IMPORTANCE: Cerebral venous sinus thrombosis (CVST) with thrombocytopenia, a rare and serious condition, has been described in Europe following receipt of the ChAdOx1 nCoV-19 vaccine (Oxford/AstraZeneca), which uses a chimpanzee adenoviral vector. A mechanism similar to autoimmune heparin-induced thrombocytopenia (HIT) has been proposed. In the US, the Ad26.COV2.S COVID-19 vaccine (Janssen/Johnson & Johnson), which uses a human adenoviral vector, received Emergency Use Authorization (EUA) on February 27, 2021. By April 12, 2021, approximately 7 million Ad26.COV2.S vaccine doses had been given in the US, and 6 cases of CVST with thrombocytopenia had been identified among the recipients, resulting in a temporary national pause in vaccination with this product on April 13, 2021. OBJECTIVE: To describe reports of CVST with thrombocytopenia following Ad26.COV2.S vaccine receipt. DESIGN, SETTING, AND PARTICIPANTS: Case series of 12 US patients with CVST and thrombocytopenia following use of Ad26.COV2.S vaccine under EUA reported to the Vaccine Adverse Event Reporting System (VAERS) from March 2 to April 21, 2021 (with follow-up reported through April 21, 2021). EXPOSURES: Receipt of Ad26.COV2.S vaccine. MAIN OUTCOMES AND MEASURES: Clinical course, imaging, laboratory tests, and outcomes after CVST diagnosis obtained from VAERS reports, medical record review, and discussion with clinicians. RESULTS: Patients' ages ranged from 18 to younger than 60 years; all were White women, reported from 11 states. Seven patients had at least 1 CVST risk factor, including obesity (n = 6), hypothyroidism (n = 1), and oral contraceptive use (n = 1); none had documented prior heparin exposure. Time from Ad26.COV2.S vaccination to symptom onset ranged from 6 to 15 days. Eleven patients initially presented with headache; 1 patient initially presented with back pain and later developed headache. Of the 12 patients with CVST, 7 also had intracerebral hemorrhage; 8 had non-CVST thromboses. After diagnosis of CVST, 6 patients initially received heparin treatment. Platelet nadir ranged from 9 ×103/µL to 127 ×103/µL. All 11 patients tested for the heparin-platelet factor 4 HIT antibody by enzyme-linked immunosorbent assay (ELISA) screening had positive results. All patients were hospitalized (10 in an intensive care unit [ICU]). As of April 21, 2021, outcomes were death (n = 3), continued ICU care (n = 3), continued non-ICU hospitalization (n = 2), and discharged home (n = 4). CONCLUSIONS AND RELEVANCE: The initial 12 US cases of CVST with thrombocytopenia after Ad26.COV2.S vaccination represent serious events. This case series may inform clinical guidance as Ad26.COV2.S vaccination resumes in the US as well as investigations into the potential relationship between Ad26.COV2.S vaccine and CVST with thrombocytopenia.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), has spread rapidly around the world since it was first recognized in late 2019. Most early reports of person-to-person SARS-CoV-2 transmission have been among household contacts, where the secondary attack rate has been estimated to exceed 10% (1), in health care facilities (2), and in congregate settings (3). However, widespread community transmission, as is currently being observed in the United States, requires more expansive transmission events between nonhousehold contacts. In February and March 2020, the Chicago Department of Public Health (CDPH) investigated a large, multifamily cluster of COVID-19. Patients with confirmed COVID-19 and their close contacts were interviewed to better understand nonhousehold, community transmission of SARS-CoV-2. This report describes the cluster of 16 cases of confirmed or probable COVID-19, including three deaths, likely resulting from transmission of SARS-CoV-2 at two family gatherings (a funeral and a birthday party). These data support current CDC social distancing recommendations intended to reduce SARS-CoV-2 transmission. U.S residents should follow stay-at-home orders when required by state or local authorities.

Objective: Asthma carries a high burden of disease for residents of Puerto Rico. We conducted this study to better understand asthma-related healthcare use and to examine potential asthma triggers. Methods: We characterized asthma-related healthcare use in 2013 by demographics, region, and date using outpatient, hospital, and emergency department (ED) insurance claims with a primary diagnostic ICD-9-CM code of 493.XX. We examined environmental asthma triggers, including outdoor allergens (i.e., mold and pollen), particulate pollution, and influenza-like illness. Analyses included descriptive statistics and Poisson time-series regression. Results: During 2013, there were 550,655 medical asthma claims reported to the Puerto Rico Healthcare Utilization database, representing 148 asthma claims/1,000 persons; 71% of asthma claims were outpatient visits, 19% were hospitalizations, and 10% were ED visits. Females (63%), children aged </=9 years (77% among children), and adults aged >/=45 years (80% among adults) had the majority of asthma claims. Among health regions, Caguas had the highest asthma claim-rate at 142/1,000 persons (overall health region claim-rate = 108). Environmental exposures varied across the year and demonstrated seasonal patterns. Metro health region regression models showed positive associations between increases in mold and particulate matter <10 microns in diameter (PM10) and outpatient asthma claims. Conclusions: This study provides information about patterns of asthma-related healthcare use across Puerto Rico. Increases in mold and PM10 were associated with increases in asthma claims. Targeting educational interventions on exposure awareness and reduction techniques, especially to persons with higher asthma-related healthcare use, can support asthma control activities in public health and clinical settings.

INTRODUCTION: Exposure to air pollution negatively affects respiratory and cardiovascular health. The objective of this study was to describe the extent to which health professionals report talking about how to limit exposure to air pollution during periods of poor air quality with their at-risk patients. METHODS: In 2015, a total of 1,751 health professionals completed an online survey and reported whether they talk with their patients about limiting their exposure to air pollution. In 2017, these data were analyzed to assess the frequency that health professionals in primary care, pediatrics, obstetrics/gynecology, and nursing reported talking about limiting air pollution exposure with patients who have respiratory or cardiovascular diseases, were aged </=18 years, were aged >/=65 years, or were pregnant women. Frequencies of positive responses were assessed across categories of provider- and practice-level characteristics. RESULTS: Overall, 714 (41%) respondents reported ever talking with their patients about limiting their exposure to air pollution. Thirty-four percent and 16% of providers specifically reported talking with their patients with respiratory or cardiovascular disease diagnoses, respectively. Percentages of health professionals who reported talking with their patients about limiting air pollution exposure were highest among respondents in pediatrics (56%) and lowest among respondents in obstetrics/gynecology (0%). CONCLUSIONS: Despite the well-described health effects of exposure to air pollution, the majority of respondents did not report talking with their patients about limiting their exposure to air pollution. These findings reveal clear opportunities to improve awareness about strategies to limit air pollution exposure among sensitive groups of patients and their health care providers.

RATIONALE: More information on risk factors for death from tuberculosis in the United States could help reduce the tuberculosis mortality rate, which has remained steady for over a decade. Objective(s) To identify risk factors for tuberculosis-related death in adults. METHODS: We performed a retrospective study of 1,304 adults with tuberculosis who died before treatment completion and 1,039 frequency-matched controls who completed tuberculosis treatment in 2005-2006 in thirteen states reporting 65% of U.S. tuberculosis cases. We used in-depth record abstractions and a standard algorithm to classify deaths in persons with tuberculosis as tuberculosis-related or not. We then compared these classifications to causes of death as coded in death certificates. We used multivariable logistic regression to calculate adjusted odds ratios (aOR) for predictors of tuberculosis-related death among adults compared with those who completed tuberculosis treatment. RESULTS: Of 1,304 adult deaths, 942 (72%) were tuberculosis-related, 272 (21%) were not, and 90 (7%) couldn't be classified. Of 847 tuberculosis-related deaths with death certificates available, 378 (45%) did not list tuberculosis as a cause of death. Adjusting for known risks, we identified new risks for tuberculosis-related death during treatment: absence of pyrazinamide in the initial regimen (aOR=3.4, 95% CI=1.9-6.0); immunosuppressive medications (aOR=2.5, 95% CI=1.1-5.6); incomplete TB diagnostic evaluation (aOR=2.2, 95% CI=1.5-3.3), and an alternative non-TB diagnosis prior to TB diagnosis (aOR=1.6, 95% CI=1.2-2.2). Conclusions Most persons who died with tuberculosis had a tuberculosis-related death. Intensive record review revealed tuberculosis as a cause of death more often than did death certificate diagnoses. New tools, such as a TB mortality risk score based on our study findings, may identify TB patients for in-hospital interventions to prevent death.

INTRODUCTION: Asthma is a leading cause of chronic disease-related school absenteeism. Few data exist on how information on absenteeism might be used to identify children for interventions to improve asthma control. This study investigated how asthma-related absenteeism was associated with asthma control, exacerbations, and associated modifiable risk factors using a sample of children from 35 states and the District of Columbia. METHODS: The Behavioral Risk Factor Surveillance System Child Asthma Call-back Survey is a random-digit dial survey designed to assess the health and experiences of children aged 0-17 years with asthma. During 2014-2015, multivariate analyses were conducted using 2006-2010 data to compare children with and without asthma-related absenteeism with respect to clinical, environmental, and financial measures. These analyses controlled for sociodemographic and clinical characteristics. RESULTS: Compared with children without asthma-related absenteeism, children who missed any school because of asthma were more likely to have not well controlled or very poorly controlled asthma (prevalence ratio=1.50; 95% CI=1.34, 1.69) and visit an emergency department or urgent care center for asthma (prevalence ratio=3.27; 95% CI=2.44, 4.38). Mold in the home and cost as a barrier to asthma-related health care were also significantly associated with asthma-related absenteeism. CONCLUSIONS: Missing any school because of asthma is associated with suboptimal asthma control, urgent or emergent asthma-related healthcare utilization, mold in the home, and financial barriers to asthma-related health care. Further understanding of asthma-related absenteeism could establish how to most effectively use absenteeism information as a health status indicator.

BACKGROUND: Centers for Disease Control and Prevention requirements for pre-immigration tuberculosis (TB) screening of children 2- to 14-years old permit a tuberculin skin test (TST) or an interferon-gamma release assay (IGRA). Few data are available on the performance of IGRAs versus TSTs in foreign-born children. METHODS: We compared the performance of TST and QuantiFERON-TB (QFT) Gold In-Tube in children 2- to 14-years old applying to immigrate to the United States from Mexico, the Philippines and Vietnam, using diagnosis of TB in immigrating family members as a measure of potential exposure. RESULTS: We enrolled 2520 children: 664 (26%) were TST+ and 142 (5.6%) were QFT+. One hundred and eleven (4.4%) were TST+/QFT+, 553 (21.9%) were TST+/QFT- and 31 (1.2%) were TST-/QFT+. Agreement between tests was poor (kappa = 0.20). Although positive results of both tests were significantly associated with older age (relative risks [RR] TST+, 1.64; 95% confidence interval [CI]: 1.36-1.97; RR QFT+, 3.05; 95% CI: 1.72-5.38) and with the presence of TB in at least 1 immigrating family member (RR TST+, 1.40; 95% CI: 1.12-1.75; RR QFT+ 2.24; 95% CI: 1.18-4.28), QFT+ results were more strongly associated with both predictive variables. CONCLUSIONS: The findings support the preferential use of QFT over TST for pre-immigration screening of foreign-born children 2 years of age and older and lend support to the preferential use of IGRAs in testing foreign-born children for latent TB infection.

OBJECTIVE: Asthma self-management education improves asthma-related outcomes. We conducted this analysis to evaluate variation in the percentages of adults with active asthma reporting components of asthma self-management education by age at asthma onset. METHODS: Data from 2011 to 2012 Asthma Call-back Surveys were used to estimate percentages of adults with active asthma reporting six components of asthma self-management education. Components of asthma self-management education include having been taught to what to do during an asthma attack and receiving an asthma action plan. Differences in the percentages of adults reporting each component and the average number of components reported across categories of age at asthma onset were estimated using linear regression, adjusted for age, education, race/ethnicity, sex, smoking status, and years since asthma onset. RESULTS: Overall, an estimated 76.4% of adults with active asthma were taught what to do during an asthma attack and 28.7% reported receiving an asthma action plan. Percentages reporting each asthma self-management education component declined with increasing age at asthma onset. Compared with the referent group of adults whose asthma onset occurred at 5-14 years of age, the percentage of adults reporting being taught what to do during an asthma attack was 10% lower among those whose asthma onset occurred at 65-93 years of age (95% CI: -18.0, -2.5) and the average number of components reported decreased monotonically across categories of age at asthma onset of 35 years and older. CONCLUSIONS: Among adults with active asthma, reports of asthma self-management education decline with increasing age at asthma onset.

INTRODUCTION: Despite the considerable overlap of asthma and chronic obstructive pulmonary disease (COPD), the extent to which the two diagnoses are the manifestations of the same disease remains unresolved. We conducted these analyses to evaluate the role of active asthma in the prevalence of physician-diagnosed COPD. METHODS: From 2006 through 2010, 74,209 adults aged 18-99 years and with a history of asthma participated in the Behavioral Risk Factor Surveillance System (BRFSS) Asthma Call-back Survey and responded to interview-administered questionnaires via telephone. We used publicly available data from 71,639 (97%) participants to identify respondents with and without active manifestations of asthma and self-reported, physician-diagnosed COPD. We generated population-weighted estimates of physician-diagnosed COPD prevalence and conducted linear regression to estimate associations between active asthma status and the prevalence of COPD among current smokers, former smokers, and lifetime nonsmokers separately. RESULTS: Physician-diagnosed COPD was reported in an estimated 29% of the population with any history of asthma, including both active and inactive asthma. Age-specific prevalences of physician-diagnosed COPD were consistently higher among adults with active asthma than adults without active asthma. Compared to inactive asthma, active asthma was associated with an 8.3% [95 % confidence interval (CI) 6.1, 10.5] higher prevalence of physician-diagnosed COPD among lifetime nonsmokers, a 20.6% (95 % CI 18.0, 23.3) higher prevalence among former smokers, and a 26.7% (95 % CI 22.5, 30.9) higher prevalence among current smokers. CONCLUSIONS: Among adults with a history of asthma, active manifestations of asthma may play an important role in the epidemiology of COPD.

BACKGROUND: Evaluation of the prevalence and incidence of asthma and research into its etiology often rely on self-reported information. We conducted this analysis to investigate reliability in reporting asthma history across categories of demographic and socio-economic characteristics. METHODS: We analyzed data from 3,109 participants in the Coronary Artery Risk Development in Young Adults study, a longitudinal study of African-American and white adults. Responses to self-administered questionnaires completed at 15- and 20-year follow-up exams were used to evaluate agreement in reporting asthma history and age at diagnosis, and assess variation in agreement across categories of demographic and health-related characteristics. RESULTS: A history of asthma was reported by 12% of participants at the 15-year exam and 11% of participants at the 20-year exam, with 97% agreement and an overall Kappa coefficient of 0.845 (95% CI: 0.815, 0.874). Kappa coefficients were higher among women than men and increased monotonically across categories of educational attainment. One hundred and eight participants (35%) reported exactly the same age at diagnosis at the two time points; for another 120 (39%) the difference in reported ages was ≤2 years. Age at asthma diagnosis reported at the 20-year exam was, on average, 1 year (SD: 5.2) older than that reported at the 15-year exam. CONCLUSIONS: Five-year reliability in self-reported asthma history is high and variation in reporting age at diagnosis is low across categories of participant characteristics. Nevertheless, agreement in responses at two times does not guarantee that self-administered questionnaires are sensitive tools for detecting a true asthma history.

INTRODUCTION: Little is known about the extent to which the age at which asthma first began influences respiratory health later in life. We conducted these analyses to examine the relationship between age at asthma onset and subsequent asthma-related outcomes. METHODS: We used data from 12,216 adults with asthma who participated in the 2010 Behavioral Risk Factor Surveillance System Asthma Call-back Survey to describe the distribution of age at asthma onset. Linear regression was used to estimate associations of age at asthma onset with asthma-related outcomes, including symptoms in the past 30 days and asthma-related emergency visits. RESULTS: Asthma onset before age 16 was reported by an estimated 42% of adults with active asthma, including 14% with onset at 5-9 years of age who reported experiencing any asthma symptoms on 21% of days in the past month. Compared to this group, the percentage of days in the past month with any asthma symptoms was 14.8% higher (95% confidence interval (CI): 5.4, 24.1) among those whose asthma onset occurred at <1 year. When age at onset occurred at 10 years or older there was little change in the prevalence of asthma-related emergency visits across age at onset categories. CONCLUSION: Age at asthma onset may affect subsequent asthma-related outcomes.

IN THIS MONTH’S Journal, Brito and colleagues | describe a survey quantifying drug-resistant tuberculosis (DR-TB) in six hospitals that together care for | approximately half of the TB cases in Rio de Janeiro | State during a one-year period.1 Their study is to be | commended for contributing to the awareness and | understanding of DR-TB in Brazil. In Brazil, which | ranks fourteenth in the list of high-burden countries | for TB, there were an estimated 1019 multidrugr esistant tuberculosis (MDR-TB) cases among the estimated 70 143 new pulmonary TB cases reported countrywide in 2007.2 Hospitals play an important role in | case fi nding, early detection, reduced transmission, and | entry into appropriate care for persons with MDR-TB. | The authors note the importance of careful monitoring for anti-tuberculosis drug resistance.1 The | World Health Organization (WHO) recommends that | drug resistance surveys be performed regularly in | high-burden countries, not only to determine the level | of DR-TB, but also to strengthen laboratory capacity.3 In the context of monitoring for drug resistance; | however, this paper raises other important issues: | 1) universal availability of drug susceptibility testing | (DST), needed for rapid and accurate diagnosis of | drug resistance, is often lacking in high-burden countries; 2) laboratory quality assurance systems, both | internal and external, are needed to maintain profi - | ciency and ensure correct diagnoses; and 3) an accurate history of previous TB treatment (especially rifamycins) is important and necessary. Of note, the WHO | also recommends that all persons with TB with a history of previous TB treatment undergo sputum culture and DST, a policy that was well followed in this | study

OBJECTIVES: Acinetobacter baumannii (A. baumannii) is a well-described cause of nosocomial outbreaks and can be highly resistant to antimicrobials. We investigated A. baumannii outbreaks at two Kentucky hospitals to find risk factors for Acinetobacter acquisition in hospitalized patients. METHODS: We performed case-control studies at both hospitals. We defined a case as a clinical culture growing A. baumannii from a patient from August 1 to October 31, 2006 (Hospital A), or April 1 to October 31, 2006 (Hospital B). RESULTS: Twenty-nine cases were identified at Hospital A and 72 cases were identified at Hospital B. The median case patient age was 42 years in Hospital A and 46 years in Hospital B. The majority of positive cultures were from sputum (Hospital A, 51.7%; Hospital B, 62.5%). The majority of case patients had multidrug-resistant A. baumannii (Hospital A, 75.9%; Hospital B, 70.8%). Using logistic regression, controlling for age and admitting location, mechanical ventilation (Hospital A odds ratio [OR] = 21.6; 95% confidence interval [CI] 3.5, 265.9; Hospital B OR = 4.5, 95% CI 1.9, 11.1) was associated with A. baumannii recovery. Presence of a nonsurgical wound (OR = 6.6, 95% CI 1.2, 50.8) was associated with recovery of A. baumannii at Hospital A. CONCLUSIONS: We identified similar patient characteristics and risk factors for A. baumannii acquisition at both hospitals. Our findings necessitate the importance of review of infection control procedures related to respiratory therapy and wound care.