The Diversifying Doulas Initiative (DDI) aims to improve maternal health outcomes in Black and Brown people through doula care in Lancaster County. DDI trained 28 Black and Brown doulas and provided fully subsidized doula care to over 200 patients of color giving birth in Lancaster County. The perinatal workforce comprises community birth workers, doulas, midwives, nurses, students, and physicians. By diversifying the perinatal workforce and increasing access to doulas, patients of color benefit from a proven intervention.

The Advisory Committee on Immunization Practices recommends that health care personnel (HCP) receive an annual influenza vaccine and that everyone aged ≥6 months stay up to date with recommended COVID-19 vaccination. Health care facilities report vaccination of HCP against influenza and COVID-19 to CDC's National Healthcare Safety Network (NHSN). During January-June 2023, NHSN defined up-to-date COVID-19 vaccination as receipt of a bivalent COVID-19 mRNA vaccine dose or completion of a primary series within the preceding 2 months. This analysis describes influenza and up-to-date COVID-19 vaccination coverage among HCP working in acute care hospitals and nursing homes during the 2022-23 influenza season (October 1, 2022-March 31, 2023). Influenza vaccination coverage was 81.0% among HCP at acute care hospitals and 47.1% among those working at nursing homes. Up-to-date COVID-19 vaccination coverage was 17.2% among HCP working at acute care hospitals and 22.8% among those working at nursing homes. There is a need to promote evidence-based strategies to improve vaccination coverage among HCP. Tailored strategies might also be useful to reach all HCP with recommended vaccines and protect them and their patients from vaccine-preventable respiratory diseases.

The in vitro activity of the novel fungal Cyp51 inhibitor VT-1129 was evaluated against a large panel of C. neoformans and C. gattii isolates. VT-1129 demonstrated potent activity against both Cryptococcus species as demonstrated by low MIC50 and MIC90 values. Against C. gattii, the in vitro potency was maintained against all genotypes. In addition, significantly lower geometric mean MICs were observed for VT-1129 compared to fluconazole against C. neoformans, including isolates with reduced fluconazole susceptibility.

MIC values were generated for caspofungin, micafungin, and anidulafungin against 106 isolates of C. lusitaniae, and these values were compared to established epidemiologic cutoff values. The majority of isolates were wild type both by MIC value as well as by FKS1 hotspot sequencing. Although C. lusitaniae isolates have MIC values to the echinocandins that are elevated compared to other common species, with regard to known mechanisms of resistance to the echinocandins, isolates with MIC values at or below the epidemiological cutoff values of 0.5 and 1mug/mL for micafungin and anidulafungin, respectively, should be considered wild type.

Candida glabrata is the second leading cause of candidemia in US hospitals. Current guidelines suggest that an echinocandin be used as primary therapy for C. glabrata due to the high rate of resistance to fluconazole. Recent case reports indicate that C. glabrata resistance to echinocandins may be increasing. We performed susceptibility testing on 1380 isolates of C. glabrata collected between 2008 and 2013 from four US cities, Atlanta, Baltimore, Knoxville and Portland. Our analysis showed that 3.1%, 3.3%, and 3.6% of the isolates were resistant to anidulafungin, caspofungin and micafungin, respectively. We screened 1032 of these isolates, including all 77 that had either a resistant or intermediate MIC value to one or more echinocandin, for mutations in the hotspot regions of FKS1 and FKS2, the major mechanism of echinocandin resistance. Fifty-one isolates were identified with hotspot mutations, 16 in FKS1 and 35 in FKS2. All but one of the isolates with an FKS mutation were resistant to one or more echinocandin by susceptibility testing. Of the isolates resistant to one or more echinocandin, 36% were also resistant to fluconazole. Echinocandin resistance among US C. glabrata isolates is a concern especially in light of the fact that a third of those isolates may be multidrug resistant. Further monitoring of US C. glabrata isolates for echinocandin resistance is warranted.

Echinocandins are the recommended treatment for invasive candidiasis due to Candida glabrata. Resistance to echinocandins is known to be caused by non-synonymous mutations in the hotspot-1 (HS1) regions of the FKS1 and FKS2 genes which encode a subunit of the beta-1,3-glucan synthase, the target of the echinocandins. Here, we describe the development of a microsphere-based assay using Luminex MagPix technology to identify mutations in the FKS1 and FKS2 HS1 domains which confer in vitro echinocandin resistance in C. glabrata isolates. The assay is rapid and can be performed with high throughput. The assay was validated using 102 isolates that had FKS1-HS1 and FKS2-HS1 domains previously characterized by DNA sequencing. The assay was 100% concordant with DNA sequencing results. The assay was then used for high throughput screening of 1032 C. glabrata surveillance isolates. Sixteen new isolates with mutations were identified, as well as a mutation new to our collection, del659F. This assay provides a rapid and cost-effective way to screen C. glabrata isolates for echinocandin resistance.

Monitoring delayed entry to HIV medical care is needed because it signifies that opportunities to prevent HIV transmission and mitigate disease progression have been missed. A central question for population-level monitoring is whether to consider a person linked to care after receipt of one CD4 or VL test. Using HIV surveillance data, we explored two definitions for estimating the number of HIV-diagnosed persons not linked to HIV medical care. We used receipt of at least one CD4 or VL test (definition 1) and two or more CD4 or VL tests (definition 2) to define linkage to care within 12 months and within 42 months of HIV diagnosis. In five jurisdictions, persons diagnosed from 12/2006-12/2008 who had not died or moved away and who had zero, or less than two reported CD4 or VL tests by 7/31/2010 were considered not linked to care under definitions 1 and 2, respectively. Among 13,600 persons followed up for 19-42 months; 1,732 (13%) had no reported CD4 or VL tests; 2,332 persons (17%) had only one CD4 or VL test and 9,536 persons (70%) had two or more CD4 or VL tests. To summarize, after more than 19 months, 30% of persons diagnosed with HIV had less than two CD4 or VL tests; more than half of them were considered to have entered care if entering care is defined as having one CD4 or VL test. Defining linkage to care as a single CD4 or VL may overestimate entry into care, particularly for certain subgroups.

Between 2008 and 2011, population-based candidemia surveillance was conducted in Atlanta, GA and Baltimore, MD. Surveillance had been previously performed in Atlanta in 1992-1993 and in Baltimore in 1998-2000, making this the first population-based candidemia surveillance conducted over multiple time points in the US. From 2,675 identified cases of candidemia in the current surveillance, 2,329 Candida isolates were collected. Candida albicans no longer comprised the majority of isolates but remained the most frequently isolated species (38%), followed by C. glabrata (29%), C. parapsilosis (17%) and C. tropicalis (10%). The species distribution has changed over time; in both Atlanta and Baltimore the proportion of C. albicans decreased and the proportion of C. glabrata increased, while the proportion of C. parapsilosis increased in Baltimore only. There were 98 multi-species episodes, with C. albicans and C. glabrata the most frequently encountered combination. The new species-specific CLSI Candida MIC breakpoints were applied to these data. With the exception of C. glabrata (11.9% resistant), resistance to fluconazole was very low (2.3% for C. albicans, 6.2% for C.tropicalis and 4.1% for C. parapsilosis). There was no change in the proportion of fluconazole resistance between surveillance periods. Overall echinocandin resistance was low (1%) but was higher for C. glabrata isolates, ranging from 2.1% resistant to caspofungin in Baltimore to 3.1% resistant to anidulafungin in Atlanta. Given the increase at both sites and the higher echinocandin resistance, C. glabrata should be closely monitored in future surveillance.

Cryptococcus gattii causes infection in tropical and subtropical regions worldwide but has garnered increased attention since its 1999 emergence in North America. C. gattii can be divided into 4 molecular types that may represent cryptic species. Recent evidence has shown that azole antifungal MIC values differ among these molecular types. We tested a large collection of C. gattii isolates for susceptibility to 4 azole drugs. We found that isolates of molecular type VGII have the highest geometric mean (GM) fluconazole MIC values (8.6 mcg/mL), while isolates of molecular type VGI have the lowest (1.7 mcg/mL). For fluconazole, itraconazole, and voriconazole GM MIC values, VGI < VGIII < VGIV < VGII. The GM MIC values for posaconazole were similarly represented across molecular types, with the exception that VGII < VGIII and VGIV. We used the MIC values to establish preliminary epidemiologic cutoff values for each azole and molecular type of C. gattii.

Early entry to HIV care and receipt of antiretroviral therapy improve the health of the individual and decrease the risk of transmission in the community. To increase the limited information on prospective decisions to enter care and how these decisions relate to beliefs about HIV medications, we analyzed interview data from the Never in Care Project, a multisite project conducted in Indiana, New Jersey, New York City, Philadelphia, and Washington State. From March 2008 through August 2010, we completed structured interviews with 134 persons with no evidence of HIV care entry, 48 of whom also completed qualitative interviews. Many respondents believed that HIV care entails the passive receipt of medications that may be harmful or unnecessary, resulting in reluctance to enter care. Respondents voiced concerns about prescription practices and preserving future treatment options, mistrust of medications and medical care providers, and ambivalence about the life-preserving properties of medications in light of an assumed negative impact on quality of life. Our results support the provision of information on other benefits of care (beyond medications), elicitation of concerns about medications, and assessment of psychosocial barriers to entering care. These tasks should begin at the time a positive test result is delivered and continue throughout the linkage-to-care process; for persons unwilling to enter care immediately, support should be provided in nonmedical settings.

Flucytosine and itraconazole are the only antifungal agents that continue to have a Clinical Laboratory and Standards Institute recommendation for MIC breakpoint readings at 48h only. Here we show good essential and categorical agreement between MIC readings for flucytosine made at 48h and those made at 24h for Candida species.