypertension in low-income and middle-income countries (LMICs) is largely undiagnosed and uncontrolled, representing an untapped opportunity for public health improvement. Implementation of hypertension control strategies in low-resource settings depends in large part on cost considerations. However, evidence on the cost-effectiveness of hypertension interventions in LMICs is varied across geographical, clinical and evaluation contexts. We conducted a comprehensive search for published economic evaluations of hypertension treatment programmes in LMICs. The search identified 71 articles assessing a wide range of hypertension intervention designs and cost components, of which 42 studies across 15 countries reported estimates of cost-effectiveness. Although comparability of results was limited due to heterogeneity in the interventions assessed, populations studied, costs and study quality score, most interventions that reported cost per averted disability-adjusted life-year (DALY) were cost-effective, with costs per averted DALY not exceeding national income thresholds. Programme elements that may reduce cost-effectiveness included screening for hypertension at younger ages, addressing prehypertension, or treating patients at lower cardiovascular disease risk. Cost-effectiveness analysis could provide the evidence base to guide the initiation and development of hypertension programmes. |
Systematic review of unintentional injury prevention economic evaluations 2010-2019 and comparison to 1998-2009
Mahalingam M , Peterson C , Bergen G . Accid Anal Prev 2020 146 105688 BACKGROUND: Health economic evaluation studies (e.g., cost-effectiveness analysis) can provide insight into which injury prevention interventions maximize available resources to improve health outcomes. A previous systematic review summarized 48 unintentional injury prevention economic evaluations published during 1998-2009, providing a valuable overview of that evidence for researchers and decisionmakers. The aim of this study was to summarize the content and quality of recent (2010-2019) economic evaluations of unintentional injury prevention interventions and compare to the previous publication period (1998-2009). METHODS: Peer-reviewed English-language journal articles describing public health unintentional injury prevention economic evaluations published January 1, 2010 to December 31, 2019 were identified using index terms in multiple databases. Injury causes, interventions, study methods, and results were summarized. Reporting on key methods elements (e.g., economic perspective, time horizon, discounting, currency year, etc.) was assessed. Reporting quality was compared between the recent and previous publication periods. RESULTS: Sixty-eight recent economic evaluation studies were assessed. Consistent with the systematic review on this topic for the previous publication period, falls and motor vehicle traffic injury prevention were the most common study subjects. Just half of studies from the recent publication period reported all key methods elements, although this represents an improvement compared to the previous publication period (25 %). CONCLUSION: Most economic evaluations of unintentional injury prevention interventions address just two injury causes. Better adherence to health economic evaluation reporting standards may enhance comparability across studies and increase the likelihood that this type of evidence is included in decision-making related to unintentional injury prevention. |
Proceedings of the AABB blood center executive summit
France C , Marks P , Jones J , Sher G , Bult JM , Winters JL , Mills Barbeau J , Carden B , Mendelsohn Stone L . Transfusion 2020 60 Suppl 4 S1-s16 AABB hosted the Blood Center Executive Summit on 20 October 2019 during the AABB Annual Meeting in San Antonio, Texas. The session was sponsored by the Commonwealth Transfusion Foundation, a nonprofit, private foundation whose mission is to inspire and champion research and education that optimizes clinical outcomes in transfusion medicine and ensures a safe and sustainable blood supply for the United States. The Summit focused on the intersection of blood centers and plasma centers. Presenters and attendees explored existing and needed data, regulatory requirements, risks and benefits of different donor models, and future direction of the plasma community and blood centers. The Summit also identified priority issues that warrant further investigation and provide opportunities to drive progress. Introductory remarks provided context for the Summit presentations. Debra BenAvram, FASAE, CAE, Chief Executive Officer, AABB (Bethesda, Maryland), noted that during the past year, she and other AABB staff have had many discussions with blood center executives on key issues and challenges. In these talks, many executives requested that AABB provide programming specifically for this member segment. The Summit is a direct result of those requests, and the AABB supports a fruitful discussion as well as important and actionable next steps. Kevin Belanger, DHS, MS, MT(ASCP)SBB, President and Chief Executive Officer of the Shepeard Community Blood Center (Evans, Georgia), observed that he and his colleagues have seen a decrease in the donor base and, at the same time, an increase in plasma centers. He also noted that the resulting discussions about competition and donor compensation have been muted. The Summit provides a forum for a broad, open discussion that can be the start of something important. As chair of the Summit planning committee, he thanked both panelists and audience members for participating. Bob Carden, Chief Executive Officer of the Commonwealth Transfusion Foundation (Richmond, Virginia), who moderated the Summit, joined BenAvram and Belanger in welcoming participants to the day's presentations. He emphasized the need for data and noted that one outcome of the day would be a list of potential research projects that could be pursued and considered for funding. |
Inappropriate empirical antibiotic therapy for bloodstream infections based on discordant in-vitro susceptibilities: a retrospective cohort analysis of prevalence, predictors, and mortality risk in US hospitals
Kadri SS , Lai YL , Warner S , Strich JR , Babiker A , Ricotta EE , Demirkale CY , Dekker JP , Palmore TN , Rhee C , Klompas M , Hooper DC , Powers JH3rd , Srinivasan A , Danner RL , Adjemian J . Lancet Infect Dis 2020 21 (2) 241-251 BACKGROUND: The prevalence and effects of inappropriate empirical antibiotic therapy for bloodstream infections are unclear. We aimed to establish the population-level burden, predictors, and mortality risk of in-vitro susceptibility-discordant empirical antibiotic therapy among patients with bloodstream infections. METHODS: Our retrospective cohort analysis of electronic health record data from 131 hospitals in the USA included patients with suspected-and subsequently confirmed-bloodstream infections who were treated empirically with systemic antibiotics between Jan 1, 2005, and Dec 31, 2014. We included all patients with monomicrobial bacteraemia caused by common bloodstream pathogens who received at least one systemic antibiotic either on the day blood cultures were drawn or the day after, and for whom susceptibility data were available. We calculated the prevalence of discordant empirical antibiotic therapy-which was defined as receiving antibiotics on the day blood culture samples were drawn to which the cultured isolate was not susceptible in vitro-overall and by hospital type by using regression tree analysis. We used generalised estimating equations to identify predictors of receiving discordant empirical antibiotic therapy, and used logistic regression to calculate adjusted odds ratios for the relationship between in-hospital mortality and discordant empirical antibiotic therapy. FINDINGS: 21 608 patients with bloodstream infections received empirical antibiotic therapy on the day of first blood culture collection. Of these patients, 4165 (19%) received discordant empirical antibiotic therapy. Discordant empirical antibiotic therapy was independently associated with increased risk of mortality (adjusted odds ratio 1·46 [95% CI, 1·28-1·66]; p<0·0001), a relationship that was unaffected by the presence or absence of resistance or sepsis or septic shock. Infection with antibiotic-resistant species strongly predicted receiving discordant empirical therapy (adjusted odds ratio 9·09 [95% CI 7·68-10·76]; p<0·0001). Most incidences of discordant empirical antibiotic therapy and associated deaths occurred among patients with bloodstream infections caused by Staphylococcus aureus or Enterobacterales. INTERPRETATION: Approximately one in five patients with bloodstream infections in US hospitals received discordant empirical antibiotic therapy, receipt of which was closely associated with infection with antibiotic-resistant pathogens. Receiving discordant empirical antibiotic therapy was associated with increased odds of mortality overall, even in patients without sepsis. Early identification of bloodstream pathogens and resistance will probably improve population-level outcomes. FUNDING: US National Institutes of Health, US Centers for Disease Control and Prevention, and US Agency for Healthcare Research and Quality. |
Duration of outpatient antibiotic therapy for common outpatient infections, 2017
King LM , Hersh AL , Hicks LA , Fleming-Dutra KE . Clin Infect Dis 2020 72 (10) e663-e666 Our objective was to describe the duration of antibiotic therapy for the management of common outpatient conditions. The median duration of antibiotic courses for most common conditions, except acute cystitis, was 10 days, in many cases exceeding guideline-recommended durations. |
Factors associated with Candida auris colonization and transmission in skilled nursing facilities with ventilator units, New York, 2016-2018
Rossow J , Ostrowsky B , Adams E , Greenko J , McDonald R , Vallabhaneni S , Forsberg K , Perez S , Lucas T , Alroy K , Slifka KJ , Walters M , Jackson BR , Quinn M , Chaturvedi S , Blog D . Clin Infect Dis 2020 72 (11) e753-e760 BACKGROUND: Candida auris is an emerging, multidrug-resistant yeast that spreads in healthcare settings. People colonized with C. auris can transmit this pathogen and are at risk for invasive infections. New York State (NYS) has the largest U.S. burden (>500 colonized and infected people); many colonized individuals are mechanically ventilated or have tracheostomy and are residents of ventilator-capable skilled nursing facilities (vSNF). We evaluated factors associated with C. auris colonization among vSNF residents to inform prevention interventions. METHODS: During 2016-2018, the NYS Department of Health conducted point prevalence surveys (PPS) to detect C. auris colonization among residents of vSNFs. In a case-control investigation, we defined a case as C. auris colonization in a resident and identified up to four residents with negative swabs during the same PPS as controls. We abstracted data from medical records on facility transfers, antimicrobials, and medical history. RESULTS: We included 60 cases and 218 controls identified from 6 vSNFs. After controlling for potential confounders, the following characteristics were associated with C. auris colonization: being on a ventilator (aOR: 5.9; CI: 2.3-15.4), receiving carbapenem antibiotics in the prior 90 days (aOR: 3.5; CI: 1.6-7.6), having ≥1 acute care hospital visit in the prior six months (aOR: 4.2; CI: 1.9-9.6), and receiving systemic fluconazole in the prior 90 days (aOR: 6.0; CI: 1.6-22.6). CONCLUSIONS: Targeted screening of patients in vSNFs with the above risk factors for C. auris can help identify colonized patients and facilitate implementation of infection control measures. Antimicrobial stewardship may be an important factor in the prevention of C. auris colonization. |
Incorporating real-time influenza detection into the test-negative design for estimating influenza vaccine effectiveness: The real-time test-negative design (rtTND).
Feldstein LR , Self WH , Ferdinands JM , Randolph AG , Aboodi M , Baughman AH , Brown SM , Exline MC , Files DC , Gibbs K , Ginde AA , Gong MN , Grijalva CG , Halasa N , Khan A , Lindsell CJ , Newhams M , Peltan ID , Prekker ME , Rice TW , Shapiro NI , Steingrub J , Talbot HK , Halloran ME , Patel M . Clin Infect Dis 2020 72 (9) 1669-1675 With rapid and accurate molecular influenza testing now widely available in clinical settings, influenza vaccine effectiveness (VE) studies can prospectively select participants for enrollment based on real-time results rather than enrolling all eligible patients regardless of influenza status, as in the traditional test-negative design (TND). Thus, we explore advantages and disadvantages of modifying the TND for estimating VE by using real-time, clinically available viral testing results paired with acute respiratory infection eligibility criteria for identifying influenza cases and test-negative controls prior to enrollment. This modification, which we have called the real-time test-negative design (rtTND), has the potential to improve influenza VE studies by optimizing the case-to-test-negative control ratio, more accurately classifying influenza status, improving study efficiency, reducing study cost, and increasing study power to adequately estimate VE. Important considerations for limiting biases in the rtTND include the need for comprehensive clinical influenza testing at study sites and accurate influenza tests. |
Progress Toward Poliomyelitis Eradication - Afghanistan, January 2019-July 2020.
Martinez M , Akbar IE , Wadood MZ , Shukla H , Jorba J , Ehrhardt D . MMWR Morb Mortal Wkly Rep 2020 69 (40) 1464-1468 Wild poliovirus type 1 (WPV1) transmission is ongoing only in Afghanistan and Pakistan (1). Following a decline in case numbers during 2013-2016, the number of cases in Afghanistan has increased each year during 2017-2020. This report describes polio eradication activities and progress toward polio eradication in Afghanistan during January 2019-July 2020 and updates previous reports (2,3). Since April 2018, insurgent groups have imposed bans on house-to-house vaccination. In September 2019, vaccination campaigns in areas under insurgency control were restarted only at health facilities. In addition, during March-June 2020, all campaigns were paused because of the coronavirus disease 2019 (COVID-19) pandemic. The number of WPV1 cases reported in Afghanistan increased from 21 in 2018 to 29 in 2019. During January-July 2020, 41 WPV1 cases were reported as of August 29, 2020 (compared with 15 during January-July 2019); in addition, 69 cases of circulating vaccine-derived poliovirus type 2 (cVDPV2), and one case of ambiguous vaccine-derived poliovirus type 2 (aVDPV2) (isolates with no evidence of person-to-person transmission or from persons with no known immunodeficiency) were detected. Dialogue with insurgency leaders through nongovernmental and international organizations is ongoing in an effort to recommence house-to-house campaigns, which are essential to stopping WPV1 transmission in Afghanistan. To increase community demand for polio vaccination, additional community health needs should be addressed, and polio vaccination should be integrated with humanitarian services. |
Meningococcal Vaccination: Recommendations of the Advisory Committee on Immunization Practices, United States, 2020
Mbaeyi SA , Bozio CH , Duffy J , Rubin LG , Hariri S , Stephens DS , MacNeil JR . MMWR Recomm Rep 2020 69 (9) 1-41 This report compiles and summarizes all recommendations from CDC's Advisory Committee on Immunization Practices (ACIP) for use of meningococcal vaccines in the United States. As a comprehensive summary and update of previously published recommendations, it replaces all previously published reports and policy notes. This report also contains new recommendations for administration of booster doses of serogroup B meningococcal (MenB) vaccine for persons at increased risk for serogroup B meningococcal disease. These guidelines will be updated as needed on the basis of availability of new data or licensure of new meningococcal vaccines. ACIP recommends routine vaccination with a quadrivalent meningococcal conjugate vaccine (MenACWY) for adolescents aged 11 or 12 years, with a booster dose at age 16 years. ACIP also recommends routine vaccination with MenACWY for persons aged ≥2 months at increased risk for meningococcal disease caused by serogroups A, C, W, or Y, including persons who have persistent complement component deficiencies; persons receiving a complement inhibitor (e.g., eculizumab [Soliris] or ravulizumab [Ultomiris]); persons who have anatomic or functional asplenia; persons with human immunodeficiency virus infection; microbiologists routinely exposed to isolates of Neisseria meningitidis; persons identified to be at increased risk because of a meningococcal disease outbreak caused by serogroups A, C, W, or Y; persons who travel to or live in areas in which meningococcal disease is hyperendemic or epidemic; unvaccinated or incompletely vaccinated first-year college students living in residence halls; and military recruits. ACIP recommends MenACWY booster doses for previously vaccinated persons who become or remain at increased risk. In addition, ACIP recommends routine use of MenB vaccine series among persons aged ≥10 years who are at increased risk for serogroup B meningococcal disease, including persons who have persistent complement component deficiencies; persons receiving a complement inhibitor; persons who have anatomic or functional asplenia; microbiologists who are routinely exposed to isolates of N. meningitidis; and persons identified to be at increased risk because of a meningococcal disease outbreak caused by serogroup B. ACIP recommends MenB booster doses for previously vaccinated persons who become or remain at increased risk. In addition, ACIP recommends a MenB series for adolescents and young adults aged 16-23 years on the basis of shared clinical decision-making to provide short-term protection against disease caused by most strains of serogroup B N. meningitidis. |
Policies among US pediatricians for dismissing patients for delaying or refusing vaccination
O'Leary ST , Cataldi JR , Lindley MC , Beaty BL , Hurley LP , Crane LA , Kempe A . JAMA 2020 324 (11) 1105-1107 This survey study assesses US pediatrician practices and office policies in response to parents who either refuse primary vaccinations or request to spread out individual vaccines in the primary series. |
Improving the quality and use of immunization and surveillance data: Summary report of the Working Group of the Strategic Advisory Group of Experts on Immunization
Scobie HM , Edelstein M , Nicol E , Morice A , Rahimi N , MacDonald NE , Carolina Danovaro-Holliday M , Jawad J . Vaccine 2020 38 (46) 7183-7197 Concerns about the quality and use of immunization and vaccine-preventable disease (VPD) surveillance data have been highlighted on the global agenda for over two decades. In August 2017, the Strategic Advisory Group of Experts (SAGE) established a Working Group (WG) onthe Quality and Use of Global Immunization and Surveillance Data to review the current status and evidence to make recommendations, which were presented to SAGE in October 2019. The WG synthesized evidence from landscape analyses, literature reviews, country case-studies, a data triangulation analysis, as well as surveys of experts. Data quality (DQ) was defined as data that are accurate, precise, relevant, complete, and timely enough for the intended purpose (fit-for-purpose), and data use as the degree to which data are actually used for defined purposes, e.g., immunization programme management, performance monitoring, decision-making. The WG outlined roles and responsibilities for immunization and surveillance DQ and use by programme level. The WG found that while DQ is dependent on quality data collection at health facilities, many interventions have targeted national and subnational levels, or have focused on new technologies, rather than the people and enabling environments required for functional information systems. The WG concluded that sustainable improvements in immunization and surveillance DQ and use will require efforts across the health system - governance, people, tools, and processes, including use of data for continuous quality improvement (CQI) - and that the approaches need to be context-specific, country-owned and driven from the frontline up. At the country level, major efforts are needed to: (1) embed monitoring DQ and use alongside monitoring of immunization and surveillance performance, (2) increase workforce capacity and capability for DQ and use, starting at the facility level, (3) improve the accuracy of immunization programme targets (denominators), (4) enhance use of existing data for tailored programme action (e.g., immunization programme planning, management and policy-change), (5) adopt a data-driven CQI approach as part of health system strengthening, (6) strengthen governance around piloting and implementation of new information and communication technology tools, and (7) improve data sharing and knowledge management across areas and organizations for improved transparency and efficiency. Global and regional partners are requested to support countries in adopting relevant recommendations for their setting and to continue strengthening the reporting and monitoring of immunization and VPD surveillance data through processes periodic needs assessment and revision processes. This summary of the WG's findings and recommendations can support "data-guided" implementation of the new Immunization Agenda 2030. |
Influenza economic burden among potential target risk groups for immunization in South Africa, 2013-2015
Tempia S , Moyes J , Cohen AL , Walaza S , McMorrow ML , Edoka I , Fraser H , Treurnicht FK , Hellferscee O , Wolter N , von Gottberg A , McAnerney JM , Dawood H , Variava E , Cohen C . Vaccine 2020 38 (45) 7007-7014 BACKGROUND: Data on influenza economic burden in risk groups for severe influenza are important to guide targeted influenza immunization, especially in resource-limited settings. However, this information is limited in low- and middle-income countries. METHODS: We estimated the cost (from a health system and societal perspective) and years of life lost (YLL) for influenza-associated illness in South Africa during 2013-2015 among (i) children aged 6-59 months, (ii) individuals aged 5-64 years with HIV, pulmonary tuberculosis (PTB) and selected underlying medical conditions (UMC), separately, (iii) pregnant women and (iv) individuals aged ≥65 years, using publicly available data and data collected through laboratory-confirmed influenza surveillance and costing studies. All costs were expressed in 2015 prices using the South Africa all-items Consumer Price Index. RESULTS: During 2013-2015, the mean annual cost of influenza-associated illness among the selected risk groups accounted for 52.1% ($140.9/$270.5 million) of the total influenza-associated illness cost (for the entire population of South Africa), 45.2% ($52.2/$115.5 million) of non-medically attended illness costs, 43.3% ($46.7/$107.9 million) of medically-attended mild illness costs and 89.3% ($42.0/$47.1 million) of medically-attended severe illness costs. The YLL among the selected risk groups accounted for 86.0% (262,069 /304,867 years) of the total YLL due to influenza-associated death. CONCLUSION: In South Africa, individuals in risk groups for severe influenza accounted for approximately half of the total influenza-associated illness cost but most of the cost of influenza-associated medically attended severe illness and YLL. This study provides the foundation for future studies on the cost-effectiveness of influenza immunization among risk groups. |
Using informatics to improve cancer surveillance.
Blumenthal W , Alimi TO , Jones SF , Jones DE , Rogers JD , Benard VB , Richardson LC . J Am Med Inform Assoc 2020 27 (9) 1488-1495 OBJECTIVES: This review summarizes past and current informatics activities at the Centers for Disease Control and Prevention National Program of Cancer Registries to inform readers about efforts to improve, standardize, and automate reporting to public health cancer registries. TARGET AUDIENCE: The target audience includes cancer registry experts, informaticians, public health professionals, database specialists, computer scientists, programmers, and system developers who are interested in methods to improve public health surveillance through informatics approaches. SCOPE: This review provides background on central cancer registries and describes the efforts to standardize and automate reporting to these registries. Specific topics include standardized data exchange activities for physician and pathology reporting, software tools for cancer reporting, development of a natural language processing tool for processing unstructured clinical text, and future directions of cancer surveillance informatics. |
Centers for Disease Control and Prevention 2019 novel coronavirus disease (COVID-19) information management: addressing national health-care and public health needs for standardized data definitions and codified vocabulary for data exchange.
Garcia M , Lipskiy N , Tyson J , Watkins R , Esser ES , Kinley T . J Am Med Inform Assoc 2020 27 (9) 1476-1487 OBJECTIVE: The 2019 novel coronavirus disease (COVID-19) outbreak progressed rapidly from a public health (PH) emergency of international concern (World Health Organization [WHO], 30 January 2020) to a pandemic (WHO, 11 March 2020). The declaration of a national emergency in the United States (13 March 2020) necessitated the addition and modification of terminology related to COVID-19 and development of the disease's case definition. During this period, the Centers for Disease Control and Prevention (CDC) and standard development organizations released guidance on data standards for reporting COVID-19 clinical encounters, laboratory results, cause-of-death certifications, and other surveillance processes for COVID-19 PH emergency operations. The CDC COVID-19 Information Management Repository was created to address the need for PH and health-care stakeholders at local and national levels to easily obtain access to comprehensive and up-to-date information management resources. MATERIALS AND METHODS: We introduce the clinical and health-care informatics community to the CDC COVID-19 Information Management Repository: a new, national COVID-19 information management tool. We provide a description of COVID-19 informatics resources, including data requirements for COVID-19 data reporting. RESULTS: We demonstrate the CDC COVID-19 Information Management Repository's categorization and management of critical COVID-19 informatics documentation and standards. We also describe COVID-19 data exchange standards, forms, and specifications. CONCLUSIONS: This information will be valuable to clinical and PH informaticians, epidemiologists, data analysts, standards developers and implementers, and information technology managers involved in the development of COVID-19 situational awareness and response reporting and analytics. |
School-level poverty and persistent feelings of sadness or hopelessness, suicidality, and experiences with violence victimization among public high school students
Jones SE , Michael Underwood J , Pampati S , Le VD , Degue S , Demissie Z , Adkins SH , Barrios LC . J Health Care Poor Underserved 2020 31 (3) 1248-1263 Objectives. To examine the association between school-level poverty status and students’ persistent feelings of sadness or hopelessness, suicidality, and experiences with violence victimization among U.S. high school students. Methods. Public schools captured in the 2015 and 2017 national Youth Risk Behavior Surveys were categorized as high-, mid-, or low-poverty based on the percentage of students eligible for free or reduced-price meals (N=29,448). Results. Students in high-poverty schools were significantly more likely than students in low-poverty schools to experience persistent feelings of sadness or hopelessness, experience suicidal thoughts and attempts, not go to school because of safety concerns, be threatened or injured with a weapon on school property, be bullied on school property, be physically forced to have sexual intercourse, and be victims of sexual and physical dating violence. Conclusions. School and community approaches to address suicide and violence victimization may be especially important for students living in poverty. |
Factors associated with concussion symptom knowledge and attitudes towards concussion care-seeking in a national survey of parents of middle school children in the U.S
Kerr ZY , Nedimyer AK , Kay MC , Chandran A , Gildner P , Byrd KH , Haarbauer-Krupa JK , Register-Mihalik JK . J Sport Health Sci 2020 10 (2) 113-121 OBJECTIVE: Developing appropriate concussion prevention and management paradigms in middle school (MS) settings requires understanding parents' general levels of concussion-related knowledge and attitudes. This study examined factors associated with concussion symptom knowledge and care-seeking attitudes among parents of MS children (aged ∼10-15 years). METHODS: A panel of 1224 randomly selected US residents, aged ≥18 years and identifying as parents of MS children, completed an online questionnaire capturing parental and child characteristics. The parents' concussion symptom knowledge was measured using 25 questions, with possible answers being "yes", "maybe", and "no". Correct answers earned 2 points, "maybe" answers earned 1 point, and incorrect answers earned 0 points (range = 0-50; higher scores = better knowledge). Concussion care-seeking attitudes were also collected using five 7-point scale items (range = 5-35; higher scores = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher scores. Models met proportional odds assumptions. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) (excluding 1.00) were deemed statistically significant. RESULTS: Median scores were 39 (interquartile range (IQR) = 32-44) for symptom knowledge and 32 (IQR = 28-35) for care-seeking attitude. In multivariable models, odds of better symptom knowledge were higher in women vs. men (aOR = 2.28; 95%CI: 1.71-3.05), white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.88; 95%CI: 1.42-2.49), higher parental age (10-year-increase aOR = 1.47; 95%CI: 1.26-1.71) and greater competitiveness (10%-scale-increase aOR = 1.24; 95%CI: 1.13-1.36). Odds of more positive care-seeking attitudes were higher in white/non-Hispanics versus other racial or ethnic groups (aOR = 1.45; 95%CI: 1.06-1.99), and higher parental age (10-year-increase aOR = 1.24; 95%CI: 1.05-1.47). CONCLUSION: Characteristics of middle school children's parents (e.g., sex, race or ethnicity, age) are associated with their concussion symptom knowledge and care-seeking attitudes. Parents' variations in concussion knowledge and attitudes warrant tailored concussion education and prevention. |
Full Molecular Typing of Neisseria meningitidis Directly from Clinical Specimens for Outbreak Investigation.
Itsko M , Retchless AC , Joseph SJ , Turner AN , Bazan JA , Sadji AY , Ouédraogo-Traoré R , Wang X . J Clin Microbiol 2020 58 (12) Neisseria meningitidis (Nm) is a leading cause of bacterial meningitis and sepsis worldwide and an occasional cause of meningococcal urethritis. When isolates are unavailable for surveillance or outbreak investigations, molecular characterization of pathogens needs to be performed directly from clinical specimens such as cerebrospinal fluid (CSF), blood, or urine. However, genome sequencing of specimens is challenging because of low bacterial and high human DNA abundances. We developed selective whole genome amplification (SWGA), an isothermal multiple displacement amplification-based method, to efficiently enrich, sequence and de novo assemble Nm DNA from clinical specimens with low bacterial loads. SWGA was validated with 12 CSF specimens from invasive meningococcal disease cases and 12 urine specimens from meningococcal urethritis cases. SWGA increased the mean proportion of Nm reads by 2-3 orders of magnitude enabling identification of at least 90% of the 1605 Nm core genome loci for 50% of the specimens. The validated method was used to investigate two meningitis outbreaks recently reported in Togo and Burkina Faso. Twenty-seven specimens with low bacterial load were processed by SWGA before sequencing and 12 of 27 were successfully assembled to obtain the full molecular typing and vaccine antigen profile of the Nm pathogen, therefore enabling thorough characterization of outbreaks. This method is particularly important for enhancing molecular surveillance in regions with low culture rate. SWGA produces enough reads for phylogenetic and allelic analysis with a low cost. More importantly, the procedure can be extended to enrich other important human bacterial pathogens. |
Complex genetic encoding of the hepatitis B virus on-drug persistence.
Thai H , Lara J , Xu X , Kitrinos K , Gaggar A , Chan HLY , Xia GL , Ganova-Raeva L , Khudyakov Y . Sci Rep 2020 10 (1) 15574 Tenofovir disoproxil fumarate (TDF) is one of the nucleotide analogs capable of inhibiting the reverse transcriptase (RT) activity of HIV and hepatitis B virus (HBV). There is no known HBV resistance to TDF. However, detectable variation in duration of HBV persistence in patients on TDF therapy suggests the existence of genetic mechanisms of on-drug persistence that reduce TDF efficacy for some HBV strains without affording actual resistance. Here, the whole genome of intra-host HBV variants (N = 1,288) was sequenced from patients with rapid (RR, N = 5) and slow response (SR, N = 5) to TDF. Association of HBV genomic and protein polymorphic sites to RR and SR was assessed using phylogenetic analysis and Bayesian network methods. We show that, in difference to resistance to nucleotide analogs, which is mainly associated with few specific mutations in RT, the HBV on-TDF persistence is defined by genetic variations across the entire HBV genome. Analysis of the inferred 3D-structures indicates no difference in affinity of TDF binding by RT encoded by intra-host HBV variants that rapidly decline or persist in presence of TDF. This finding suggests that effectiveness of TDF recognition and binding does not contribute significantly to on-drug persistence. Differences in patterns of genetic associations to TDF response between HBV genotypes B and C and lack of a single pattern of mutations among intra-host variants sensitive to TDF indicate a complex genetic encoding of the trait. We hypothesize that there are many genetic mechanisms of on-drug persistence, which are differentially available to HBV strains. These pervasive mechanisms are insufficient to prevent viral inhibition completely but may contribute significantly to robustness of actual resistance. On-drug persistence may reduce the overall effectiveness of therapy and should be considered for development of more potent drugs. |
Cross-protection by inactivated H5 pre-pandemic vaccine seed strains against diverse Goose/Guangdong lineage H5N1 highly pathogenic avian influenza viruses.
Criado MF , Sá ESilva M , Lee DH , de Lima Salge CA , Spackman E , Donis R , Wan XF , Swayne DE . J Virol 2020 94 (24) The highly pathogenic avian influenza virus (HPAIV) H5N1 A/goose/Guangdong/1996 lineage (Gs/GD) is endemic in poultry across several countries in the world, and has caused lethal, sporadic infections in humans. Vaccines are important in HPAI control for both poultry and in pre-pandemic preparedness in humans. This study assessed inactivated pre-pandemic vaccine strains in a One Health framework, focusing on the genetic and antigenic diversity of field H5N1 Gs/GD viruses from the agricultural sector and assessing cross protection in a chicken challenge model. Nearly half (47.92%) of the forty-eight combinations of vaccine/challenge viruses examined had bird protection of 80% or above. Most vaccinated groups had prolonged mean death time (MDT) and the virus shedding titers were significantly lower compared to the sham group (p≤ 0.05). The antibody titers in the pre-challenge sera were not predictive of protection. Although vaccinated birds had higher titers of hemagglutination inhibiting (HI) antibodies against homologous vaccine antigen, most of them also had lower or no antibody titer against the challenge antigen. The comparison of all parameters, homologous or closely related vaccine and challenge viruses, gave the best prediction protection. Through additional analysis, we identified a pattern of epitopes substitutions in the hemagglutinin (HA) of each challenge virus that impacted protection, regardless of the vaccine used. These changes were situated in the antigenic sites and/or reported epitopes associated with virus escape from antibody neutralization. As a result, this study highlights virus diversity, immune response complexity, and the importance of strain selection for vaccine development to control H5N1 HPAIV in the agricultural sector and for human pre-pandemic preparedness. We suggest that the engineering of specific antigenic sites can improve the immunogenicity of H5 vaccines.ImportanceThe sustained circulation of highly pathogenic avian influenza virus (HPAIV) H5N1 A/goose/Guangdong/1996 lineage (Gs/GD) in the agricultural sector and some wild birds has led to the evolution and selection of distinct viral lineages involved in the escape from vaccine protection. Our results using inactivated vaccine candidates from the human pandemic preparedness program in a chicken challenge model identified critical antigenic conformational epitopes on the H5 hemagglutinin (HA) from different clades that were associated with antibody recognition and escape. Even though other investigators have reported epitope mapping in the H5 HA, much of this information pertains to epitopes reactive towards mouse antibodies. Our findings validate changes in antigenic epitopes of HA associated with virus escape from antibody neutralization in chickens, which has direct relevance to field protection and virus evolution. Therefore, the knowledge of these immunodominant regions is essential to proactively develop diagnostic tests, improve surveillance platforms to monitor AIV outbreaks, and design more efficient and broad-spectrum agricultural and human prepandemic vaccines. |
A Culture Collection of 50 Neisseria gonorrhoeae Isolates.
Liu H , Vidyaprakash E , Schmerer MW , Pham DC , St Cyr S , Kersh EN . Microbiol Resour Announc 2020 9 (40) A culture collection of 50 Neisseria gonorrhoeae isolates is available from the CDC & FDA Antibiotic Resistance Isolate Bank. Associated data include antibiotic susceptibility information for azithromycin, cefixime, cefpodoxime, ceftriaxone, tetracycline, ciprofloxacin, penicillin, and spectinomycin and linked whole-genome sequences. |
Diagnostic Laboratory Testing and Clinical Preparedness for Dengue Outbreaks during the COVID-19 Pandemic.
Waterman SH , Paz-Bailey G , San Martin JL , Gutierrez G , Castellanos LG , Mendez-Rico JA . Am J Trop Med Hyg 2020 103 (3) 1339-1340 Wilder-Smith and coauthors made key observations regarding the importance of maintaining mosquito control and clinical preparedness for dengue during the COVID-19 pandemic crisis, especially given the resurgence of dengue in Latin America in 2019 and 2020.1–3 Clearly, simultaneous outbreaks of COVID-19 and dengue pose high potential for overwhelming healthcare systems; and because the two diseases can have similar nonspecific clinical presentation in early stages, alerting clinicians and putting in place carefully drawn clinical algorithms for triage are critical to reducing mortality. We would like however to qualify and elaborate on Wilder-Smith et al.’s comment regarding virologic and diagnostic testing in this context. |
Epidemiological Correlates of PCR Cycle Threshold Values in the Detection of SARS-CoV-2.
Salvatore PP , Dawson P , Wadhwa A , Rabold EM , Buono S , Dietrich EA , Reses HE , Vuong J , Pawloski L , Dasu T , Bhattacharyya S , Pevzner E , Hall AJ , Tate JE , Kirking HL . Clin Infect Dis 2020 72 (11) e761-e767 BACKGROUND: Detection of SARS-CoV-2 infection has principally been performed through the use of real-time reverse-transcription PCR (rRT-PCR) testing. Results of such tests can be reported as cycle threshold (Ct) values, which may provide semi-quantitative or indirect measurements of viral load. Previous reports have examined temporal trends in Ct values over the course of a SARS-CoV-2 infection. METHODS: Using testing data collected during a prospective household transmission investigation of outpatient and mild COVID-19 cases, we examined the relationship between Ct values of the viral RNA N1 target and demographic, clinical, and epidemiological characteristics collected through participant interviews and daily symptom diaries. RESULTS: We found Ct values are lowest (corresponding to higher viral RNA concentration) soon after symptom onset and are significantly correlated with time elapsed since onset (p<0.001); within 7 days after symptom onset, the median Ct value was 26.5 compared with a median Ct value of 35.0 occurring 21 days after onset. Ct values were significantly lower among participants under 18 years of age (p=0.01) and those reporting upper respiratory symptoms at the time of sample collection (p=0.001) and were higher among participants reporting no symptoms (p=0.05). CONCLUSIONS: These results emphasize the importance of early testing for SARS-CoV-2 among individuals with symptoms of respiratory illness and allows cases to be identified and isolated when their viral shedding may be highest. |
Risk of transmissibility from neurodegenerative disease-associated proteins: Experimental knowns and unknowns
Asher DM , Belay E , Bigio E , Brandner S , Brubaker SA , Caughey B , Clark B , Damon I , Diamond M , Freund M , Hyman BT , Jucker M , Keene CD , Lieberman AP , Mackiewicz M , Montine TJ , Morgello S , Phelps C , Safar J , Schneider JA , Schonberger LB , Sigurdson C , Silverberg N , Trojanowski JQ , Frosch MP . J Neuropathol Exp Neurol 2020 79 (11) 1141-1146 Recent studies in animal models demonstrate that certain misfolded proteins associated with neurodegenerative diseases can support templated misfolding of cognate native proteins, to propagate across neural systems, and to therefore have some of the properties of classical prion diseases like Creutzfeldt-Jakob disease. The National Institute of Aging convened a meeting to discuss the implications of these observations for research priorities. A summary of the discussion is presented here, with a focus on limitations of current knowledge, highlighting areas that appear to require further investigation in order to guide scientific practice while minimizing potential exposure or risk in the laboratory setting. The committee concluded that, based on all currently available data, although neurodegenerative disease-associated aggregates of several different non-prion proteins can be propagated from humans to experimental animals, there is currently insufficient evidence to suggest more than a negligible risk, if any, of a direct infectious etiology for the human neurodegenerative disorders defined in part by these proteins. Given the importance of this question, the potential for noninvasive human transmission of proteopathic disorders is deserving of further investigation. |
Indoor surface chemistry: Developing a molecular picture of reactions on indoor interfaces
Ault AP , Grassian VH , Carslaw N , Collins DB , Destaillats H , Donaldson DJ , Farmer DK , Jimenez JL , McNeill VF , Morrison GC , O'Brien RE , Shiraiwa M , Vance ME , Wells JR , Xiong W . Chem 2020 6 (12) 3203-3218 Chemical reactions on indoor surfaces play an important role in air quality in indoor environments, where humans spend 90% of their time. We focus on the challenges of understanding the complex chemistry that takes place on indoor surfaces and identify crucial steps necessary to gain a molecular-level understanding of environmental indoor surface chemistry: (1) elucidate key surface reaction mechanisms and kinetics important to indoor air chemistry, (2) define a range of relevant and representative surfaces to probe, and (3) define the drivers of surface reactivity, particularly with respect to the surface composition, light, and temperature. Within the drivers of surface composition are the roles of adsorbed/absorbed water associated with indoor surfaces and the prevalence, inhomogeneity, and properties of secondary organic films that can impact surface reactivity. By combining laboratory studies, field measurements, and modeling we can gain insights into the molecular processes necessary to further our understanding of the indoor environment. |
Molecular typing of Rickettsia akari
Eremeeva ME , Sturgeon MM , Willard JK , Karpathy SE , Madan A , Dasch GA . Rus J Infect Immun 2020 10 (3) 497-505 Rickettsia akari, an obligately intracellular bacterium, is the causative agent of the cosmopolitan urban disease rickettsialpox. R. akari is an atypical representative of spotted fever group rickettsiae (SFG) as it is associated with rodent mites rather than ticks or fleas; however, only limited information is available about the degree of genetic variability found among isolates of R. akari. We examined 13 isolates of R. akari from humans, rodents and mites in the USA, the former Soviet Union, and the former Yugoslavia made between 1946 and 2003 for diversity in their tandem repeat regions (TR) and intergenic regions (IGR). The 1.23 Mb genome of R. akari strain Hartford CWPP was analyzed using Tandem Repeat Finder software (http://tandem.bu.edu) and 374 different TRs were identified, with size variation from 1 to 483 bp and with TR copy numbers ranging between 21 and 1.9, respectively. No size polymorphisms were detected among the 11 TR regions examined from 5 open reading frames and 6 IGR. Eighteen non-TR IGR’s were amplified and sequenced for the same isolates comprising a total of 5.995 bp (0.49%) of the Hartford CWPP strain chromosome. Three single nucleotide polymorphism (SNP) sites were detected in two IGR’s which permitted separation of the five R. akari isolates from Ukraine SSR from the other eight isolates. In conclusion, this is the first study reporting genetic heterogeneity among R. akari isolates of different geographic origins. Further exploration of this genetic diversity is needed to understand better the geographic distribution of R. akari and the epidemiology of rickettsialpox. The potential of mites as hosts for other rickettsial agents also needs further investigation. |
Limited added value of oropharyngeal swabs for detecting pneumococcal carriage in adults
Farrar JL , Odiembo H , Odoyo A , Bigogo G , Kim L , Lessa FC , Feikin DR , Breiman RF , Whitney CG , Carvalho MG , Pimenta FC . Open Forum Infect Dis 2020 7 (9) ofaa368 We compared pneumococcal isolation rates and evaluated the benefit of using oropharyngeal (OP) specimens in addition to nasopharyngeal (NP) specimens collected from adults in rural Kenya. Of 846 adults, 52.1% were colonized; pneumococci were detected from both NP and OP specimens in 23.5%, NP only in 22.9%, and OP only in 5.7%. Ten-valent pneumococcal conjugate vaccine strains were detected from both NP and OP in 3.4%, NP only in 4.1%, and OP only in 0.7%. Inclusion of OP swabs increased carriage detection by 5.7%; however, the added cost of collecting and processing OP specimens may justify exclusion from future carriage studies among adults. |
Four new species of the Hylomyscus anselli group (Mammalia: Rodentia: Muridae) from the Democratic Republic of Congo and Tanzania
Kerbis Peterhans JC , Hutterer R , Doty JB , Malekani JM , Moyer DC , Krásová J , Bryja J , Banasiak RA , Demos TC . Bonn Zoological Bulletin 2020 69 (1) 55-83 As in many other small mammal groups from the Afrotropics, the number of species recognized within the genus Hylomyscus has increased considerably over the past dozen years. The last comprehensive review (2005) of the genus recognized eight species. Since that time, nine additional species have been elevated from synonymy (n = 4) or described as new (n = 5). Here we describe four additional new species supported by morphological and molecular evidence, all collected by the late William Stanley. Two of the new taxa are sympatric and come from the poorly known left bank (direction source to mouth) of the Congo River. One of these (Hylomyscus pygmaeus sp. nov.) is easily recognized, as it is tiny and significantly smaller than any known species of the genus; the second new species (Hylomyscus thornesmithae sp. nov.) is also small, and syntopic with the first. The third new species (Hylomyscus stanleyi sp. nov.), from the SW corner of Tanzania, is quite large and had been previously included within the hypodigm of Hylomyscus anselli following its recognition from within the synonymy of Hylomyscus denniae. The fourth species (Hylomyscus mpungamachagorum sp. nov.) is from Mahale Mountains National Park, western Tanzania. Our study reveals a much higher species diversity of the genus than previously known, providing insights into additional Afrotropical and Afromontane centers of endemism that require further exploration. |
Middle East respiratory coronavirus (MERS-CoV) spike (S) protein vesicular stomatitis virus pseudoparticle neutralization assays offer a reliable alternative to the conventional neutralization assay in human seroepidemiological studies
Lester S , Harcourt J , Whitt M , Al-Abdely HM , Midgley CM , Alkhamis AM , Aziz Jokhdar HA , Assiri AM , Tamin A , Thornburg N . Access Microbiol 2019 1 (9) e000057 Middle East respiratory syndrome coronavirus (MERS-CoV) is a novel zoonotic coronavirus that was identified in 2012. MERS-CoV infection in humans can result in an acute, severe respiratory disease and in some cases multi-organ failure; the global mortality rate is approximately 35 %. The MERS-CoV spike (S) protein is a major target for neutralizing antibodies in infected patients. The MERS-CoV microneutralization test (MNt) is the gold standard method for demonstrating prior infection. However, this method requires the use of live MERS-CoV in biosafety level 3 (BSL-3) containment. The present work describes the generation and validation of S protein-bearing vesicular stomatitis virus (VSV) pseudotype particles (VSV-MERS-CoV-S) in which the VSV glycoprotein G gene has been replaced by the luciferase reporter gene, followed by the establishment of a pseudoparticle-based neutralization test to detect MERS-CoV neutralizing antibodies under BSL-2 conditions. Using a panel of human sera from confirmed MERS-CoV patients, the VSV-MERS-CoV particle neutralization assay produced results that were highly comparable to those of the microneutralization test using live MERS-CoV. The results suggest that the VSV-MERS-CoV-S pseudotype neutralization assay offers a highly specific, sensitive and safer alternative method to detect MERS-CoV neutralizing antibodies in human sera. |
Investigation of melioidosis using blood culture and indirect hemagglutination assay serology among patients with fever, Northern Tanzania
Maze MJ , Elrod MG , Biggs HM , Bonnewell J , Carugati M , Hoffmaster AR , Lwezaula BF , Madut DB , Maro VP , Mmbaga BT , Morrissey AB , Saganda W , Sakasaka P , Rubach MP , Crump JA . Am J Trop Med Hyg 2020 103 (6) 2510-2514 Prediction models indicate that melioidosis may be common in parts of East Africa, but there are few empiric data. We evaluated the prevalence of melioidosis among patients presenting with fever to hospitals in Tanzania. Patients with fever were enrolled at two referral hospitals in Moshi, Tanzania, during 2007-2008, 2012-2014, and 2016-2019. Blood was collected from participants for aerobic culture. Bloodstream isolates were identified by conventional biochemical methods. Non-glucose-fermenting Gram-negative bacilli were further tested using a Burkholderia pseudomallei latex agglutination assay. Also, we performed B. pseudomallei indirect hemagglutination assay (IHA) serology on serum samples from participants enrolled from 2012 to 2014 and considered at high epidemiologic risk of melioidosis on the basis of admission within 30 days of rainfall. We defined confirmed melioidosis as isolation of B. pseudomallei from blood culture, probable melioidosis as a ≥ 4-fold rise in antibody titers between acute and convalescent sera, and seropositivity as a single antibody titer ≥ 40. We enrolled 3,716 participants and isolated non-enteric Gram-negative bacilli in five (2.5%) of 200 with bacteremia. As none of these five isolates was B. pseudomallei, there were no confirmed melioidosis cases. Of 323 participants tested by IHA, 142 (44.0%) were male, and the median (range) age was 27 (0-70) years. We identified two (0.6%) cases of probable melioidosis, and 57 (17.7%) were seropositive. The absence of confirmed melioidosis from 9 years of fever surveillance indicates melioidosis was not a major cause of illness. |
Human intestinal enteroids to evaluate human norovirus GII.4 inactivation by aged-green tea
Randazzo W , Costantini V , Morantz EK , Vinje J . Front Microbiol 2020 11 1917 Human noroviruses are the leading cause of epidemic and sporadic acute gastroenteritis worldwide and the most common cause of foodborne illness in the United States. Several natural compounds, such as aged-green tea extract (aged-GTE), have been suggested as ingestible antiviral agents against human norovirus based on data using murine norovirus and feline calicivirus as surrogates. However, in vitro data showing their effectiveness against infectious human norovirus are lacking. We tested the activity of aged-GTE to inhibit human norovirus in a human intestinal enteroids (HIEs) model and Tulane virus in LLC-monkey kidney (LLC-MK2) cell culture. HIE monolayers pretreated with aged-GTE at different temperatures showed complete inhibition of human norovirus GII.4 replication at concentrations as low as 1.0 mg/ml for 37degreeC, 1.75 mg/ml for 21degreeC, and 2.5 mg/ml for 7degreeC. In contrast, a moderate decrease in Tulane virus infectivity of 0.85, 0.75, and 0.65 log TCID50/ml was observed for 2.5 mg/ml aged-GTE at 37, 21, and 7degreeC, respectively. Our findings demonstrate that GTE could be an effective natural compound against human norovirus GII.4, while only minimally effective against Tulane virus. |
Tobacco smoke exposure exacerbated crystalline silica-induced lung toxicity in rats
Sager TM , Umbright CM , Mustafa GM , Yanamala N , Leonard HD , McKinney WG , Kashon ML , Joseph P . Toxicol Sci 2020 178 (2) 375-390 Smoking may modify the lung response to silica exposure including cancer and silicosis. Nevertheless, the precise role of exposure to tobacco smoke (TS) on the lung response to crystalline silica (CS) exposure and the underlying mechanisms need further clarification. The objectives of the present study were to determine the role of TS on lung response to CS exposure and the underlying mechanism(s). Male Fischer 344 rats were exposed by inhalation to air, CS (15 mg/m3, 6 hrs/day, 5 days), TS (80 mg/m3, 3 hrs/day, twice weekly, 6 months), or CS (15 mg/m3, 6 hrs/day, 5 days) followed by TS (80 mg/m3, 3 hrs/day, twice weekly, 6 months). The rats were euthanized 6 months and 3 weeks following initiation of the first exposure and the lung response was assessed. Silica exposure resulted in significant lung toxicity as evidenced by lung histological changes, enhanced neutrophil infiltration, increased LDH levels, enhanced oxidant production, and increased cytokine levels. The TS exposure alone had only a minimal effect on these toxicity parameters. However, the combined exposure to TS and CS exacerbated the lung response, compared to TS or CS exposure alone. Global gene expression changes in the lungs correlated with the lung toxicity severity. Bioinformatic analysis of the gene expression data demonstrated significant enrichment in functions, pathways, and networks relevant to the response to CS exposure which correlated with the lung toxicity detected. Collectively our data demonstrated an exacerbation of CS-induced lung toxicity by TS exposure and the molecular mechanisms underlying the exacerbated toxicity. |
Development of a sensitive high-resolution mass spectrometry approach for urea nitrogen quantitation in small volumes of bronchoalveolar lavage fluid (BALF)
Ulmer CZ , Smith B , Thonkulpitak J , Hardin J , Danilenko U , Frame T , Cheng PY , Vesper HW . J Am Soc Mass Spectrom 2020 31 (11) 2270-2276 A sensitive, selective, and quantitative method incorporating high-resolution mass spectrometry was developed for the determination of blood urea nitrogen (BUN) in bronchoalveolar lavage fluid. The method requires no sample cleanup or derivatization prior to analysis. High-performance liquid chromatography (HPLC) on a Hypersil Gold PFP column (100 × 3 mm, 3 μm particle size) connected to a C18 guard column was employed for a 10 min chromatographic separation. The detection of urea was achieved using a Thermo Scientific Q-Exactive Plus instrument incorporating selected ion monitoring (SIM) modes for the protonated adduct of urea. The urea analytical measuring range for the method is 0.047-17.134 mg/dL, resulting in a BUN analytical measurement range of 0.022-8.007 mg/dL, which allows for quantitation over 3 orders of magnitude (R(2) = 0.999). In addition, the method is suitable for small sample volumes (15 μL) with a high level of accuracy, precision, and specificity. |
Two discrete choice experiments on laboratory safety decisions and practices
Wirth O , Foreman AM , Friedel JE , Andrew ME . J Safety Res 2020 75 99-110 Introduction: The path toward enhancing laboratory safety requires a thorough understanding of the factors that influence the safety-related decision making of laboratory personnel. Method: We developed and administered a web-based survey to assess safety-related decision making of laboratory personnel of a government research organization. The survey included two brief discrete choice experiments (DCEs) that allowed for quantitative analysis of specific factors that potentially influence safety-related decisions and practices associated with two different hypothetical laboratory safety scenarios. One scenario related to reporting a laboratory spill, and the other scenario involved changing protective gloves between laboratory rooms. The survey also included several brief self-report measures of attitude, perception, and behavior related to safety practices. Results: Risk perception was the most influential factor in safety-related decision making in both scenarios. Potential negative consequences and effort associated with reporting an incident and the likelihood an incident was detected by others also affected reporting likelihood. Wearing gloves was also affected somewhat by perceived exposure risk, but not by other social or work-related factors included in the scenarios. Conclusions: The study demonstrated the promise of DCEs in quantifying the relative impact of several factors on safety-related choices of laboratory workers in two hypothetical but realistic scenarios. Participants were faced with hypothetical choice scenarios with realistic features instead of traditional scaling techniques that ask about attitudes and perceptions. The methods are suitable for addressing many occupational safety concerns in which workers face tradeoffs in their safety-related decisions and behavior. Practical Application: Safety-related decisions regarding laboratory practices such as incident reporting and use of PPE were influenced primarily by workers’ perceptions of risk of exposure and severity of risks to health and safety. This finding suggests the importance of providing laboratory workers with adequate and effective education and training on the hazards and risks associated with their work. DCEs are a promising research method for better understanding the relative influences of various personal, social, and organizational factors that shape laboratory safety decisions and practices. The information gained from DCEs may lead to more targeted training materials and interventions. |
3,3'-dichlorobiphenyl is metabolized to a complex mixture of oxidative metabolites, including novel methoxylated metabolites, by HepG2 cells
Zhang CY , Flor S , Ruiz P , Dhakal R , Hu X , Teesch LM , Ludewig G , Lehmler HJ . Environ Sci Technol 2020 54 (19) 12345-12357 3,3'-Dichlorobiphenyl (PCB 11) is a byproduct of industrial processes and detected in environmental samples. PCB 11 and its metabolites are present in human serum, and emerging evidence demonstrates that PCB 11 is a developmental neurotoxicant. However, little is known about the metabolism of PCB 11 in humans. Here, we investigated the metabolism of PCB 11 and the associated metabolomics changes in HepG2 cells using untargeted high-resolution mass spectrometry. HepG2 cells were exposed for 24 h to PCB 11 in DMSO or DMSO alone. Cell culture media were analyzed with ultra-high-performance liquid chromatography coupled with high-resolution mass spectrometry. Thirty different metabolites were formed by HepG2 cells exposed to 10 μM PCB 11, including monohydroxylated, dihydroxylated, methoxylated-hydroxylated, and methoxylated-dihydroxylated metabolites and the corresponding sulfo and glucuronide conjugates. The methoxylated PCB metabolites were observed for the first time in a human-relevant model. 4-OH-PCB 11 (3,3'-dichlorobiphenyl-4-ol) and the corresponding catechol metabolite, 4,5-di-OH-PCB 11 (3',5-dichloro-3,4-dihydroxybiphenyl), were unambiguously identified based on liquid and gas chromatographic analyses. PCB 11 also altered several metabolic pathways, in particular vitamin B(6) metabolism. These results demonstrate that complex PCB 11 metabolite profiles are formed in HepG2 cells that warrant further toxicological investigation, particularly since catechol metabolites are likely reactive and toxic. |
CE: From the CDC: Understanding autism spectrum disorder
Christensen D , Zubler J . Am J Nurs 2020 120 (10) 30-37 Autism spectrum disorder (ASD) is a condition characterized by impaired social communication as well as restricted and repetitive behaviors. It is considered a neurodevelopmental disorder because it is associated with neurologic changes that may begin in prenatal or early postnatal life, alters the typical pattern of child development, and produces chronic signs and symptoms that usually manifest in early childhood and have potential long-term consequences. In past decades, autism was conceptualized as a strictly defined set of behaviors, usually accompanied by intellectual impairment. Today, it is recognized as a spectrum, ranging from mild to severe, in which behaviors vary substantially and the majority of children who fall on the spectrum have average to above average intellectual ability. Here, the authors discuss the risk factors for ASD, its epidemiology, common concurrent conditions, evaluation, diagnosis, treatments, and outcomes. |
Receipt and timeliness of newborn hearing screening and diagnostic services among babies born in 2017 in 9 states
Deng X , Ema S , Mason C , Nash A , Carbone E , Gaffney M . J Public Health Manag Pract 2020 28 (1) E100-E108 CONTEXT: By providing timely services at all steps along the continuum of the early hearing detection and intervention (EHDI) process, providers may be able to lessen potential adverse effects of late identification of hearing loss on children's language development. OBJECTIVE: To examine the timeliness of key events in the EHDI process from birth through diagnosis of hearing loss among different populations. DESIGN: Retrospective, cross-sectional. SETTING: Data pooled from 9 states' EHDI information systems were used to determine the extent to which timely screening and diagnosis were achieved by 754 613 infants born in calendar year 2017. Enrollment into early intervention for children diagnosed is not examined here due to incomplete data. PARTICIPANTS: Nine state EHDI programs were selected to participate in this study for their successful experience in using EHDI-IS to collect detailed child-level data. MAIN OUTCOME MEASURES: Age of service, rate of service receipt. RESULTS: Median age of newborn hearing screening was 1 day, and median age of hearing loss diagnosis was 68 days. Early completion of newborn hearing screening was associated with maternal education, maternal race/ethnicity, and admission into a neonatal intensive care unit (NICU). Receiving and completing follow-up diagnostic services were associated with maternal education, maternal race/ethnicity, age of screening, and enrollment into the Women, Infants, and Children program. CONCLUSIONS: Timely completion of the newborn hearing screening is achieved by most of the population among the participating states. Increased efforts may be considered by state EHDI programs to provide additional follow-up and education to underrepresented racial/ethnic groups, mothers with less education, and NICU infants and their families as these groups appear to be at an increased risk for delayed diagnostic testing for hearing loss. |
Assessing the relationship between neonatal abstinence syndrome and birth defects in Delaware
Hussaini KS , Drummond D , EBartoshesky L , Acheson A , Stomieroski K , APaul D , Kirby RS . Birth Defects Res 2020 113 (2) 144-151 BACKGROUND: Neonatal abstinence syndrome (NAS) is a withdrawal syndrome in newborns and is frequently caused by maternal opioid use during pregnancy. Our study examines whether NAS is associated with birth defects in Delaware. METHODS: We conducted a retrospective analysis of linked Delaware birth certificate data (BCD), hospital discharge data (HDD), and birth defects registry (BDR) data to examine the association between NAS and birth defects for all hospital births to Delaware residents from 2010 to 2017. Birth defects data were abstracted from medical records from Delaware's BDR. We used International Classification of Diseases Ninth and Tenth Revision Clinical Modification (ICD-9-CM/ICD-10-CM) 779.5 and P96.1 codes to determine NAS using HDD and excluded iatrogenic cases of NAS. We estimated crude and adjusted odds ratio with 95% confidence intervals (CIs). RESULTS: During 2010-2017, there were 2,784 cases of birth defects and 1,651 cases of NAS in Delaware. Among infants with a diagnosis of NAS, 56 also had a birth defect (3.4%), similar to 2,728 birth defects among 79,636 infants without a diagnosis of NAS (3.4%). We found no statistically significant association between an NAS diagnosis and birth defects (adjusted odds ratios = 1.0; 95% CI: 0.8-1.3). CONCLUSIONS: Our multiyear state-wide study using linked BCD, HDD, and BDR data for Delaware did not show a statistically significant association between infants diagnosed with NAS and birth defects, overall. |
Kindergarten readiness in children who are deaf or hard of hearing who received early intervention
Meinzen-Derr J , Wiley S , Grove W , Altaye M , Gaffney M , Satterfield-Nash A , Folger AT , Peacock G , Boyle C . Pediatrics 2020 146 (4) BACKGROUND: Children who are deaf or hard of hearing (D/HH) have improved language outcomes when enrolled in early intervention (EI) before the age of 6 months. Little is understood about the long-term impact of EI on outcomes of kindergarten readiness (K-readiness). The study objective was to evaluate the impact of EI before the age of 6 months (early) versus after 6 months (later) on K-readiness in children who are D/HH. METHODS: In this study, we leveraged data from the Ohio Early Hearing Detection and Intervention Data Linkage Project, which linked records of 1746 infants identified with permanent hearing loss born from 2008 to 2014 across 3 Ohio state agencies; 417 had kindergarten records. The Kindergarten Readiness Assessment was used to identify children as ready for kindergarten; 385 had Kindergarten Readiness Assessment scores available. Multiple logistic regression was used to investigate the relationship between K-readiness and early EI entry while controlling for confounders (eg, hearing loss severity and disability status). RESULTS: Children who were D/HH and entered EI early (n = 222; 57.7% of the cohort) were more likely to demonstrate K-readiness compared with children who entered EI later (33.8% vs 20.9%; P = .005). Children who entered early had similar levels of K-readiness as all Ohio students (39.9%). After controlling for confounders, children who entered EI early were more likely to be ready for kindergarten compared with children who entered later (odds ratio: 2.02; 95% confidence interval 1.18-3.45). CONCLUSIONS: These findings support the sustained effects of early EI services on early educational outcomes among children who are D/HH. EI entry before the age of 6 months may establish healthy trajectories of early childhood development, reducing the risk for later academic struggles. |
Investigation of the anisotropic confinement-dependent brittleness of a Utah coal
Kim BH , Walton G , Larson MK , Berry S . Int J Coal Sci Technol 2020 8 (2) 274-290 Changes of failure mechanism with increasing confinement, from extensional to shear-dominated failure, are widely observed in the rupture of intact specimens at the laboratory scale and in rock masses. In an analysis published in 2018, both unconfined and triaxial compressive tests were conducted to investigate the strength characteristics of 84 specimens of a Utah coal, including the spalling limits, the ratio of apparent unconfined compressive strength to unconfined compressive strength (UCS), the damage characteristics, and the post-yield dilatancy. These mechanical characteristics were found to be strongly anisotropic as a function of the orientation of the cleats relative to the loading direction, defined as the included angle. A total of four different included angles were used in the work performed in 2018. The authors found that the degree of anisotropic strength differed according to the included angle. However, the transition from extensional to shear failure at the given confinements was not clearly identified. In this study, a total of 20 specimens were additionally prepared from the same coal sample used in the previous study and then tested under both unconfined and triaxial compressive conditions. Because the authors already knew the most contrasting cases of the included angles from the previous work using the four included angles, they chose only two of the included angles (0° and 30°) for this study. For the triaxial compressive tests, a greater confining stress than the mean UCS was applied to the specimens in an attempt to identify the brittle-ductile transition of the coal. The new results have been compiled with the previous results in order to re-evaluate the confinement-dependency of the coal behavior. Additionally, the different confining stresses are used as analogs for different width-to-height (W/H) conditions of pillar strength. Although the W/H ratios of the specimens were not directly considered during testing, the equivalent W/H ratios of a pillar as a function of the confining stresses were estimated using an existing empirical solution. According to this relationship, the W/H at which in situ pillar behavior would be expected to transition from brittle to ductile is identified. |
Barriers to and facilitators of iron and folic acid supplementation within a school-based integrated nutrition and health promotion program among Ghanaian adolescent girls
Gosdin L , Sharma AJ , Tripp K , Amoaful EF , Mahama AB , Selenje L , Jefferds ME , Ramakrishnan U , Martorell R , Addo OY . Curr Dev Nutr 2020 4 (9) nzaa135 BACKGROUND: Anemia is a moderate public health problem among adolescent girls in Ghana. OBJECTIVES: We aimed to evaluate the barriers to and facilitators of program fidelity to a school-based anemia reduction program with weekly iron and folic acid (IFA) supplementation. METHODS: Authors analyzed directly observed weekly IFA consumption data collected longitudinally and cross-sectional data from a representative survey of 60 secondary schools and 1387 adolescent girls in the Northern and Volta regions of Ghana after 1 school year (2017-2018) of the intervention (30-36 wk). A bottleneck analysis was used to characterize the levels of IFA coverage and used adjusted generalized linear mixed-effects models to quantify the school and student drivers of IFA intake adherence. RESULTS: Of girls, 90% had ever consumed the tablet, whereas 56% had consumed ≥15 weekly tablets (mean: 16.4, range: 0-36), indicating average intake adherence was about half of the available tablets. Among ever consumers, 88% of girls liked the tablet, and 27% reported undesirable changes (primarily heavy menstrual flow). School-level factors represented 75% of the variance in IFA consumption over the school year. Total IFA tablets consumed was associated with the ability to make up missed IFA distributions (+1.4 tablets; 95% CI: +0.8, +2.0 tablets), junior compared with senior secondary school (+5.8; 95% CI: +0.1, +11.5), educators' participating in a program-related training (+7.6; 95% CI: +2.9, 12.2), and educator perceptions that implementation was difficult (-6.9; 95% CI: -12.1, -1.7) and was an excessive time burden (-4.4; 95% CI: -8.4, -0.4). CONCLUSIONS: Although the program reached Ghanaian schoolgirls, school-level factors were barriers to adherence. Modifications such as expanded training, formalized make-up IFA distributions, sensitization (awareness promotion), and additional support to senior high schools may improve adherence. Spreading the responsibility for IFA distribution to other teachers and streamlining monitoring may reduce the burden at the school level. Strengthening the health education component and improving knowledge of IFA among students may also be beneficial. |
Predictors of anaemia among adolescent schoolchildren of Ghana
Gosdin L , Tripp K , Mahama AB , Quarshie K , Amoaful EF , Selenje L , Sharma D , Jefferds ME , Sharma AJ , Whitehead RD Jr , Suchdev PS , Ramakrishnan U , Martorell R , Addo OY . J Nutr Sci 2020 9 e43 Anaemia is a public health problem in Ghana. We sought to identify factors associated with haemoglobin concentration (Hb) and anaemia among school-attending adolescents. We analysed data from 2948 adolescent girls and 609 boys (10-19 years) selected from 115 schools from regions of Ghana as a secondary analysis of baseline surveys conducted at two time-points. We measured Hb, malaria from capillary blood, anthropometry and used a modified food frequency questionnaire to assess diet. Multivariable linear and Poisson regression models were used to identify predictors of Hb and anaemia. The prevalence of anaemia, malaria and geophagy were 24, 25, and 24 %, respectively, among girls and 13, 27 and 6 %, respectively, among boys. Girls engaging in geophagy had a 53 % higher adjusted prevalence of anaemia and 0⋅39 g/dl lower Hb. There were similar results among those who tested positive for malaria (+52 % anaemia; -0⋅42 g/dl Hb). Among girls, lower anaemia prevalence and higher Hb were associated with consumption of foods rich in haeme iron (-22 %; +0⋅18 g/dl), consumption of iron-fortified cereal/beverages consumed with citrus (-50 %; +0⋅37 g/dl) and being overweight (-22 %; +0⋅22 g/dl). Age was positively associated with anaemia among girls, but negatively associated among boys. Boys who tested positive for malaria had 0⋅31 g/dl lower Hb. Boys who were overweight or had obesity and consumed flour products were also more likely to be anaemic (119 and 56 %, respectively). Factors associated with Hb and anaemia may inform anaemia reduction interventions among school-going adolescents and suggest the need to tailor them uniquely for boys and girls. |
Meeting breastfeeding intentions differ by race/ethnicity, Infant and Toddler Feeding Practices Study-2
Hamner HC , Beauregard JL , Li R , Nelson JM , Perrine CG . Matern Child Nutr 2020 17 (2) e13093 Prenatal breastfeeding intentions impact breastfeeding practices. Racial/ethnic disparities exist in breastfeeding rates; it is unknown if prenatal intentions and meeting intentions differ by race/ethnicity. A longitudinal cohort of USDA's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) which enrolled participants beginning in 2013 were used to estimate prenatal intentions for breastfeeding initiation, exclusive breast milk feeds at 1 and 3 months by race/ethnicity (n = 2070). Meeting intentions were determined by reported breast milk consumption at birth, 1 month and 3 months. Multivariable logistic regression was used to determine the association of race/ethnicity with meeting intentions. There were no differences in prenatal breastfeeding intentions between non-Hispanic White and non-Hispanic Black women (initiation: 86.9% and 87.2%; Month 1: 52.3% and 48.3%; Month 3: 43.8% and 40.9%; respectively), but a higher percentage of Hispanic women intended to breastfeed at all time points (95.5%, 68.3% and 56.4%; respectively, P < 0.05). Among women who intended to breastfeed at Month 1, non-Hispanic Black and Hispanic women had significantly lower odds of meeting intentions compared with non-Hispanic White women after adjusting for covariates (aORs: 0.63 [95% CI: 0.41, 0.98]; 0.64 [95% CI: 0.44, 0.92], respectively). Similar findings were seen for Month 3. Despite no differences in breastfeeding intentions, non-Hispanic Black women were less likely to meet their breastfeeding intentions than non-Hispanic White women. Hispanic women were more likely to intend to breastfeed yet were less likely to meet their intentions. This suggests that non-Hispanic Black and Hispanic women face challenges to meeting their longer breastfeeding intentions. Understanding how racism, bias and discrimination contribute to women not meeting their breastfeeding intentions may help efforts to reduce breastfeeding disparities. |
Clinical decision support for worker health: A five-site qualitative needs assessment in primary care settings
Ash JS , Chase D , Baron S , Filios MS , Shiffman RN , Marovich S , Wiesen J , Luensman GB . Appl Clin Inform 2020 11 (4) 635-643 BACKGROUND: Although patients who work and have related health issues are usually first seen in primary care, providers in these settings do not routinely ask questions about work. Guidelines to help manage such patients are rarely used in primary care. Electronic health record (EHR) systems with worker health clinical decision support (CDS) tools have potential for assisting these practices. OBJECTIVE: This study aimed to identify the need for, and barriers and facilitators related to, implementation of CDS tools for the clinical management of working patients in a variety of primary care settings. METHODS: We used a qualitative design that included analysis of interview transcripts and observational field notes from 10 clinics in five organizations. RESULTS: We interviewed 83 providers, staff members, managers, informatics and information technology experts, and leaders and spent 35 hours observing. We identified eight themes in four categories related to CDS for worker health (operational issues, usefulness of proposed CDS, effort and time-related issues, and topic-specific issues). These categories were classified as facilitators or barriers to the use of the CDS tools. Facilitators related to operational issues include current technical feasibility and new work patterns associated with the coordinated care model. Facilitators concerning usefulness include users' need for awareness and evidence-based tools, appropriateness of the proposed CDS for their patients, and the benefits of population health data. Barriers that are effort-related include additional time this proposed CDS might take, and other pressing organizational priorities. Barriers that are topic-specific include sensitive issues related to health and work and the complexities of information about work. CONCLUSION: We discovered several themes not previously described that can guide future CDS development: technical feasibility of the proposed CDS within commercial EHRs, the sensitive nature of some CDS content, and the need to assist the entire health care team in managing worker health. |
Estimating trunk angle kinematics during lifting using a computationally efficient computer vision method
Greene RL , Lu ML , Barim MS , Wang X , Hayden M , Hu YH , Radwin RG . Hum Factors 2020 64 (3) 482-498 OBJECTIVE: A computer vision method was developed for estimating the trunk flexion angle, angular speed, and angular acceleration by extracting simple features from the moving image during lifting. BACKGROUND: Trunk kinematics is an important risk factor for lower back pain, but is often difficult to measure by practitioners for lifting risk assessments. METHODS: Mannequins representing a wide range of hand locations for different lifting postures were systematically generated using the University of Michigan 3DSSPP software. A bounding box was drawn tightly around each mannequin and regression models estimated trunk angles. The estimates were validated against human posture data for 216 lifts collected using a laboratory-grade motion capture system and synchronized video recordings. Trunk kinematics, based on bounding box dimensions drawn around the subjects in the video recordings of the lifts, were modeled for consecutive video frames. RESULTS: The mean absolute difference between predicted and motion capture measured trunk angles was 14.7°, and there was a significant linear relationship between predicted and measured trunk angles (R(2) = .80, p < .001). The training error for the kinematics model was 2.3°. CONCLUSION: Using simple computer vision-extracted features, the bounding box method indirectly estimated trunk angle and associated kinematics, albeit with limited precision. APPLICATION: This computer vision method may be implemented on handheld devices such as smartphones to facilitate automatic lifting risk assessments in the workplace. |
New respirator performance monitor (RePM) for powered air-purifying respirators
Grinshpun SA , Corey J , Yermakov M , Wu B , Strickland KT , Bergman M , Zhuang Z . J Occup Environ Hyg 2020 17 1-8 Powered air-purifying respirators (PAPRs) that offer protection from particulates are deployed in different workplace environments. Usage of PAPRs by healthcare workers is rapidly increasing; these respirators are often considered the best option in healthcare settings, particularly during public health emergency situations, such as outbreaks of pandemic diseases. At the same time, lack of user training and certain vigorous work activities may lead to a decrease in a respirator's performance. There is a critical need for real-time performance monitoring of respiratory protective devices, including PAPRs. In this effort, a new robust and low-cost real-time performance monitor (RePM) capable of evaluating the protection offered by a PAPR against aerosol particles at a workplace was developed. The new device was evaluated on a manikin and on human subjects against a pair of condensation nuclei counters (P-Trak) used as the reference protection measurement system. The outcome was expressed as a manikin-based protection factor (mPF) and a Simulated Workplace Protection Factor (SWPF) determined while testing on subjects. For the manikin-based testing, the data points collected by the two methods were plotted against each other; a near-perfect correlation was observed with a correlation coefficient of 0.997. This high correlation is particularly remarkable since RePM and condensation particle counter (CPC) measure in different particle size ranges. The data variability increased with increasing mPF. The evaluation on human subjects demonstrated that RePM prototype provided an excellent Sensitivity (96.3% measured on human subjects at a response time of 60 sec) and a Specificity of 100%. The device is believed to be the first of its kind to quantitatively monitor PAPR performance while the wearer is working; it is small, lightweight, and does not interfere with job functions. |
Biological effects of inhaled hydraulic fracturing sand dust. VI. Cardiovascular effects
Krajnak K , Kan H , Russ KA , McKinney W , Waugh S , Zheng W , Kashon ML , Johnson C , Cumpston J , Fedan JS . Toxicol Appl Pharmacol 2020 406 115242 Hydraulic fracturing is used to access oil and natural gas reserves. This process involves the high-pressure injection of fluid to fracture shale. Fracking fluid contains approximately 95% water, chemicals and 4.5% fracking sand. Workers may be exposed to fracking sand dust (FSD) during the manipulation of the sand, and negative health consequences could occur if FSD is inhaled. In the absence of any information about its potential toxicity, a comprehensive rat animal model study (see Fedan, J.S., Toxicol Appl Pharmacol. 000, 000-000, 2020) was designed to investigate the bioactivities of several FSDs in comparison to MIN-U-SIL® 5, a respirable α-quartz reference dust used in previous animal models of silicosis, in several organ systems. The goal of this study was to assess the effects of inhalation of one FSD, i.e., FSD 8, on factors and tissues that affect cardiovascular function. Male rats were exposed to 10 or 30 mg/m(3) FSD (6 h/d for 4 d) by whole body inhalation, with measurements made 1, 7 or 27 d post-exposure. One day following exposure to 10 mg/m(3) FSD the sensitivity to phenylephrine-induced vasoconstriction in tail arteries in vitro was increased. FSD exposure at both doses resulted in decreases in heart rate (HR), HR variability, and blood pressure in vivo. FSD induced changes in hydrogen peroxide concentrations and transcript levels for pro-inflammatory factors in heart tissues. In kidney, expression of proteins indicative of injury and remodeling was reduced after FSD exposure. When analyzed using regression analysis, changes in proteins involved in repair and remodeling were correlated. Thus, it appears that inhalation of FSD does have some prolonged effects on cardiovascular, and, possibly, renal function. The findings also provide information regarding potential mechanisms that may lead to these changes, and biomarkers that could be examined to monitor physiological changes that could be indicative of impending cardiovascular dysfunction. |
Pre-pregnancy handling of antineoplastic drugs and risk of miscarriage in female nurses
Nassan FL , Chavarro JE , Johnson CY , Boiano JM , Rocheleau CM , Rich-Edwards JW , Lawson CC . Ann Epidemiol 2020 53 95-102 e2 OBJECTIVE: To examine the association between handling of antineoplastic drugs (AD), use of exposure controls, and risk of miscarriage. METHODS: Women in the Nurses' Health Study 3 self-reported AD administration and use of engineering controls (EC) and personal protective equipment (PPE) at baseline. Nurses who reported pregnancies after baseline were included in this analysis. We estimated the Hazard Ratio (HR) of miscarriage in relation to baseline AD handling using multivariable Cox proportional regression modified for discrete time data. RESULTS: 2,440 nurses reported 3,327 pregnancies within a median of 3 years after baseline (range:1-8 years), of which 550 (17%) ended as miscarriages. Mean (standard deviation) age at baseline was 29.7 years (4.3). At baseline, 12% of the nurses self-reported currently handling AD and 28% previously handling. Compared to nurses who never handled AD, nurses who handled AD at baseline had a HR of miscarriage of 1.26 (95% CI: 0.97, 1.64) after adjusting for age, body mass index, and smoking. This association was stronger for losses after 12 weeks gestation (HR=2.39 [95% CI: 1.13, 5.07]), and among nurses who did not always use EC and PPE. Nurses who did not always use gloves had a HR of 1.51 (95% CI:0.91, 2.51) compared to 1.19 (95% CI:0.89, 1.60) for those always using gloves; nurses who did not always use gowns had a HR of 1.32 (95% CI:0.95, 1.83) compared to 1.19 (95% CI:0.81, 1.75) for nurses always using gowns. AD handling prior to baseline was unrelated to risk of miscarriage. CONCLUSION(S): We observed a suggestive positive association between AD handling and miscarriage, particularly among nurses who did not consistently use PPE and EC. These associations appeared to be more evident among second trimester losses. |
Biomechanical assessment while using production tables on mast climbing work platforms
Pan CS , Ning X , Wimer B , Zwiener J , Kau TY . Appl Ergon 2020 90 103276 The objective of this study was to assess the impact of using alternative mast climbing work platform (MCWP) designs on trunk motion and postural stability with masonry workers while performing bricklaying and stepping down tasks using a conventional MCWP setting (i.e. with a step deck) as well as two types of production tables (straight- and L-shaped). The trunk angles and postural sway parameters of twenty-five masonry workers were recorded for the following tasks: (1) standing on a simulated MCWP and laying bricks on an adjacent wall, and (2) stepping down onto the step deck to get into position for doing the bricklaying task. Results indicated that the use of the L-shaped production table resulted in the lowest trunk ranges of motion and significantly reduced the workers' trunk angles in all three planes when compared to both the straight-shaped production table and the conventional approach of not using a production table. Data showed that both body sway velocity and area were significantly reduced when using either one of the production tables. The use of production tables significantly reduced impact sway forces when workers stepped from the main platform to the step deck. The use of production tables on MCWPs improved workers' postures and overall stability, which could reduce the risk of injury. |
Original research: Suicide among RNs: An analysis of 2015 data from the National Violent Death Reporting System
Patrician PA , Peterson C , McGuinness TM . Am J Nurs 2020 120 (10) 24-28 BACKGROUND: Suicide is now the 10th leading cause of death in the United States. Suicide rates for health care providers are thought to be higher than for people in other occupations because of job strain and burnout. Despite the National Academy of Medicine's Action Collaborative on Clinician Well-Being and Resilience, which focuses on reducing stress and preventing suicide, a shortage of data limits our understanding of nurse suicide. Neither employers nor professional nursing associations track suicide data. PURPOSE: To determine the number of suicides and estimated rate of suicide among RNs, using data from the National Violent Death Reporting System (NVDRS). METHODS: We extracted data from the NVDRS, which is based on death certificates, coroner reports, and law enforcement reports, for the year 2015. The National Institute for Occupational Safety and Health's Industry and Occupation Computerized Coding System was used to code the data. Industry and occupation coding experts reviewed the coding for accuracy. RESULTS: Analysis of 2015 NVDRS data from 17 states showed that among civilian employed nurses ages 16 to 64 years, the estimated suicide rates for female and male nurses (11.4 and 29.3 per 100,000 nurses, respectively) were each higher than the rates for the comparable total population (8.2 and 26.1 per 100,000 people, respectively). CONCLUSIONS: Our findings indicate that RNs may die by suicide at higher rates than the total employed population in the 16-to-64-year age range. Implementation of evidence-based approaches to prevent suicide are warranted. |
Envisioning the future of work to safeguard the safety, health, and well-being of the workforce: A perspective from the CDC's National Institute for Occupational Safety and Health
Tamers SL , Streit J , Pana-Cryan R , Ray T , Syron L , Flynn MA , Castillo D , Roth G , Geraci C , Guerin R , Schulte P , Henn S , Chang CC , Felknor S , Howard J . Am J Ind Med 2020 63 (12) 1065-1084 The future of work embodies changes to the workplace, work, and workforce, which require additional occupational safety and health (OSH) stakeholder attention. Examples include workplace developments in organizational design, technological job displacement, and work arrangements; work advances in artificial intelligence, robotics, and technologies; and workforce changes in demographics, economic security, and skills. This paper presents the Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health's Future of Work Initiative; suggests an integrated approach to address worker safety, health, and well-being; introduces priority topics and subtopics that confer a framework for upcoming future of work research directions and resultant practical applications; and discusses preliminary next steps. All future of work issues impact one another. Future of work transformations are contingent upon each of the standalone factors discussed in this paper and their combined effects. Occupational safety and health stakeholders are becoming more aware of the significance and necessity of these factors for the workplace, work, and workforce to flourish, merely survive, or disappear altogether as the future evolves. The future of work offers numerous opportunities, while also presenting critical but not clearly understood difficulties, exposures, and hazards. It is the responsibility of OSH researchers and other partners to understand the implications of future of work scenarios to translate effective interventions into practice for employers safeguarding the safety, health, and well-being of their workers. |
Assessment of pneumoconiosis in surface coal miners after implementation of a national radiographic surveillance program, United States, 2014-2019
Hall NB , Halldin CN , Blackley DJ , Laney AS . Am J Ind Med 2020 63 (12) 1104-1108 BACKGROUND: Pneumoconiosis can occur in surface coal miners. The Coal Workers' Health Surveillance Program (CWHSP) has only included surface coal miners as part of its regular disease surveillance since 2014. This analysis identifies the prevalence of pneumoconiosis among working surface coal miners participating in the CWHSP since their initial inclusion, through 2019. METHODS: Working surface coal miners who had chest radiographs through the CWHSP from January 1, 2014 through December 31, 2019 were included in this analysis. Demographic information, mining tenure and occupation, and radiographic classifications according to the International Labour Office system were included from each miner's most recent encounter with the CWHSP. Prevalence ratios were calculated comparing the prevalence of the disease by region and occupation by log-binomial regression. RESULTS: Pneumoconiosis was present in 109 (1.6%) surface coal miners, including 12 miners with progressive massive fibrosis, the most severe form of the disease. After taking surface mining tenure into account, surface miners in Central Appalachia (prevalence ratio [PR], 3.2; 95% confidence interval [CI], 2.2-4.7) and surface miners who worked as a driller or blaster (PR, 2.1; 95% CI, 1.3-3.5) were at increased risk of pneumoconiosis. CONCLUSION: The occurrence of pneumoconiosis in surface coal miners supports including them within a systematic respiratory health surveillance program. The current surveillance findings are consistent with past findings of pneumoconiosis, particularly silicosis, in surface mining occupations such as drilling and blasting. |
Causes of death among Federal Black Lung Benefits Program beneficiaries enrolled in Medicare, 1999-2016
Kurth L , Halldin C , Laney AS , Blackley DJ . Am J Ind Med 2020 63 (11) 973-979 BACKGROUND: Coal miners with totally disabling pneumoconiosis are eligible for benefits through the Federal Black Lung Benefits Program (FBLP). We identify the causes of death among Medicare beneficiaries with a claim for which the FBLP was the primary payer and compare these causes of death to all deceased Medicare beneficiaries to better understand elevated death and disease among miners with occupational respiratory exposures. METHODS: From 1999 to 2016 Medicare data, we extracted beneficiary and National Death Index data for 28,003 beneficiaries with an FBLP primary payer claim. We summarized the International Classification of Diseases, Clinical Modification 10th revision-coded underlying causes of death and entity-axis multiple causes of death for 22,242 deceased Medicare beneficiaries with an FBLP primary payer Medicare claim and compared their causes of death to the deceased Medicare beneficiary population. RESULTS: Among deceased FBLP beneficiaries, the three leading underlying causes of death were chronic obstructive pulmonary disease, unspecified (J44.9, 10.1%), atherosclerotic heart disease (I25.1, 9.3%), and coal workers' pneumoconiosis (CWP) (J60, 9.2%). All diseases of the respiratory system combined (J00-J99) were the underlying cause of death for 29.1% of all beneficiaries, with pneumoconioses (J60-J64) as the underlying cause for 11.0% of all beneficiaries. CONCLUSIONS: Coal miners enrolled in Medicare with an FBLP primary payer claim were more likely to have specific respiratory and cardiovascular diseases listed as a cause of death than deceased Medicare beneficiaries overall, and were also more likely to die from CWP or any pneumoconioses. |
Verification of 3D numerical modeling approach for longwall mines with a case study mine from the northern Appalachian coal fields
Tuncay D , Tulu IB , Klemetti T . Min Metall Explor 2020 38 (1) 447-456 Accurately estimating load distributions and ground responses around underground openings plays a significant role in the safety of the operations in underground mines. Adequately designing pillars and other support measures relies highly on the accurate assessment of the mining-induced loads, as well as the load-bearing capacities of the supports. There are various methods that can be used to approximate mining-induced loads in stratified rock masses, both empirical and numerical. In this study, the numerical modeling approach recently developed at West Virginia University, which is based on the modeling approach developed by the National Institute for Occupational Safety and Health (NIOSH), is investigated using the finite difference software FLAC3D. The model includes the longwall panels, the adjacent chain pillar systems, and the different stratigraphic layers of the overburden. Using the 3D model, changes in loading conditions and deformations on the areas of interest, induced by an approaching longwall face, can be examined. This paper details the 3D modeling of a longwall panel utilizing this approach, and the verification of the results against field observations. The studied panel was 360 m wide with a 3-entry chain pillar system and about a 160-m average overburden depth around the studied area. The overburden strata consist of alternating layers of shale, sandstone, and limestone. The FLAC3D results were compared against field measurements from the mine site. The stress change values measured in the chain pillars were comparable with the modeling results. The model also replicated the surface subsidence profile obtained from field measurements fairly well. Overall, the 3D modeling approach was found to be successful for the case study longwall panel. |
Establishing a National Molecular Surveillance Program for the Detection of Plasmodium falciparum Markers of Resistance to Antimalarial Drugs in Haiti.
Hamre KES , Pierre B , Namuyinga R , Mace K , Rogier EW , Udhayakumar V , Boncy J , Lemoine JF , Chang MA . Am J Trop Med Hyg 2020 103 (6) 2217-2223 Chloroquine remains the first-line treatment for uncomplicated malaria in Haiti, and until recently, sulfadoxine-pyrimethamine was the second-line treatment. A few studies have reported the presence of molecular markers for resistance in Plasmodium falciparum parasites, and in vivo therapeutic efficacy studies (TESs) have been limited. Recognizing the history of antimalarial resistance around the globe and the challenges of implementing TESs in low-endemic areas, the Ministry of Health established a surveillance program to detect molecular markers of antimalarial resistance in Haiti. Sentinel sites were purposefully selected in each of Haiti's 10 administrative departments; an 11th site was selected in Grand'Anse, the department with the highest number of reported cases. Factors considered for site selection included the number of malaria cases identified, observed skills of laboratory technicians conducting rapid diagnostic tests (RDTs), stock and storage conditions of RDTs, accuracy of data reporting to the national surveillance system, and motivation to participate. Epidemiologic data from 2,437 patients who tested positive for malaria from March 2016 to December 2018 and consented to provide samples for molecular sequencing are presented here. Of these, 936 (38.4%) patients reported self-treatment with any medication since the onset of their illness before diagnosis; overall, 69 (2.8%) patients reported taking an antimalarial. Ten patients (0.4%) reported travel away from their home for at least one night in the month before diagnosis. Establishing a molecular surveillance program for antimalarial drug resistance proved practical and feasible in a resource-limited setting and will provide the evidence needed to make informed treatment policy decisions at the national level. |
Malaria case management and elimination readiness in health facilities of five districts of Madagascar in 2018
Anand A , Favero R , Dentinger C , Ralaivaomisa A , Ramamonjisoa S , Rabozakandraina O , Razafimandimby E , Razafindrakoto J , Wolf K , Steinhardt L , Gomez P , Rabary M , Andriamananjara MN , Mioramalala SA , Rakotovao JP . Malar J 2020 19 (1) 351 BACKGROUND: Madagascar's Malaria National Strategic Plan 2018-2022 calls for progressive malaria elimination beginning in low-incidence districts (< 1 case/1000 population). Optimizing access to prompt diagnosis and quality treatment and improving outbreak detection and response will be critical to success. A malaria elimination readiness assessment (MERA) was performed in health facilities (HFs) of selected districts targeted for malaria elimination. METHODS: A mixed methods survey was performed in September 2018 in five districts of Madagascar. Randomly selected HFs were assessed for availability of malaria commodities and frequency of training and supervision conducted. Health providers (HPs) and community health volunteers (CHVs) were interviewed, and outpatient consultations at HFs were observed. To evaluate elimination readiness, a composite score ranging from 0 to 100 was designed from all study tools and addressed four domains: (1) resource availability, (2) case management (CM), (3) data management and use, and (4) training, supervision, and technical assistance; scores were calculated for each HF catchment area and district based on survey responses. Stakeholder interviews on malaria elimination planning were conducted at national, regional and district levels. RESULTS: A quarter of the 35 HFs surveyed had no rapid diagnostic tests (RDTs). Of 129 patients with reported or recorded fever among 300 consultations observed, HPs tested 56 (43%) for malaria. Three-quarters of the 35 HF managers reviewed data for trends. Only 68% of 41 HPs reported receiving malaria-specific training. Of 34 CHVs surveyed, 24% reported that treating fever was no longer among their responsibilities. Among treating CHVs, 13 (50%) reported having RDTs, and 11 (42%) had anti-malarials available. The average district elimination readiness score was 52 out of 100, ranging from 48 to 57 across districts. Stakeholders identified several challenges to commodity management, malaria CM, and epidemic response related to lack of training and funding disruptions. CONCLUSION: This evaluation highlighted gaps in malaria CM and elimination readiness in Madagascar to address during elimination planning. Strategies are needed that include training, commodity provision, supervision, and support for CHVs. The MERA can be repeated to assess progress in filling identified gaps and is a feasible tool that could be used to assess elimination targets in other countries. |
Assessment of health service delivery parameters in Kano and Zamfara States, Nigeria
Bala U , Ajumobi O , Umar A , Adewole A , Waziri N , Gidado S , Mohammed AB , Uhomoibhi P , Muhammad B , Ismail M , Kachur SP , Cash S , Asamoa K . BMC Health Serv Res 2020 20 (1) 874 BACKGROUND: In 2013, the Nigeria Federal Ministry of Health established a Master Health Facility List (MHFL) as recommended by WHO. Since then, some health facilities (HFs) have ceased functioning and new facilities were established. We updated the MHFL and assessed service delivery parameters in the Malaria Frontline Project implementing areas in Kano and Zamfara States. METHODS: We assessed all HFs in each of the 34 project local government areas (LGAs) between July and September 2017. Project staff administered a semi-structured questionnaire developed for this assessment to heads of HFs about the type of facility, category and number of staff working at the facility and to record geo-coordinates of facility. RESULTS: In the Kano State project area, 726 HFs were identified and geo-located: 31 were new facilities, 608 (84%), 116 (16%) and two (0.3%) were Primary Health Care (PHC), secondary and tertiary facilities respectively. Using the national definition, there were 710 (98%) functional facilities and 644 (91%) of these reported to the national health information platform, District Health Information System, version 2 (DHIS2). The Zamfara project area had 739 HFs: eight were new, 715 (97%), 22 (3.0%) and two (0.2%) PHCs, secondary and tertiary facilities respectively. There were 695 (94%) functional facilities with 656 (94%) of these reporting to DHIS2. Using national criteria for primary health care designation, only 95 (9%) of all PHCs in the two States met the minimum human resource requirements. CONCLUSION: Most HFs were functional and reported to DHIS2. A comprehensive MHFL having all the important parameters that should be established and updated regularly by authorities to make it more useful for health services administration and management. Most functional facilities are understaffed. |
The use of serology for trachoma surveillance: Current status and priorities for future investigation
Martin DL , Saboyà-Díaz MI , Abashawl A , Alemayeh W , Gwyn S , Hooper PJ , Keenan J , Kalua K , Szwarcwald CL , Nash S , Oldenburg C , West SK , White M , Solomon AW . PLoS Negl Trop Dis 2020 14 (9) e0008316 Programs seeking to eliminate the eye disease trachoma use prevalence of the clinical sign trachomatous inflammation–follicular (TF) in 1- to 9-year-olds as a proxy for population-level transmission of ocular Chlamydia trachomatis (Ct). TF prevalence determines the need for the A, F, and E components of the “SAFE” (surgery, antibiotics, facial cleanliness, environmental improvement) strategy. Ocular Ct infection, like its associated signs of conjunctival inflammation, is most common and most intense in young children [1, 2] who are repeatedly infected in areas of active transmission [3]: a model suggests that people can be infected more than 150 times in their lifetime [4]. Repeated infection leads to multiple episodes of TF plus more intense conjunctival inflammation and eventually conjunctival scarring (trachomatous scarring [TS])[5, 6]. Contraction of conjunctival scar can, over a period of years or decades, cause the upper eyelid to turn in and the eyelashes to rub against the eyeball (trachomatous trichiasis [TT]), which can lead to corneal opacity (CO) and blindness. |
Teaching public and population health in medical education: An evaluation framework
Johnson SB , Fair MA , Howley LD , Prunuske J , Cashman SB , Carney JK , Jarris YS , Deyton LR , Blumenthal D , Krane NK , Fiebach NH , Strelnick AH , Morton-Eggleston E , Nickens C , Ortega L . Acad Med 2020 95 (12) 1853-1863 Curriculum models and training activities in medical education have been markedly enhanced to prepare physicians to address the health needs of diverse populations and to advance health equity. While different teaching and experiential learning activities in the public health and population health sciences have been implemented, there is no existing framework to measure the effectiveness of public and population health (PPH) education in medical education programs. In 2015, the Association of American Medical Colleges (AAMC) established the Expert Panel on Public and Population Health in Medical Education, which convened 20 U.S. medical faculty members whose goal was to develop an evaluation framework adapted from the New World Kirkpatrick Model. Institutional leaders can use this framework to assess the effectiveness of PPH curricula for learners, faculty, and community partners. It may also assist institutions with identifying opportunities to improve the integration of PPH content into medical education programs. In this article, the authors present outcomes metrics and practical curricular or institutional illustrations at each Kirkpatrick training evaluation level to assist institutions with the measurement of (1) reaction to the PPH education content, (2) learning accomplished, (3) application of knowledge and skills to practice, and (4) outcomes achieved as a result of PPH education and practice. A fifth level was added to measure the benefit of PPH curricula on the health system and population health. The framework may assist with developing a locally relevant evaluation to further integrate and support PPH education at U.S. medical schools and teaching hospitals. |
Hypertension in pregnancy in the US - one step closer to better ascertainment and management
Kuklina EV . JAMA Netw Open 2020 3 (10) e2019364 The study by Butwick et al1 examined the prevalence of prepregnancy (chronic) and pregnancy-associated hypertension using 2017 US birth certificate data. The 2003 version of the birth certificate that was in use in all states in 2017 provides checkboxes for prepregnancy (chronic) hypertension, gestational hypertension, and eclampsia.2 Gestational hypertension includes transient hypertension, preeclampsia, and hemolysis, elevated liver enzyme levels, and low platelet levels syndrome.2 Thus, while Butwick et al1 use the term hypertensive disorders of pregnancy, gestational hypertension is used as an overarching term and applied to any hypertensive disorder diagnosed after 20 weeks of pregnancy. A recorder of a birth certificate can select eclampsia with either chronic hypertension or gestational hypertension. The authors report the prevalence of chronic hypertension (1.9%), gestational hypertension (6.5%), and eclampsia (0.3%) in the US, with the overall prevalence of any hypertension being 8.6% during pregnancy.1 Using the 2017 data from more than 3 500 000 births in analyses adjusted for patient-level factors, prevalence estimates of chronic hypertension were the lowest in Hawaii (1.0%; 95% CI, 0.9%-1.2%) and the highest in Alaska (3.4%; 95% CI, 3.0%-3.9%). The prevalence estimates of gestational hypertension were lowest in Massachusetts (4.3%; 95% CI, 4.1%-4.6%) and highest in Louisiana (9.3%; 95% CI, 8.9%-9.8%). The reported adjusted prevalence of eclampsia among states ranged from 0.03% in Delaware (95% CI, 0.01%-0.09%) to 2.8% in Hawaii (95% CI, 2.2%-3.4%) or 3 to 280 per 10 000 births. In addition to Hawaii, 3 other states (Alabama, Alaska, and Virginia) had rates of eclampsia greater than 1% or 100 per 10 000 births. The median difference in the adjusted odds ratio (MOR) assessed the variation in estimated odds of outcomes between states. The MOR varied by outcomes with a substantially greater MOR observed for eclampsia (MOR, 2.36; 95% CI, 1.88-2.82) than for chronic hypertension (MOR, 1.27; 95% CI, 1.20-1.33) or gestational hypertension (MOR, 1.17; 95% CI, 1.17-1.21). |
Marginal quantile regression for longitudinal data analysis in the presence of time-dependent covariates
Chen IC , Westgate PM . Int J Biostat 2020 17 (2) 267-282 When observations are correlated, modeling the within-subject correlation structure using quantile regression for longitudinal data can be difficult unless a working independence structure is utilized. Although this approach ensures consistent estimators of the regression coefficients, it may result in less efficient regression parameter estimation when data are highly correlated. Therefore, several marginal quantile regression methods have been proposed to improve parameter estimation. In a longitudinal study some of the covariates may change their values over time, and the topic of time-dependent covariate has not been explored in the marginal quantile literature. As a result, we propose an approach for marginal quantile regression in the presence of time-dependent covariates, which includes a strategy to select a working type of time-dependency. In this manuscript, we demonstrate that our proposed method has the potential to improve power relative to the independence estimating equations approach due to the reduction of mean squared error. |
The association between opioid discontinuation and heroin use: A nested case-control study
Binswanger IA , Glanz JM , Faul M , Shoup JA , Quintana LM , Lyden J , Xu S , Narwaney KJ . Drug Alcohol Depend 2020 217 108248 BACKGROUND: Opioid prescribing guidelines recommend reducing or discontinuing opioids for chronic pain if harms of opioid treatment outweigh benefits. As opioid discontinuation becomes more prevalent, it is important to understand whether opioid discontinuation is associated with heroin use. In this study, we sought to assess the association between opioid discontinuation and heroin use documented in the medical record. METHODS: A matched nested case-control study was conducted in an integrated health plan and delivery system in Colorado. Patients receiving opioid therapy in the study period (January 2006-June 2018) were included. Opioid discontinuation was defined as ≥45 days with no opioids dispensed after initiating opioid therapy. The heroin use onset date represented the index date. Case patients were matched to up to 20 randomly selected patients without heroin use (control patients) by age, sex, calendar time, and time between initiating opioid therapy and the index date. Conditional logistic regression models estimated matched odds ratios (mOR) for the association between an opioid discontinuation prior to the index date and heroin use. RESULTS: Among 22,962 patients prescribed opioid therapy, 125 patients (0.54%) used heroin after initiating opioid therapy, of which 74 met criteria for inclusion in the analysis. The odds of opioid discontinuation were approximately two times higher in case patients (n = 74) than control patients (n = 1045; mOR = 2.19; 95% CI 1.27-3.78). CONCLUSIONS: Among patients prescribed chronic opioid therapy, the observed increased risk for heroin use associated with opioid discontinuation should be balanced with potential benefits. |
Adolescent marijuana use and related risk behaviors, national findings from 2015 to 2017
Schauer GL , Clayton HB , Njai R , Grant AM . Am J Prev Med 2020 59 (5) 714-724 INTRODUCTION: As policies legalizing nonmedical marijuana have increased in states, understanding the implications of marijuana use among adolescents is increasingly important. This study uses nationally representative data to assess behavioral risk factors among students with different patterns of marijuana use. METHODS: Data from the 2015 and 2017 Youth Risk Behavior Surveys, cross-sectional surveys conducted among a nationally representative sample of students in Grades 9-12 (n=30,389), were used to examine the association between self-reported current marijuana use status and self-report of 30 risk behaviors across 3 domains: substance use, injury/violence, and sexual health. Among current marijuana users, authors assessed differences between established (≥100 lifetime uses) and nonestablished (<100 uses) users. Multivariable models were used to calculate adjusted prevalence ratios. Data were analyzed in 2019. RESULTS: Current marijuana users (regardless of use pattern) had a significantly greater likelihood of engaging in 27 of the 30 behaviors assessed across the 3 domains than the noncurrent users. Those with established use patterns (versus nonestablished) had a greater risk of lifetime use of most other substances (licit and illicit, including tobacco, alcohol, heroin, misuse of opioids), some injury/violence behaviors (including driving while using marijuana and suicide ideation and attempt), and sexual risk behaviors. CONCLUSIONS: Both established and nonestablished patterns of adolescent marijuana use are associated with a number of other risky behaviors. In addition to interventions focused on preventing youth initiation of marijuana, clinicians and public health professionals should consider interventions to help adolescents who have nonestablished use patterns to avoid continued, established use. |
Exposure to secondhand smoke in homes and vehicles among US youths, United States, 2011-2019
Walton K , Gentzke AS , Murphy-Hoefer R , Kenemer B , Neff LJ . Prev Chronic Dis 2020 17 E103 In this study, we report the prevalence of self-reported secondhand smoke (SHS) exposure in homes and vehicles among US middle and high school students in 2019 and changes in SHS exposure over time. Data were from 7 years of the National Youth Tobacco Survey (NYTS; 2011, 2013, and 2015-2019). In 2019, 25.3% (an estimated 6.7 million) of students reported home SHS exposure and 23.3% (6.1 million) reported vehicle SHS exposure. Home and vehicle SHS exposure significantly declined during 2011 through 2018, except for home exposure among non-Hispanic black students. Implementation of smoke-free policies in public and private settings can reduce SHS exposure. |
A heterogenous swine show circuit drives zoonotic transmission of influenza A viruses in the United States.
Nelson MI , Perofsky A , McBride DS , Rambo-Martin BL , Wilson MM , Barnes JR , van Bakel H , Khan Z , Dutta J , Nolting JM , Bowman AS . J Virol 2020 94 (24) Influenza pandemics are associated with severe morbidity, mortality, and social and economic disruption. Every summer in the United States, youths attending agricultural fairs are exposed to genetically diverse influenza A viruses (IAVs) circulating in exhibition swine, resulting in over 450 lab-confirmed zoonotic infections since 2010. Exhibition swine represent a small, defined population (∼1.5% of the US herd), presenting a realistic opportunity to mitigate a pandemic threat by reducing IAV transmission in the animals themselves. Through intensive surveillance and genetic sequencing of IAVs in exhibition swine in six US states in 2018 (n = 212), we characterize how a heterogenous circuit of swine shows, comprised of fairs with different sizes and geographic coverage, facilitates IAV transmission among exhibition swine and into humans. Specifically, we identify the role of an early-season national show in the propagation and spatial dissemination of a specific virus (H1δ-2) that becomes dominant among exhibition swine and is associated with the majority of zoonotic infections in 2018. These findings suggest that a highly targeted mitigation strategy, such as postponing swine shows for 1-2 weeks following the early-season national show, could potentially reduce IAV transmission in exhibition swine and spillover into humans, and merits further study.IMPORTANCE The varying influenza A virus (IAV) exposure and infection status of individual swine facilitates introduction, transmission, and dissemination of diverse IAVs. Since agricultural fairs bring people into intimate contact with swine is provides a unique interface for zoonotic transmission of IAV. Understanding the transmission dynamics of IAV through exhibition swine is critical to mitigating the high incidence of variant IAV cases reported in association with agricultural fairs. We used genomic sequences from our exhibition swine surveillance to characterize the hemagglutinin and full genotypic diversity of IAV at early season shows and the subsequent dissemination through later season agricultural fairs. We were able to identify a critical time point with large implications for downstream IAV and zoonotic transmission. With improved understanding of evolutionary origins of zoonotic IAV, we can inform public health mitigation strategies to ultimately reduce zoonotic IAV transmission and risk of pandemic IAV emergence. |
Defining new pathways to manage the ongoing emergence of bat rabies in Latin America
Benavides JA , Valderrama W , Recuenco S , Uieda W , Suzán G , Avila-Flores R , Velasco-Villa A , Almeida M , Andrade FAG , Molina-Flores B , Vigilato MAN , Pompei JCA , Tizzani P , Carrera JE , Ibanez D , Streicker DG . Viruses 2020 12 (9) Rabies transmitted by common vampire bats (Desmodus rotundus) has been known since the early 1900s but continues to expand geographically and in the range of species and environments affected. In this review, we present current knowledge of the epidemiology and management of rabies in D. rotundus and argue that it can be reasonably considered an emerging public health threat. We identify knowledge gaps related to the landscape determinants of the bat reservoir, reduction in bites on humans and livestock, and social barriers to prevention. We discuss how new technologies including autonomously-spreading vaccines and reproductive suppressants targeting bats might manage both rabies and undesirable growth of D. rotundus populations. Finally, we highlight widespread under-reporting of human and animal mortality and the scarcity of studies that quantify the efficacy of control measures such as bat culling. Collaborations between researchers and managers will be crucial to implement the next generation of rabies management in Latin America. |
Metabolic response in patients with post-treatment Lyme disease symptoms/syndrome
Fitzgerald BL , Graham B , Delorey MJ , Pegalajar-Jurado A , Islam MN , Wormser GP , Aucott JN , Rebman AW , Soloski MJ , Belisle JT , Molins CR . Clin Infect Dis 2020 73 (7) e2342-e2349 BACKGROUND: Post-treatment Lyme disease symptoms/syndrome (PTLDS) occurs in approximately 10% of Lyme disease patients following antibiotic treatment. Biomarkers or specific clinical symptoms to identify PTLDS patients do not currently exist and the PTLDS classification is based on the report of persistent, subjective symptoms for ≥ 6 months following antibiotic treatment for Lyme disease. METHODS: Untargeted liquid chromatography-mass spectrometry metabolomics was used to determine longitudinal metabolic responses and biosignatures in PTLDS and clinically cured non-PTLDS Lyme patients. Evaluation of biosignatures included: 1) defining altered classes of metabolites; 2) elastic net regularization to define metabolites that most strongly defined PTLDS and non-PTLDS patients at different timepoints; 3) changes in the longitudinal abundance of metabolites; 4) linear discriminant analysis to evaluate robustness in a second patient cohort. RESULTS: This study determined that observable metabolic differences exist between PTLDS and non-PTLDS patients at multiple timepoints. The metabolites with differential abundance included those from glycerophospholipid, bile acid and acylcarnitine metabolism. Distinct longitudinal patterns of metabolite abundance indicated a greater metabolic variability in PTLDS vs non-PTLDS patients. Small numbers of metabolites (6-40) could be used to define PTLDS vs. non-PTLDS patients at defined time points, and the findings were validated in a second cohort of PTLDS and non-PTLDS patients. CONCLUSIONS: These data provide evidence that an objective metabolite-based measurement can distinguish patients with PTLDS and help understand the underlying biochemistry of PTLDS. |
Japanese encephalitis virus as cause of acute encephalitis, Bhutan
Wangchuk S , Tamang TD , Darnal JB , Pelden S , Lhazeen K , Mynak ML , Letson GW , Khare S , Leader BT , Marfin AA , Hills SL . Emerg Infect Dis 2020 26 (9) 2239-2242 In 2011, Bhutan's Royal Centre for Disease Control began Japanese encephalitis (JE) surveillance at 5 sentinel hospitals throughout Bhutan. During 2011-2018, a total of 20 JE cases were detected, indicating JE virus causes encephalitis in Bhutan. Maintaining JE surveillance will help improve understanding of JE epidemiology in this country. |
Content Index (Achived Edition)
- Chronic Diseases and Conditions
- Communicable Diseases
- Disease Reservoirs and Vectors
- Environmental Health
- Epidemiology and Surveillance
- Food Safety
- Genetics and Genomics
- Health Communication and Education
- Health Economics
- Healthcare Associated Infections
- Immunity and Immunization
- Informatics
- Injury and Violence
- Laboratory Sciences
- Maternal and Child Health
- Mining
- Nutritional Sciences
- Occupational Safety and Health
- Occupational Safety and Health - Mining
- Parasitic Diseases
- Public Health Leadership and Management
- Reproductive Health
- Statistics as Topic
- Substance Use and Abuse
- Zoonotic and Vectorborne Diseases
About
CDC Science Clips is an online, continuously updated, searchable database of scientific literature published by CDC authors. Each article features an Altmetric Attention Score to track social and mainstream media mentions. If you are aware of a CDC-authored publication that does not appear in this database, please let us know.
- Page last reviewed:Feb 1, 2024
- Page last updated:Apr 22, 2024
- Content source:
- Powered by CDC PHGKB Infrastructure