The Centers for Disease Control and Prevention's Diabetes Prevention Recognition Program (DPRP) has helped organizations deliver the National Diabetes Prevention Program (National DPP) lifestyle change program for over 10 years. Four delivery modes are now approved: in person, online (self-paced, asynchronous delivery), distance learning (remote, synchronous delivery), and combination (hybrid delivery using more than one delivery mode). We assessed outcomes using data from 333,715 participants who started the 12-month program between January 1, 2012, and December 31, 2018. The average number of sessions attended was highest for in-person participants (15.0), followed by online (12.9), distance learning (12.2), and combination (10.7). The average number of weeks in the program was highest for in-person participants (28.1), followed by distance learning (20.1), online (18.7), and combination (18.6). The average difference between the first and last reported weekly physical activity minutes reflected an increase for in person (42.0), distance learning (27.1), and combination (15.0), but a decrease for online (-19.8). Among participants retained through session 6 or longer, average weekly physical activity minutes exceeded the program goal of 150 for all delivery modes. Average weight loss (percent of body weight) was greater for in person (4.4%) and distance learning (4.7%) than for online (2.6%) or combination (2.9%). Average participant weight loss increased gradually by session for all delivery modes; among participants who remained in the program for 22 sessions, average weight loss exceeded the program goal of 5% for all delivery modes. In summary, if participants stay in the program, most have positive program outcomes regardless of delivery mode; they have some outcome improvement even if they leave early; and their outcomes improve more the longer they stay. This highlights the benefits of better retention and increased enrollment in the National DPP lifestyle change programs, as well as enhancements to online delivery.

Type 2 diabetes disproportionately affects older adults, persons from racial and ethnic minority groups, and persons of low socioeconomic status. It can be prevented or delayed through evidence-based interventions such as the National Diabetes Prevention Program (National DPP) lifestyle change program (LCP). This analysis is aimed at evaluating the outcomes (i.e., retention, physical activity, and weight loss) associated with participation in the National DPP LCP by participant characteristics and delivery mode (i.e., in-person, online, distance learning, and combination) using the 2012-2018 Diabetes Prevention Recognition Program (DPRP) data. Across all delivery modes, there were generally no substantial differences in retention between male and female participants, but male participants tended to have higher physical activity and weight loss (e.g., average weight loss for in-person delivery: 5.0% for males and 4.3% for females). Older participants had better retention rates than younger participants in all delivery modes and mostly higher physical activity and weight loss except for distance learning delivery (e.g., average weight loss for in-person delivery: 5.1% for those aged 65+ and 3.3% for those aged 18-34). Among the seven racial and ethnic groups studied, retention was generally highest for non-Hispanic/Latino (NH)-White participants and lowest for Hispanic/Latino participants. Physical activity varied by racial and ethnic groups and delivery mode. NH-White participants generally had the most weight loss except for distance learning delivery, and NH-Black/African American participants had the least (e.g., average weight loss for in-person delivery: 5.1% for NH-White participants, 3.3% for both NH-Black/African American and NH-American Indian/Alaska Native participants, and other racial and ethnic minority groups ranged from 3.4% to 4.9%). Monitoring and identifying disparities across demographics and delivery modes, particularly across multiple racial and ethnic groups, provides information that can be used to improve the implementation of the National DPP LCP by tailoring the intervention to reduce disparities.

INTRODUCTION: We examined the effectiveness of providing incentives to participants in lifestyle modification programs to improve diabetes-related health indicators: body weight, body mass index (BMI), blood pressure, cholesterol, and hemoglobin A(1C) (HbA(1C)). We also examined the potential effect of 4 different incentive domains (ie, type, monetary value, attainment certainty, and schedule) on those indicators. METHODS: We searched Medline, Embase, PsycINFO, and Cochrane Library to identify relevant studies published from January 2008 through August 2021. We used a random-effects model to pool study results and examine between-study heterogeneity by using the I(2) statistic and the Cochran Q test. We also conducted moderator analyses by using a mixed-effects model to examine differences between subgroups of incentive domains (eg, incentive type [cash vs other types]). RESULTS: Our search yielded 10,965 articles, of which 19 randomized controlled trials met our selection criteria. The random-effects model revealed that, relative to the control group, the incentive group had significant reductions in weight (-1.85kg; 95% CI, -2.40 to -1.29; P < .001), BMI (-0.47kg/m(2); 95% CI, -0.71 to -0.22; P < .001), and both systolic blood pressure (-2.59 mm HG; 95% CI, -4.98 to -0.20; P = .03) and diastolic blood pressure (-2.62 mm Hg; 95% CI, -4.61 to -0.64; P = .01). A reduction in cholesterol level was noted but was not significant (-2.81 mg/dL; 95% CI, -8.89 to -3.28; P = .37). One study found a significant reduction in hemoglobin A(1c) (-0.17%; 95% CI, -0.30% to -0.05%; P < .05). The moderator analyses showed that the incentive effect did not vary significantly between the subgroups of the incentive domains, except on weight loss for the attainment certainty domain, suggesting that a variety of incentive subgroups could be equally useful. CONCLUSION: Providing incentives in lifestyle modification programs is a promising strategy to decrease weight, BMI, and blood pressure.

The aim of the US Centers for Disease Control and Prevention's (CDC) National Diabetes Prevention Program (National DPP) is to make an evidence-based lifestyle change program widely available to the more than 88 million American adults at risk for developing type 2 diabetes. The National DPP allows for program delivery using four delivery modes: in person, online, distance learning, and combination. The objective of this study was to analyze cumulative enrollment in the National DPP by delivery mode. We included all participants who enrolled in CDC-recognized organizations delivering the lifestyle change program between January 1, 2012, and December 31, 2019, and whose data were submitted to CDC's Diabetes Prevention Recognition Program. During this time, the number of participants who enrolled was 455,954. Enrollment, by delivery mode, was 166,691 for in-person; 269,004 for online; 4,786 for distance-learning; and 15,473 for combination. In-person organizations enrolled the lowest proportion of men (19.4%) and the highest proportions of non-Hispanic Black/African American (16.1%) and older (65+ years) participants (28.2%). Online organizations enrolled the highest proportions of men (27.1%), younger (18-44 years) participants (41.5%), and non-Hispanic White participants (70.3%). Distance-learning organizations enrolled the lowest proportion of Hispanic/Latino participants (9.0%). Combination organizations enrolled the highest proportions of Hispanic/Latino participants (37.3%) and participants who had obesity (84.1%). Most in-person participants enrolled in organizations classified as community-centered entities (41.4%) or medical providers (31.2%). Online and distance-learning participants were primarily enrolled (93.3% and 70.2%, respectively) in organizations classified as for-profit businesses or insurers. Participants in combination programs were enrolled almost exclusively in organizations classified as medical providers (89%). The National DPP has reached nearly half a million participants since its inception in 2012, but continued expansion is critical to stem the tide of type 2 diabetes among the many Americans at high risk.

OBJECTIVES: We sought to understand long-term retrospective parental perceptions of the utility of newborn screening in a context where many affected children never develop sequelae but where intensive support services and ongoing healthcare were provided. STUDY DESIGN: Qualitative study. METHODS: Focus groups and interviews among parents (N = 41) of children with congenital CMV who had been enrolled in a long-term follow-up study at a large medical college for a mean of 22 years following diagnosis. Groups included parents whose children were: symptomatic at birth; initially asymptomatic but later developed sensorineural hearing loss; and who remained asymptomatic into adulthood. RESULTS: With proper follow-up support, newborn CMV screening was viewed positively by parents, who felt empowered by the knowledge, though parents often felt that they and healthcare providers needed more information on congenital CMV. Parents in all groups valued newborn CMV screening in the long term and believed it should be embedded within a comprehensive follow-up program. CONCLUSIONS: Despite initial distress, parents of CMV-positive children felt newborn CMV screening was a net positive. Mandatory or opt-out screening for conditions with variable presentations and treatment outcomes may be valuable in contexts where follow-up and care are readily available.

PURPOSE: To examine how health care providers' knowledge, attitudes, and practices affect their referrals to the National Diabetes Prevention Program. DESIGN: Cross-sectional, self-report data from DocStyles-a web-based survey. SETTING: USA. SAMPLE: Practicing family practitioners, nurse practitioners, pharmacists, and internists, n = 1,503. MEASURES: Questions regarding health care providers' knowledge, attitudes, and practices and their referrals to the National Diabetes Prevention Program. ANALYSIS: Bivariate and multivariate analyses were used to calculate predictive margins and the average marginal effect. RESULTS: Overall, 15.2% of health care providers (n = 1,503) reported making a referral to the National Diabetes Prevention Program. Health care providers were more likely to make referrals if they were familiar with the program (average marginal effect = 36.0%, 95% CI: 29.1%, 42.8%), reported knowledge of its availability (average marginal effect=49.1%, 95% CI: 40.2%, 57.9%), believed it was important to make referrals to the program (average marginal effect = 20.7%, 95% CI: 14.4%, 27.0%), and used electronic health records to manage patients with prediabetes (average marginal effect = 9.1%, 95% CI: 5.4%, 12.7%). Health care providers' demographic characteristics had little to no association with making referrals. CONCLUSION: Making referrals to the National Diabetes Prevention Program was associated with health care providers' knowledge of the program and its reported availability, their attitudes, and their use of the electronic health record system to manage patients with prediabetes.

Food fortification has proven to be an effective approach for preventing micronutrient deficiencies in many settings. Factors that lead to successful fortification programs are well established. However, due to the multisectoral nature of fortification and the added complexities present in many settings, the barriers to success are not always evident and the strategies to address them are not always obvious. We developed a systematic process for identifying and addressing gaps in the implementation of a food fortification program. The framework is composed of 4 phases: (1) connect program theory of change to program implementation; (2) develop an implementation research agenda; (3) conduct implementation research; and (4) analyze findings and develop/disseminate recommendations for next steps. We detail steps in each phase to help guide teams through the process. To our knowledge, this is the first attempt to outline a systematic process for applying implementation science research to food fortification. The development of this framework is intended to promote implementation research in the field of food fortification, thus improving access to and effectiveness of this key public health intervention.

AIMS: To estimate the prevalence and medical expenditures of diabetes-related complications (DRCs) among adult Medicaid enrollees with diabetes. METHODS: We estimated the prevalence and medical expenditures for 12 diabetes-related complications by Medicaid eligibility category (disability-based vs. non-disability-based) in eight states. We used generalized linear models with log link and gamma distribution to estimate the total per-person annual medical expenditures for DRCs, controlling for demographics, and other comorbidities. RESULTS: Among non-disability-based enrollees (NDBEs), 40.1% (in California) to 47.5% (in Oklahoma) had one or more DRCs, compared to 53.6% (in Alabama) to 64.8% (in Florida) among disability-based enrollees (DBEs). The most prevalent complication was neuropathy (16.1%-27.1% for NDBEs; 20.2%-30.4% for DBEs). Lower extremity amputation (<1% for both eligibilities) was the least prevalent complication. The costliest per-person complication was dialysis (per-person excess annual expenditure of $22,481-$41,298 for NDBEs; $23,569-$51,470 for DBEs in 2012 USD). Combining prevalence and per-person excess expenditures, the three costliest complications were nephropathy, heart failure, and ischemic heart disease (IHD) for DBEs, compared to neuropathy, nephropathy, and IHD for NDBEs. CONCLUSIONS: Our study provides data that can be used for assessing the health care resources needed for managing DRCs and evaluating cost-effectiveness of interventions to prevent and management DRCs.

INTRODUCTION: Diabetes imposes large health and financial burdens on Medicare beneficiaries. Type 2 diabetes can be prevented or delayed through lifestyle modification programs. In 2018, Medicare began to offer the Medicare Diabetes Prevention Program (MDPP), a lifestyle intervention, to eligible beneficiaries nationwide. The number of MDPP-eligible beneficiaries is not known, but this information is essential in efforts to expand the program and increase enrollment. This study aimed to estimate the number and spatial variation of MDPP-eligible Part B beneficiaries at the county level and by urban-rural classification. METHODS: Data from 2011-2016 National Health and Nutrition Examination Surveys and a survey-weighted logistic regression model were used to estimate proportions of prediabetes in the United States by sex, age, and race/ethnicity based on the MDPP eligibility criteria. The results from the predictive model were applied to 2015 Medicare Part B beneficiaries to estimate the number of MDPP-eligible beneficiaries. The National Center for Health Statistics' Urban-Rural Classification Scheme for Counties from 2013 were used to define urban and rural categories. RESULTS: An estimated 5.2 million (95% CI = 3.5-7.0 million) Part B beneficiaries were eligible for the MDPP. By state, estimates ranged from 13,000 (95% CI = 8,500-18,000) in Alaska to 469,000 (95% CI = 296,000-641,000) in California. There were 2,149 counties with ≤1,000 eligible beneficiaries and 11 with >25,000. Consistent with demographic patterns, urban counties had more eligible beneficiaries than rural counties. CONCLUSIONS: These estimates could be used to plan locations for new MDPPs and reach eligible Part B beneficiaries for enrollment.

PURPOSE: The purpose of the study was to examine how gender was related to enrollment and number of sessions attended in the National Diabetes Prevention Program's Lifestyle Change Program (DPP LCP). METHODS: To better understand program uptake, a population of those who would be eligible for the LCP was compared to those who enrolled. Estimates of those eligible were computed using data from the National Health and Nutrition Examination Survey, whereas enrollment and sessions attended were computed using data from the Centers for Disease Control and Prevention's Diabetes Prevention Recognition Program. RESULTS: Results revealed that although similar numbers of males and females were eligible for the program, only 39 321 males versus 121 007 females had enrolled in the National DPP LCP by the end of 2017 (odds ratio = 3.20; 95% CI, 3.17-3.24). The gender differences persisted even when stratifying by age or race/ethnicity. In contrast, no significant gender differences were found between the average number of sessions attended for males (14.0) and females (13.8). DISCUSSION: Results of the study can help inform efforts to market and tailor programs to appeal more directly to men and other groups that are underrepresented in the National DPP LCP.

OBJECTIVE: To assess retention in the National Diabetes Prevention Program (DPP) lifestyle change program, which seeks to prevent type 2 diabetes in adults at high risk. RESEARCH DESIGN AND METHODS: We analyzed retention among 41,203 individuals who enrolled in Centers for Disease Control and Prevention (CDC)-recognized in-person lifestyle change programs at organizations that submitted data to CDC's Diabetes Prevention Recognition Program during January 2012-February 2017. RESULTS: Weekly attrition rates were typically <1-2% but were between 3.5% and 5% at week 2 and at weeks 17 and 18, where session frequency typically transitions from weekly to monthly. The percent of participants retained through 18 weeks varied by age (45.9% for 18-29 year olds, 53.4% for 30-44 year olds, 60.2% for 45-54 year olds, 66.7% for 55-64 year olds, and 67.6% for >/=65 year olds), race/ethnicity (70.5% for non-Hispanic whites, 60.5% for non-Hispanic blacks, 52.6% for Hispanics, and 50.6% for other), mean weekly percentage of body weight lost (41.0% for </=0% lost, 66.2% for >0 to <0.25% lost, 72.9% for 0.25 to <0.5% lost, and 73.9% for >/=0.5% lost), and mean weekly physical activity minutes (12.8% for 0 min, 56.1% for >0 to <60 min, 74.8% for 60 to <150 min, and 82.8% for >/=150 min) but not by sex (63.0% for men and 63.1% for women). CONCLUSIONS: Our results demonstrate the need to identify strategies to improve retention, especially among individuals who are younger or are members of racial/ethnic minority populations and among those who report less physical activity or less early weight loss. Strategies that address retention after the first session and during the transition from weekly to monthly sessions offer the greatest opportunity for impact.

BACKGROUND: For women of reproductive age, a population-level red blood cell (RBC) folate concentration below the threshold 906 nmol/L or 400 ng/mL indicates folate insufficiency and suboptimal neural tube defect (NTD) prevention. A corresponding population plasma/serum folate concentration threshold for optimal NTD prevention has not been established. OBJECTIVE: The aim of this study was to examine the association between plasma and RBC folate concentrations and estimated a population plasma folate insufficiency threshold (pf-IT) corresponding to the RBC folate insufficiency threshold (RBCf-IT) of 906 nmol/L. METHODS: We analyzed data on women of reproductive age (n = 1673) who participated in a population-based, randomized folic acid supplementation trial in northern China. Of these women, 565 women with anemia and/or vitamin B-12 deficiency were ineligible for folic acid intervention (nonintervention group); the other 1108 received folic acid supplementation for 6 mo (intervention group). We developed a Bayesian linear model to estimate the pf-IT corresponding to RBCf-IT by time from supplementation initiation, folic acid dosage, methyltetrahydrofolate reductase (MTHFR) genotype, body mass index (BMI), vitamin B-12 status, or anemia status. RESULTS: Using plasma and RBC folate concentrations of the intervention group, the estimated median pf-IT was 25.5 nmol/L (95% credible interval: 24.6, 26.4). The median pf-ITs were similar between the baseline and postsupplementation samples (25.7 compared with 25.2 nmol/L) but differed moderately (+/-3-4 nmol/L) by MTHFR genotype and BMI. Using the full population-based baseline sample (intervention and nonintervention), the median pf-IT was higher for women with vitamin B-12 deficiency (34.6 nmol/L) and marginal deficiency (29.8 nmol/L) compared with the sufficient group (25.6 nmol/L). CONCLUSIONS: The relation between RBC and plasma folate concentrations was modified by BMI and genotype and substantially by low plasma vitamin B-12. This suggests that the threshold of 25.5 nmol/L for optimal NTD prevention may be appropriate in populations with similar characteristics, but it should not be used in vitamin B-12 insufficient populations. This trial was registered at clinicaltrials.gov as NCT00207558.

BACKGROUND: Caring for young children is a known risk factor for cytomegalovirus (CMV) infection mainly through exposure to their saliva and urine. In a previous study, 36 CMV-seropositive children 2 mo. to 4 years old were categorized as CMV shedders (n = 23) or non-shedders (n = 13) based on detection of CMV DNA in their saliva and urine. The current study evaluated the presence of CMV on surfaces in homes of the children. METHODS: Study staff made 4 visits to homes of the 36 enrolled children over 100 days. Saliva was collected by swabbing the mouth and urine was collected on filter paper inserted into diapers. In addition, five surface specimens were collected: three in contact with children's saliva (spoon, child's cheek, washcloth) and two in contact with children's urine (diaper changing table, mother's hand). Samples were tested by PCR and viral culture to quantify the presence of CMV DNA and viable virus. RESULTS: A total of 654 surface samples from 36 homes were tested; 136 were CMV DNA positive, 122 of which (90%) were in homes of the children shedding CMV (p < 0.001). Saliva-associated samples were more often CMV positive with higher viral loads than urine-associated samples. The higher the CMV viral load of the child in the home, the more home surfaces that were PCR positive (p = 0.01) and viral culture positive (p = 0.05). CONCLUSIONS: The main source for CMV on surfaces in homes was saliva from the child in the home. Higher CMV viral loads shed by children correlated with more viable virus on surfaces which could potentially contribute to viral transmission.

BACKGROUND: Congenital cytomegalovirus (CMV) is the most common non-genetic cause of sensorineural hearing loss. Currently, there are no universal CMV screening programs for newborns or routine CMV testing of neonates with hearing loss in Australia, or elsewhere. OBJECTIVES: This study was undertaken to determine the prevalence of congenital CMV infection in infants with hearing loss identified using routine resources via the Australian universal neonatal hearing screening (UNHS) program. STUDY DESIGN: Infants who failed UNHS, referred for audiological testing and found to have permanent hearing loss were screened for CMV via PCR of urine and saliva. Congenital CMV was diagnosed if CMV was detected in infants </=30days of age, or using retrospective testing on stored new born screening cards, retrospective testing, or using clinical criteria if >30days of age. The cohort was analyzed for time of testing and prevalence of congenital CMV determined. RESULTS: The Audiology Department reviewed 1669 infants who failed UNHS between 2009 and 2016. Thirty percent (502/1669) had permanent hearing loss confirmed, of whom 336/502 were offered CMV testing. A definite (n=11) or probable (n=8) diagnosis of congenital CMV occurred in 19/323 (5.9%), of whom definite diagnoses were made in 4/19 on tests positive prior to 21days of life, in 5/19 who were positive on neonatal blood screening card (NBSC) testing, in 2/19 who were positive on placental testing. In 8/19 probable diagnoses were made based on positive testing between ages 23-42days and a consistent clinical syndrome in the absence of another cause for hearing loss after genetic and other testing. CMV testing mirrored the timing of audiological testing, with approximately 40% completing audiology and CMV testing by 21days, and 64% by 30days. CONCLUSION: This program, utilizing existing clinical services identified probable congenital CMV in approximately 6% of a large cohort failing UNHS with permanent hearing loss, of whom more than half were definite diagnoses. No additional assets were required to those already existing in this tertiary referral pediatric centre, whilst providing useful and timely data for clinical and audiological management.

BACKGROUND: An estimated 1 in 150 infants is born each year with congenital cytomegalovirus (CMV); nearly 1 in 750 suffers permanent disabilities. Congenital CMV is the result of a pregnant woman becoming infected with CMV. Educating pregnant women about CMV is currently the best approach to prevention. Limited research is available on how to effectively communicate with women about CMV. We conducted formative research on fear appeals theory-based messages about CMV and prevention with U.S. women. Fear appeal theories suggest that message recipients will take action if they feel fear. METHODS: First, we conducted in-depth interviews (N = 32) with women who had young children who tested positive for CMV. Second, we conducted eight focus groups (N = 70) in two phases and two cities (Phase 2: Atlanta, GA; Phase 3: San Diego, CA) with pregnant women and non-pregnant women who had young children. Few participants knew about CMV before the focus groups. Participants reviewed and gave feedback on messages created around fear appeals theory-based communication concepts. The following concepts were tested in one or more of the three phases of research: CMV is severe, CMV is common, CMV is preventable, CMV preventive strategies are similar to other behavior changes women make during pregnancy, CMV preventive strategies can be incorporated in moderation to reduce exposure, and CMV is severe but preventable. RESULTS: Participants recommended communicating that CMV is common by using prevalence ratios (e.g., 1 in 150) or comparing CMV to other well-known disabilities. To convey the severity of CMV, participants preferred stories about CMV along with prevention strategies. Participants also welcomed prevention strategies when it included a message about risk reduction. In general, participants said messages were motivating, even if they felt that it could be difficult to make certain behavior changes. CONCLUSIONS: Findings from this research can contribute to future efforts to educate pregnant women about CMV, especially regarding use of fear appeals-based messages. Pregnant women may face certain challenges to practicing prevention strategies but, overall, are motivated make changes to increase their chances of having a healthy baby.

OBJECTIVE: To describe fetal and neonatal mortality due to congenital anomalies in Colombia. METHODS: We analyzed all fetal and neonatal deaths due to a congenital anomaly registered with the Colombian vital statistics system during 1999-2008. RESULTS: The registry included 213,293 fetal deaths and 7,216,727 live births. Of the live births, 77,738 (1.08%) resulted in neonatal deaths. Congenital anomalies were responsible for 7321 fetal deaths (3.4% of all fetal deaths) and 15,040 neonatal deaths (19.3% of all neonatal deaths). The fetal mortality rate due to congenital anomalies was 9.9 per 10,000 live births and fetal deaths; the neonatal mortality rate due to congenital anomalies was 20.8 per 10,000 live births. Mortality rates due to congenital anomalies remained relatively stable during the study period. The most frequent fatal congenital anomalies were congenital heart defects (32.0%), central nervous system anomalies (15.8%), and chromosomal anomalies (8.0%). Risk factors for fetal and neonatal death included: male or undetermined sex, living in villages or rural areas, mother's age >35 years, low and very low birthweight, and <28 weeks gestation at birth. CONCLUSIONS: Congenital anomalies are an important cause of fetal and neonatal deaths in Colombia, but many of the anomalies may be preventable or treatable.

BACKGROUND: Folate-sensitive neural tube defects (NTDs) are an important, preventable cause of morbidity and mortality worldwide. There is a need to describe the current global burden of NTDs and identify gaps in available NTD data. METHODS AND FINDINGS: We conducted a systematic review and searched multiple databases for NTD prevalence estimates and abstracted data from peer-reviewed literature, birth defects surveillance registries, and reports published between January 1990 and July 2014 that had greater than 5,000 births and were not solely based on mortality data. We classified countries according to World Health Organization (WHO) regions and World Bank income classifications. The initial search yielded 11,614 results; after systematic review we identified 160 full text manuscripts and reports that met the inclusion criteria. Data came from 75 countries. Coverage by WHO region varied in completeness (i.e., % of countries reporting) as follows: African (17%), Eastern Mediterranean (57%), European (49%), Americas (43%), South-East Asian (36%), and Western Pacific (33%). The reported NTD prevalence ranges and medians for each region were: African (5.2-75.4; 11.7 per 10,000 births), Eastern Mediterranean (2.1-124.1; 21.9 per 10,000 births), European (1.3-35.9; 9.0 per 10,000 births), Americas (3.3-27.9; 11.5 per 10,000 births), South-East Asian (1.9-66.2; 15.8 per 10,000 births), and Western Pacific (0.3-199.4; 6.9 per 10,000 births). The presence of a registry or surveillance system for NTDs increased with country income level: low income (0%), lower-middle income (25%), upper-middle income (70%), and high income (91%). CONCLUSIONS: Many WHO member states (120/194) did not have any data on NTD prevalence. Where data are collected, prevalence estimates vary widely. These findings highlight the need for greater NTD surveillance efforts, especially in lower-income countries. NTDs are an important public health problem that can be prevented with folic acid supplementation and fortification of staple foods.

CDC has developed interim guidelines for health care providers in the United States who are caring for infants born to mothers who traveled to or resided in an area with Zika virus transmission during pregnancy. These guidelines include recommendations for the testing and management of these infants. Guidance is subject to change as more information becomes available; the latest information, including answers to commonly asked questions, can be found online (http://www.cdc.gov/zika). Pediatric health care providers should work closely with obstetric providers to identify infants whose mothers were potentially infected with Zika virus during pregnancy (based on travel to or residence in an area with Zika virus transmission [http://wwwnc.cdc.gov/travel/notices]), and review fetal ultrasounds and maternal testing for Zika virus infection (see Interim Guidelines for Pregnant Women During a Zika Virus Outbreak*) (1). Zika virus testing is recommended for 1) infants with microcephaly or intracranial calcifications born to women who traveled to or resided in an area with Zika virus transmission while pregnant; or 2) infants born to mothers with positive or inconclusive test results for Zika virus infection. For infants with laboratory evidence of a possible congenital Zika virus infection, additional clinical evaluation and follow-up is recommended. Health care providers should contact their state or territorial health department to facilitate testing. As an arboviral disease, Zika virus disease is a nationally notifiable condition.

INTRODUCTION: The U.S. Preventive Services Task Force recommends for adults alcohol screening and brief behavioral counseling interventions in primary care settings. However, there is a paucity of population-based data on the prevalence of alcohol screening. This study examines adherence to this U.S. Preventive Services Task Force recommendation by estimating the prevalence of alcohol screening by demographic characteristics and binge drinking. METHODS: A cross-sectional analysis was conducted in 2013 and 2014 on data from the 2013 fall wave of the ConsumerStyles survey. ConsumerStyles is drawn from an Internet panel randomly recruited by probability-based sampling to be representative of the U.S. POPULATION: Data from 2,592 adult respondents who visited primary care physicians in the last year were analyzed to determine the prevalence of alcohol screening. RESULTS: Only 24.7% of respondents reported receiving alcohol screening. The prevalence of screening was similar among women (24.9%) and men (24.5%). Black non-Hispanics reported a significantly lower prevalence of screening than white non-Hispanics (16.2% vs 26.9%, prevalence ratio=0.60, 95% CI=0.40, 0.90). College graduates reported a significantly higher prevalence of screening than respondents with a high school degree or less (28.1% vs 20.8%, prevalence ratio=1.35, 95% CI=1.08, 1.69). CONCLUSIONS: Only about one in four respondents who visited a primary care physician in the last year reported being screened for alcohol misuse. Therefore, many men and women who misuse alcohol are unlikely to be identified. Increased screening may help reduce alcohol misuse and related negative health outcomes.

Neural tube defects (NTDs) such as spina bifida, anencephaly, and encephalocele are serious birth defects of the brain and spine that occur during the first month of pregnancy when the neural tube fails to close completely. Randomized controlled trials and observational studies have shown that adequate daily consumption of folic acid before and during early pregnancy considerably reduces the risk for NTDs. The U.S. Public Health Service recommends that women capable of becoming pregnant consume 400 microg of folic acid daily for NTD prevention. Furthermore, fortification of staple foods (e.g., wheat flour) with folic acid has decreased folate-sensitive NTD prevalence in multiple settings and is a highly cost-effective intervention.

BACKGROUND: Young, healthy children shedding cytomegalovirus (CMV) in urine and saliva appear to be the leading source of CMV in primary infection of pregnant women. FINDINGS: We screened 48 children 6 months - 5 years old for CMV IgG and measured levels of CMV IgG, IgM and IgG avidity antibodies, frequency of CMV shedding, and viral loads in blood, urine, and saliva. Thirteen of the 48 children (27%) were CMV IgG positive, among whom 3 were also CMV IgM positive with evidence of recent primary infection. Nine of the 13 seropositive children (69%) were shedding 102-105 copies/ml of CMV DNA in one or more bodily fluid. Among seropositive children, low IgG antibody titer (1:20-1:80) was associated with the absence of shedding (p = 0.014), and enrollment in daycare was associated with the presence of CMV shedding (p = 0.037). CONCLUSIONS: CMV antibody profiles correlated with CMV shedding. The presence of CMV IgM more often represents primary infection in children than in adults. Correlating antibodies with primary infection and viral shedding in healthy children adds to the understanding of CMV infection in children that can inform the prevention of CMV transmission to pregnant women.

BACKGROUND: Congenital cytomegalovirus (CMV) is the leading infectious cause of birth defects in the United States. To better understand factors that may influence CMV transmission risk, we compared viral and immunological factors in healthy children and their mothers. METHODS: We screened for CMV IgG antibodies in a convenience sample of 161 children aged 0-47 months from the Atlanta, Georgia metropolitan area, along with 32 mothers of children who screened CMV-seropositive. We assessed CMV shedding via PCR using saliva collected with oral swabs (children and mothers) and urine collected from diapers using filter paper inserts (children only). RESULTS: CMV IgG was present in 31% (50/161) of the children. Half (25/50) of seropositive children were shedding in at least one fluid. The proportion of seropositive children who shed in saliva was 100% (8/8) among the 4-12 month-olds, 64% (9/14) among 13-24 month-olds, and 40% (6/15) among 25-47 month-olds (P for trend=0.003). Seropositive mothers had a lower proportion of saliva shedding (21% [6/29]) than children (P<0.001). Among children who were shedding CMV, viral loads in saliva were significantly higher in younger children (P<0.001); on average, the saliva viral load of infants (i.e., <12 months) was approximately 300 times that of two year-olds (i.e., 24-35 months). Median CMV viral loads were similar in children's saliva and urine but were 10-50 times higher (P<0.001) than the median viral load of the mothers' saliva. However, very high viral loads (> one million copies/mL) were only found in children's saliva (31% of those shedding); children's urine and mothers' saliva specimens all had fewer than 100,000 copies/mL. Low IgG avidity, a marker of primary infection, was associated with younger age (p=0.03), higher viral loads in saliva (p=0.02), and lower antibody titers (p=0.005). CONCLUSIONS: Young CMV seropositive children, especially those less than one year-old may present high-risk CMV exposures to pregnant women, especially via saliva, though further research is needed to see if this finding can be generalized across racial or other demographic strata.

BACKGROUND: To better understand potential transmission risks from contact with the body fluids of children, we monitored the presence and amount of CMV shedding over time in healthy CMV-seropositive children. METHODS: Through screening we identified 36 children from the Atlanta, Georgia area who were CMV-seropositive, including 23 who were shedding CMV at the time of screening. Each child received 12 weekly in-home visits at which field workers collected saliva and urine. During the final two weeks, parents also collected saliva and urine daily. RESULTS: Prevalence of shedding was highly correlated with initial shedding status: children shedding at the screening visit had CMV DNA in 84% of follow-up saliva specimens (455/543) and 28% of follow-up urine specimens (151/539); those not shedding at the screening visit had CMV DNA in 16% of follow-up saliva specimens (47/303) and 5% of follow-up urine specimens (16/305). Among positive specimens we found median viral loads of 82,900 copies/mL in saliva and 34,730 copies/mL in urine (P=0.01), while the viral load for the 75th percentile was nearly 1.5 million copies/mL for saliva compared to 86,800 copies/mL for urine. Younger age was significantly associated with higher viral loads, especially for saliva (P<0.001). Shedding prevalence and viral loads were relatively stable over time. All children who were shedding at the screening visit were still shedding at least some days during weeks 11 and 12, and median and mean viral loads did not change substantially over time. CONCLUSIONS: Healthy CMV-seropositive children can shed CMV for months at high, relatively stable levels. These data suggest that behavioral prevention messages need to address transmission via both saliva and urine, but also need to be informed by the potentially higher risks posed by saliva and by exposures to younger children.

Cytomegalovirus (CMV) seroprevalence among U.S. children 1-5 years-old was assessed in the National Health and Nutrition Examination Survey 2011-2012. Overall seroprevalence (95% confidence interval) of IgG was 20.7% (14.4-28.2%), IgM 1.1% (0.4-2.4%), and low IgG avidity 3.6% (1.7-6.6%), corresponding to a 17.3% (10.1-26.7%) prevalence of recent infection among IgG-positive children.

Non-pregnant women can avoid alcohol-exposed pregnancies (AEPs) by modifying drinking and/or contraceptive practices. The purpose of this study was to estimate the number and characteristics of women in the United States who are at risk of AEPs. We analyzed data from in-person interviews obtained from a national probability sample (i.e., the National Survey of Family Growth) of reproductive-aged women conducted from January 2002 to March 2003. To be at risk of AEP, a woman had to have met the following criteria in the last month: (1) was drinking; (2) had vaginal intercourse with a man; and (3) did not use contraception. During a 1-month period, nearly 2 million U.S. women were at risk of an AEP (95 % confidence interval 1,760,079-2,288,104), including more than 600,000 who were binge drinking. Thus, 3.4 %, or 1 in 30, of all non-pregnant women were at risk of an AEP. Most demographic and behavioral characteristics were not clearly associated with AEP risk. However, pregnancy intention was strongly associated with AEP risk (prevalence ratio = 12.0, P < 0.001) because women often continued to drink even after they stopped using contraception. Nearly 2 million U.S. women are at AEP risk and therefore at risk of having children born with fetal alcohol spectrum disorders. For pregnant women and women intending a pregnancy, there is an urgent need for wider implementation of prevention programs and policy approaches that can reduce the risk for this serious public health problem.

Congenital CMV infection is a leading cause of childhood disability. Many children born with congenital CMV infection are asymptomatic or have nonspecific symptoms and therefore are typically not diagnosed. A strategy of newborn CMV screening could allow for early detection and intervention to improve clinical outcomes. Interventions might include antiviral drugs or nonpharmaceutical therapies such as speech-language therapy or cochlear implants. Using published data from developed countries, we analyzed existing evidence of potential benefit that could result from newborn CMV screening. We first estimated the numbers of children with the most important CMV-related disabilities (i.e. hearing loss, cognitive deficit, and vision impairment), including the age at which the disabilities occur. Then, for each of the disabilities, we examined the existing evidence for the effectiveness of various interventions. We concluded that there is good evidence of potential benefit from nonpharmaceutical interventions for children with delayed hearing loss that occurs by 9 months of age. Similarly, we concluded that there is fair evidence of potential benefit from antiviral therapy for children with hearing loss at birth and from nonpharmaceutical interventions for children with delayed hearing loss occurring between 9 and 24 months of age and for children with CMV-related cognitive deficits. We found poor evidence of potential benefit for children with delayed hearing loss occurring after 24 months of age and for children with vision impairment. Overall, we estimated that in the United States, several thousand children with congenital CMV could benefit each year from newborn CMV screening, early detection, and interventions.

Congenital cytomegalovirus (CMV) transmission can occur when women acquire CMV while pregnant. Infection control guidelines may reduce risk for transmission. We studied the duration of CMV survival after application of bacteria to the hands and after transfer from the hands to surfaces and the effectiveness of cleansing with water, regular and antibacterial soaps, sanitizer, and diaper wipes. Experiments used CMV AD169 in saliva at initial titers of 1 x 10(5) infectious particles/ml. Samples from hands or surfaces (points between 0 and 15 min) were placed in culture and observed for at least 2 weeks. Samples were also tested using CMV real-time PCR. After application of bacteria to the hands, viable CMV was recovered from 17/20 swabs at 0 min, 18/20 swabs at 1 min, 5/20 swabs at 5 min, and 4/20 swabs at 15 min. After transfer, duration of survival was at least 15 min on plastic (1/2 swabs), 5 min on crackers and glass (3/4 swabs), and 1 min or less on metal and cloth (3/4 swabs); no viable virus was collected from wood, rubber, or hands. After cleansing, no viable virus was recovered using water (0/22), plain soap (0/20), antibacterial soap (0/20), or sanitizer (0/22). Viable CMV was recovered from 4/20 hands 10 min after diaper wipe cleansing. CMV remains viable on hands for sufficient times to allow transmission. CMV may be transferred to surfaces with reduced viability. Hand-cleansing methods were effective at eliminating viable CMV from hands.

BACKGROUND: Rates of laboratory testing and diagnostic practices for congenital CMV in the United States are unknown. We determined rates of CMV testing and diagnostic coding for CMV among insured infants in the United States using a national healthcare claims database. METHODS: We analyzed medical claims from 2011 Truven Health MarketScan Commercial databases for infants who were <=30 days of age. We used ICD-9-CM codes to identify infants with CMV and CMV-associated conditions. We computed frequencies of infants with CPT codes for CMV testing. RESULTS: A total of 368,266 infants met the study criteria. We identified 61 (0.02%) infants with a diagnostic code for CMV. Among the 368,266 infants, 229 (0.1%) infants had a code for CMV-specific testing, of which 43% had codes for CMV polymerase chain reaction (PCR) and/or CMV direct florescent antibody (DFA) testing, 44% for CMV serologic testing alone, and 13% for CMV serology and non-specific PCR and/or culture. Over 80% (187/229) with CMV testing had a code for >=1 CMV-associated conditions. Although infrequently coded for, CMV testing was more common among infants with a code for a condition possibly associated with CMV than infants without these conditions (0.14% (187/ 136,857) vs. 0.02% (42/231,409)). CONCLUSIONS: The low rates of CMV testing among infants with symptoms suggestive of congenital CMV infection and the substantial proportion of infants tested with only serologic assays instead of PCR or viral culture suggests gaps in awareness and knowledge of congenital CMV and its diagnosis among healthcare providers. Although claims databases presumably do not capture all diagnosed CMV cases or CMV-specific testing, healthcare claims are a potential source for surveillance and monitoring practices of CMV-specific testing and diagnostic coding for CMV among infants.

OBJECTIVE: Congenital cytomegalovirus (CMV) infection is a common cause of hearing loss and intellectual disability. We assessed CMV knowledge and the frequency of women's behaviors that may enable CMV transmission to inform strategies for communicating prevention messages to women. METHODS: We analyzed survey responses from 4184 participants (2181 women, 2003 men) in the 2010 HealthStyles survey, a national mail survey designed to be similar to the United States population. RESULTS: Only 7% of men and 13% of women had heard of congenital CMV. Women with children under age 19 (n=918) practiced the following risk behaviors at least once per week while their youngest child was still in diapers: kissing on the lips (69%), sharing utensils (42%), sharing cups (37%), and sharing food (62%). Women practiced protective, hand cleansing behaviors most of the time or always after: changing a dirty diaper (95%), changing a wet diaper (85%), or wiping the child's nose (65%), but less commonly after handling the child's toys (26%). CONCLUSIONS: Few women are aware of CMV and most regularly practice behaviors that may place them at risk when interacting with young children. Women should be informed of practices that can reduce their risk of CMV infection during pregnancy.

The objectives of this study are (1) to design an accurate method for linking newborn screening (NBS) and state birth certificate databases to create a de-identified study database; (2) To assess maternal cytomegalovirus (CMV) seroprevalence by measuring CMV IgG in newborn dried blood spots; (3) To assess congenital CMV infection among newborns and possible association with preterm birth. NBS and birth databases were linked and patient records were de-identified. A stratified random sample of records based on gestational age was selected and used to retrieve blood spots from the state NBS laboratory. Serum containing maternal antibodies was eluted from blood spots and tested for the presence of CMV IgG. DNA was extracted from blood spots and tested for the presence of CMV DNA. Analyses were performed with bivariable and multivariable logistic regression models. Linkage rates and specimen collection exceeded 98% of the total possible yielding a final database with 3,101 newborn blood spots. CMV seroprevalence was 91% among Black mothers, 83% among Hispanic mothers, 59% among White mothers, and decreased with increasing amounts of education. The prevalence of CMV infection in newborns was 0.45% and did not vary significantly by gestational age. Successful methods for database linkage, newborn blood spots collection, and de-identification of records can serve as a model for future congenital exposure surveillance projects. Maternal CMV seroprevalence was strongly associated with race/ethnicity and educational level. Congenital CMV infection rates were lower than those reported by other studies and lacked statistical power to examine associations with preterm birth.