We present a nation-wide network analysis of non-fatal opioid-involved overdose journeys in the United States. Leveraging a unique proprietary dataset of Emergency Medical Services incidents, we construct a journey-to-overdose geospatial network capturing nearly half a million opioid-involved overdose events spanning 2018-2023. We analyze the structure and sociological profiles of the nodes, which are counties or their equivalents, characterize the distribution of overdose journey lengths, and investigate changes in the journey network between 2018 and 2023. Our findings include that authority and hub nodes identified by the HITS algorithm tend to be located in urban areas and involved in overdose journeys with particularly long geographical distances.

BACKGROUND: Opioid-involved overdoses, especially those involving synthetic opioids like fentanyl, have driven increases in overdose morbidity and mortality. Emergency medical services (EMS) and emergency department (ED) data can each provide near real-time information on trends in nonfatal opioid-involved overdoses; however, minimal data exist on the comparability of trends in these two data sources. METHODS: EMS data from biospatial© and ED data from CDC's Drug Overdose Surveillance and Epidemiology system and National Syndromic Surveillance Program were queried for nine states. Counts of total encounters, opioid-involved overdose encounters, and rates of opioid-involved overdoses per 10,000 total encounters were calculated for each data source from 2020-2022. Trends in monthly counts and rates were assessed using Joinpoint regression. RESULTS: On average, EMS data captured 1.8 times more monthly opioid-involved overdose encounters than ED data. Trends in the counts of opioid-involved overdose encounters were similar in both data sources with increases and decreases occurring during roughly the same periods. Overall, trends in rates of opioid-involved overdose encounters were also comparable. CONCLUSIONS: EMS and ED data provide complementary information for understanding overdose trends. Study findings underscore the importance of implementing post-overdose response protocols by both EMS and ED providers to ensure patient receive services irrespective of care setting.

INTRODUCTION: US drug overdose deaths are at historic levels. For every fatal drug overdose, there are many more non-fatal; however, minimal nationally representative data exist on trends in the ratio of fatal to non-fatal drug overdoses and how this differs by drug type. METHODS: Data from the Centers for Disease Control and Prevention's National Vital Statistics System were used to assess the number of fatal overdoses; data from the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database were used to estimate the number of non-fatal overdoses treated in emergency departments. Counts of fatal and non-fatal overdoses by drug type (all drug, all opioid, synthetic opioid, heroin, stimulant, and opioid and stimulant polysubstance) were calculated from 2010 to 2020 (for non-fatal synthetic opioid-involved overdoses, from 2016 to 2020 only). Trends in overdose counts and the ratio of fatal to non-fatal overdoses were assessed. RESULTS: On average, counts of fatal overdoses increased quarterly among all drug types, and non-fatal overdoses increased among most drug types. Over the 11-year period, the greatest average quarterly percent change (AQPC) in fatal overdose counts was among synthetic opioid-involved overdoses (AQPC: 7.1%; 95% CI: 6.0 to 8.2) and for non-fatal overdoses was among heroin-involved overdoses (AQPC: 4.3%; 95% CI: 3.9 to 4.8). During 2010‒2020, there was approximately 1 fatal overdose per 15 non-fatal. The ratio of fatal to non-fatal drug overdoses increased among every drug type except heroin; ratio increases were driven by greater relative increases in fatal overdoses compared with non-fatal. CONCLUSIONS: Assessment of the ratio of fatal to non-fatal drug overdoses can be used to understand the lethality of different drugs and inform response and prevention efforts.

BACKGROUND: Humans are likely exposed to microplastics (MPs) in a variety of places including indoor and outdoor air. Research to better understand how exposure to MPs correlates to health is growing. To fully understand the possible impacts of MPs on human health, it is necessary to quantify MP exposure and identify what critical data gaps exist. OBJECTIVES: The current paper provides a human exposure assessment of microplastics in the air using systematically reviewed literature that provided concentration of MPs in air as well as doses used in toxicology studies to calculate inhalation exposure dose. METHODS: All published peer-reviewed journal articles, non-published papers, and grey literature that focused on micro- or nano-plastics in indoor and outdoor air were systematically searched using PRISMA guidelines. Literature that defined specific concentrations and size of MPs in air or exposed to human lung cells, animals, or humans with measurable health impacts were included in data extraction. Inhalational exposures were calculated for different age groups using published MP concentrations from the included literature using exposure dose equations and values from U.S. ATSDR and EPA. RESULTS: Calculated mean indoor inhalational exposures from passive sampling methods were higher than those calculated from active sampling methods. When comparing indoor and outdoor sampling, calculated inhalation exposures from indoor samples were greater than those from outdoor samples. Inhalation exposures of MPs differed between age groups with infants having the highest calculated dose values for all locations followed by preschool age children, middle-school aged children, pregnant women, adolescents, and non-pregnant adults. MP doses used in toxicology studies produced higher calculated mean inhalational exposures than those from environmental samples. IMPACT: This study is the first known systematic review of inhalational MP exposure from indoor and outdoor air. It also provides inhalational exposures calculated from previously published environmental samples of MPs as well as from toxicology studies.

BACKGROUND: Plastic debris pervades our environment. Some breaks down into microplastics (MPs) that can enter and distribute in living organisms causing effects in multiple target organs. MPs have been demonstrated to harm animals through environmental exposure. Laboratory animal studies are still insufficient to evaluate human impact. And while MPs have been found in human tissues, the health effects at environmental exposure levels are unclear. AIM: We reviewed and summarized existing evidence on health effects from occupational exposure to MPs. Additionally, the diverse effects documented for workers were organized by MP type and associated co-contaminants. Evidence of the unique effects of polyvinyl chloride (PVC) on liver was then highlighted. METHODS: We conducted two stepwise online literature reviews of publications focused on the health risks associated with occupational MP exposures. This information was supplemented with findings from animal studies. RESULTS: Our analysis focused on 34 published studies on occupational health effects from MP exposure with half involving exposure to PVC and the other half a variety of other MPs to compare. Liver effects following PVC exposure were reported for workers. While PVC exposure causes liver toxicity and increases the risk of liver cancers, including angiosarcomas and hepatocellular carcinomas, the carcinogenic effects of work-related exposure to other MPs, such as polystyrene and polyethylene, are not well understood. CONCLUSION: The data supporting liver toxicity are strongest for PVC exposure. Overall, the evidence of liver toxicity from occupational exposure to MPs other than PVC is lacking. The PVC worker data summarized here can be useful in assisting clinicians evaluating exposure histories from PVC exposure and designing future cell, animal, and population exposure-effect research studies.

Plastics are a group of useful chemicals that have increased in usage since the 1950s (Miranda, Silva et al. 2019). Plastics are stable regarding both temperature resistance and chemical interactivity. Because of these properties, plastics are utilized in a variety of health products such as toothbrushes, break-resistant beverage containers, and intravenous tubing. Although plastics are extremely useful, they also break down in the environment and present a source of exposure to humans in the form of microplastics. A microplastic is commonly defined as a plastic with any dimension less than 5 millimeters (Guven, Gokdag et al., 2017; Stapleton 2019). Researchers have defined a smaller group of plastics as nanoplastics, as smaller than 1000 nanometers (Gigault et al., 2018). Here we will retain the term microplastics to include all plastic particles smaller than 5 millimeters. | | To address the emerging public health concerns for exposure to microplastics, an interdisciplinary working group was formed, combining staff from the National Center of Environmental Health (NCEH) and the Agency for Toxic Substances and Disease Registry (ATSDR). NCEH has taken the lead on investigating microplastics in drinking water. This is consistent with its other efforts to provide safe water support to local and state health departments to address risks to human health. ATSDR has evaluated whether exposures to microplastics in the environment are hazardous, in alignment with its mandate to evaluate potential health effects of hazardous substances in the environment.

Synthetic opioids, including illicitly manufactured fentanyls, are driving recent increases in US overdose deaths. Beginning October 2020, the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) code for poisonings involving synthetic narcotics (T40.4X) was split into three codes: fentanyl (T40.41), tramadol (T40.42), and other synthetic narcotics (T40.49). Emergency department data from October 2019-September 2021 in the Centers for Disease Control and Prevention's National Syndromic Surveillance Program BioSense platform were queried for synthetic opioid codes in the chief complaint and discharge diagnosis fields. Trend analyses assessed average monthly percent change overall and by sex and age. Emergency department visits for overdoses involving synthetic narcotics increased on average 3.2% each month before the code split and 4.8% after. Visits with fentanyl codes drove this increase after the split, accounting for most visits among males, females, and every age group except65years. The average monthly percent increase for ED visits for fentanyl-involved overdoses was greater than for all synthetic narcotics combined (i.e., T40.41, T40.42, and/or T40.49), suggesting that the old code (T40.4X) masked the full extent of the increase in ED visits for fentanyl overdoses. Usage of these new codes can improve tracking of non-fatal synthetic opioid overdose trends.

The number of nonfatal opioid-involved overdoses treated by health care providers has risen in the United States; the median number of emergency department (ED) visits for these overdoses was significantly higher during 2020 than during 2019 (1). ED visit data can underestimate nonfatal opioid-involved overdose incidence because, increasingly, persons experiencing a nonfatal opioid overdose are refusing transport to EDs by emergency medical services (EMS) (2). A study in Kentucky found that during a 6-month period, 19.8% of persons treated by EMS for an opioid overdose refused transport to an ED (2). Thus, EMS encounter data involving suspected nonfatal opioid-involved overdoses complement ED data and also allow for near real-time analysis (3). This report describes trends in rates of EMS encounters for nonfatal opioid-involved overdoses per 10,000 total EMS encounters (rates) by selected patient- and county-level characteristics during January 2018–March 2022 in 491 counties from 21 states using data from biospatial, Inc.* During this period, the nonfatal opioid-involved overdose rate increased, on average, 4.0% quarterly. Rates increased for both sexes and for most age groups. Rates were highest among non-Hispanic White (White) and non-Hispanic Native Hawaiian or other Pacific Islander (NH/OPI) persons, and increases were largest among non-Hispanic Black (Black), followed by Hispanic or Latino (Hispanic) persons. Rates increased in both urban and rural counties and for all quartiles of county-level characteristics (i.e., unemployment, education, and uninsured), except in counties with the lowest percentage of uninsured persons. Rates were highest and rate increases were largest in urban counties and counties with higher unemployment rates. This analysis of nonfatal opioid-involved overdose trends in EMS data highlights the utility of these data and the importance of addressing inequities that contribute to disproportionate overdose risk, such as through focused outreach to racial and ethnic minority groups, who disproportionately experience these inequities, and communities with higher levels of unemployment. EMS providers are in a unique position to engage in postoverdose response protocols and promote evidence-based overdose education and facilitate linkage to care and harm reduction services.†,§

INTRODUCTION: Nonfatal and fatal drug overdoses have recently increased. There are limited data describing the range of illicit, prescribed, and over-the-counter drugs involved in overdoses presenting to U.S. emergency departments (EDs). METHODS: Using 2018 Healthcare Cost and Utilization Project (HCUP) Nationwide ED Sample (NEDS) data, we calculated weighted counts and percentages by drug among overdose-related ED visits. Overdose-related ED visits were those having an International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) drug poisoning code falling under parent codes T36-T50 (codes involving alcohol were not explicitly queried). We identified the top 30 mutually exclusive polydrug combinations and compared characteristics of visits by polydrug status. RESULTS: In 2018, 908,234 ED visits had a T36-T50 drug poisoning code. The most frequently reported drugs involved were opioids (30.3% of visits; heroin: 15.2%), benzodiazepines (11.0%), stimulants (7.9%), other/unspecified antidepressants (7.1%), 4-aminophenol derivatives (6.6%), and other/unspecified drugs, medicaments, and biological substances (11.8%). Overdose was uncommon for most other drug classes (e.g., antibiotics). Polydrug visits were more likely to involve females (prevalence ratio [PR]: 1.14, 95% confidence interval [CI]: 1.12-1.16), be coded intentional self-harm (PR: 1.81, 95% CI: 1.77-1.85), and result in hospitalization (PR: 1.84, 95% CI: 1.79-1.89) or death (PR: 1.37, 95% CI: 1.22-1.53) compared to single-drug overdose-related visits. Benzodiazepines, opioids, and/or stimulants were most frequently involved in polydrug overdoses. CONCLUSION: Opioids, benzodiazepines, and stimulants were most commonly reported in both single-drug and polydrug overdose-involved ED visits. Other drugs involved in overdoses included antidepressants and 4-aminophenol derivatives. Jurisdictions can use data on drugs involved in overdoses to better tailor prevention strategies to emerging needs.

Unprecedented inland precipitation and catastrophic flooding associated with Hurricane Harvey potentially redistributed contaminants from industrial sites and transportation infrastructure to recreational areas that make up networks of green infrastructure, creeks, and waterways used for flood control throughout the Greater Houston Area. Sediment samples were collected in parks located near the Buffalo Bayou watershed 1 week after Hurricane Harvey made landfall and again 7 weeks later. Total concentrations of the U.S. Environmental Protection Agency's (EPA's) 16 priority polycyclic aromatic hydrocarbons (PAHs) were measured in each sample at both time points. Diagnostic ratios were calculated to improve understanding of potential sources of PAHs after flooding. Diagnostic ratios suggest vehicular traffic to be a potential source for PAHs in parks. Although the concentrations of PAHs in all samples were below EPA actionable levels, given that no background values were available for comparison, it is difficult to quantify the impact flooding from Hurricane Harvey had on PAH concentrations in Houston parks. However, given the high frequency of flooding in Houston, and the concentration of industrial facilities and transportation infrastructure adjacent to recreation areas, these data demonstrate that PAHs were still present after unprecedented flooding. This study may also serve as a baseline for future efforts to understand the environmental health impacts of disasters.

Outbreaks of cyclosporiasis, a food-borne illness caused by the coccidian parasite Cyclospora cayetanensis have increased in the USA in recent years, with approximately 2300 laboratory-confirmed cases reported in 2018. Genotyping tools are needed to inform epidemiological investigations, yet genotyping Cyclospora has proven challenging due to its sexual reproductive cycle which produces complex infections characterized by high genetic heterogeneity. We used targeted amplicon deep sequencing and a recently described ensemble-based distance statistic that accommodates heterogeneous (mixed) genotypes and specimens with partial genotyping data, to genotype and cluster 648 C. cayetanensis samples submitted to CDC in 2018. The performance of the ensemble was assessed by comparing ensemble-identified genetic clusters to analogous clusters identified independently based on common food exposures. Using these epidemiologic clusters as a gold standard, the ensemble facilitated genetic clustering with 93.8% sensitivity and 99.7% specificity. Hence, we anticipate that this procedure will greatly complement epidemiologic investigations of cyclosporiasis.

Cyclosporiasis is an infection caused by Cyclospora cayetanensis, which is acquired by consumption of contaminated fresh food or water. In the United States, cases of cyclosporiasis are often associated with foodborne outbreaks linked to imported fresh produce or travel to disease-endemic countries. Epidemiologic investigation has been the primary method for linking outbreak cases. A molecular typing marker that can identify genetically related samples would be helpful in tracking outbreaks. We evaluated the mitochondrial junction region as a potential genotyping marker. We tested stool samples from 134 laboratory-confirmed cases in the United States by using PCR and Sanger sequencing. All but 2 samples were successfully typed and divided into 14 sequence types. Typing results were identical among samples within each epidemiologically defined case cluster for 7 of 10 clusters. These findings suggest that this marker can distinguish between distinct case clusters and might be helpful during cyclosporiasis outbreak investigations.

Sexually reproducing pathogens such as Cyclospora cayetanensis often produce genetically heterogeneous infections where the number of unique sequence types detected at any given locus varies depending on which locus is sequenced. The genotypes assigned to these infections quickly become complex when additional loci are analysed. This genetic heterogeneity confounds the utility of traditional sequence-typing and phylogenetic approaches for aiding epidemiological trace-back, and requires new methods to address this complexity. Here, we describe an ensemble of two similarity-based classification algorithms, including a Bayesian and heuristic component that infer the relatedness of C. cayetanensis infections. The ensemble requires a set of haplotypes as input and assigns arbitrary distances to specimen pairs reflecting their most likely relationships. The approach was applied to data generated from a test cohort of 88 human fecal specimens containing C. cayetanensis, including 30 from patients whose infections were associated with epidemiologically defined outbreak clusters of cyclosporiasis. The ensemble assigned specimens to plausible clusters of genetically related infections despite their complex haplotype composition. These relationships were corroborated by a significant number of epidemiological linkages (P < 0.0001) suggesting the ensemble's utility for aiding epidemiological trace-back investigations of cyclosporiasis.

PROBLEM/CONDITION: Cyclosporiasis is an intestinal illness caused by the parasite Cyclospora cayetanensis, which is transmissible by ingestion of fecally contaminated food or water. Cyclosporiasis is most common in tropical and subtropical regions of the world. In the United States, foodborne outbreaks of cyclosporiasis have been linked to various types of imported fresh produce (e.g., basil, raspberries, and snow peas). Validated molecular typing tools, which could facilitate detection and investigation of outbreaks, are not yet available for C. cayetanensis. PERIOD COVERED: 2011-2015. DESCRIPTION OF SYSTEM: CDC has been conducting national surveillance for cyclosporiasis since it became a nationally notifiable disease in January 1999. As of 2015, cyclosporiasis was a reportable condition in 42 states, the District of Columbia, and New York City (NYC). Health departments voluntarily notify CDC of cases of cyclosporiasis through the National Notifiable Diseases Surveillance System and submit additional case information using the CDC cyclosporiasis case report form or the Cyclosporiasis National Hypothesis Generating Questionnaire (CNHGQ). RESULTS: For the 2011-2015 surveillance period, CDC was notified by 37 states and NYC of 2,207 cases of cyclosporiasis, including 1,988 confirmed cases (90.1%) and 219 probable cases (9.9%). The annual number of reported cases ranged from 130 in 2012 to 798 in 2013; the annual population-adjusted incidence rate ranged from 0.05 cases per 100,000 persons in 2012 to 0.29 in 2013. A total of 415 patients (18.8%) had a documented history of international travel during the 14 days before illness onset, 1,384 (62.7%) did not have a history of international travel, and 408 (18.5%) had an unknown travel history. Among the 1,359 domestically acquired cases with available information about illness onset, 1,263 (92.9%) occurred among persons who became ill during May-August. During 2011-2015, a total of 10 outbreaks of cyclosporiasis associated with 438 reported cases were investigated; a median of 21 cases were reported per outbreak (range: eight to 162). A food vehicle of infection (i.e., a food item or ingredient thereof) was identified (or suspected) for at least five of the 10 outbreaks; the food vehicles included a berry salad (one outbreak), cilantro imported from Mexico (at least three outbreaks), and a prepackaged salad mix from Mexico (one outbreak). INTERPRETATION: Cyclosporiasis continues to be a U.S. public health concern, with seasonal increases in reported cases during spring and summer months. The majority of cases reported for this 5-year surveillance period occurred among persons without a history of international travel who became ill during May-August. Many of the seemingly sporadic domestically acquired cases might have been associated with identified or unidentified outbreaks; however, those potential associations were not detected using the available epidemiologic information. Prevention of cases and outbreaks of cyclosporiasis in the United States depends on outbreak detection and investigation, including identification of food vehicles of infection and their sources, which could be facilitated by the availability of validated molecular typing tools. PUBLIC HEALTH ACTION: Surveillance for cases of cyclosporiasis and efforts to develop and validate molecular typing tools should remain U.S. public health priorities. During periods and seasons when increased numbers of domestically acquired cases are reported, the CNHGQ should be used to facilitate outbreak detection and hypothesis generation. Travelers to areas of known endemicity (e.g., in the tropics and subtropics) should follow food and water precautions similar to those for other enteric pathogens but should be advised that use of routine chemical disinfection or sanitizing methods is unlikely to kill C. cayetanensis. Health care providers should consider the possibility of Cyclospora infection in persons with persistent or remitting-relapsing diarrheal illness, especially for persons with a history of travel to areas of known endemicity or with symptom onset during spring or summer. If indicated, laboratory testing for Cyclospora should be explicitly requested because such testing is not typically part of routine examinations for ova and parasites and is not included in all gastrointestinal polymerase chain reaction panels. Newly identified cases of cyclosporiasis should be promptly reported to state or local public health authorities, who are encouraged to notify CDC of the cases.

Cyclospora cayetanensis is a human parasite transmitted via ingestion of contaminated food or water. Cases of C. cayetanensis infection acquired in the United States often go unexplained, partly because of the difficulties associated with epidemiologic investigations of such cases and the lack of genotyping methods. A Multilocus Sequence Typing (MLST) method for C. cayetanensis based on five microsatellite loci amplified by nested PCR was described in 2016. The MLST loci had high variability, but many specimens could not be assigned a type because of poor DNA sequencing quality at one or more loci. We analyzed Cyclospora-positive stool specimens collected during 1997-2016 from 54 patients, including 51 from the United States. We noted limited inter-specimen variability for one locus (CYC15) and the frequent occurrence of unreadable DNA sequences for two loci (CYC3 and CYC13). Overall, using the remaining two loci (CYC21 and CYC22), we detected 17 different concatenated sequence types. For four of five clusters of epidemiologically linked cases for which we had specimens from >1 case-patient, the specimens associated with the same cluster had the same type. However, we also noted the same type for specimens that were geographically and temporally unrelated, indicating poor discriminatory power. Furthermore, many specimens had what appeared to be a mixture of sequence types at locus CYC22. We conclude that it may be difficult to substantially improve the performance of the MLST method because of the nucleotide repeat features of the markers, along with the frequent occurrence of mixed genotypes in Cyclospora infections.

Cyclosporiasis is an intestinal illness caused by the parasite Cyclospora cayetanensis through ingestion of fecally contaminated food or water. Symptoms of cyclosporiasis might include watery diarrhea (most common), loss of appetite, weight loss, cramping, bloating, increased gas, nausea, and fatigue. Typically, increased numbers of cases are reported in the United States during spring and summer; since the mid-1990s, outbreaks have been identified and investigated almost every year. Past outbreaks have been associated with various types of imported fresh produce (e.g., basil, cilantro, and raspberries) (1). There are currently no validated molecular typing tools* to facilitate linking cases to each other, to food vehicles, or their sources. Therefore, cyclosporiasis outbreak investigations rely primarily on epidemiologic data.

On January 15, 2017, a hospital physician notified the Alameda County Public Health Department (ACPHD) in California of a patient with a suspected diagnosis of trichinellosis, a roundworm disease transmitted by the consumption of raw or undercooked meat containing Trichinella spp. larvae (1). A family member of the initial patient reported that at least three other friends and family members had been evaluated at area hospitals for fever, myalgia, abdominal pain, diarrhea, and vomiting. The patients had attended a celebration on December 28, 2016, at which several pork dishes were served, including larb, a traditional Laotian raw pork dish, leading the hospital physician to suspect a diagnosis of trichinellosis. Although the event hosts did not know the exact number of attendees, ACPHD identified 29 persons who attended the event and seven persons who did not attend the event, but consumed pork taken home from the event by attendees. The event hosts reported that the meat had come from a domesticated wild boar raised and slaughtered on their private family farm in northern California. ACPHD conducted a case investigation that included identification of additional cases, testing of leftover raw meat, and a retrospective cohort study to identify risk factors for infection.

During 1975-2012, CDC surveillance identified 1,680 trichinellosis cases in the United States with implicated food items; among these cases, 1,219 were attributed to consumption of raw or pork products, and 461 were attributed to nonpork products. Although trichinellosis in the United States has historically been associated with consumption of pork, multiple nonporcine species of wild game also are competent hosts for Trichinella spp. and have been collectively implicated in the majority of trichinellosis cases since the late 1990s (1-4) (Figure 1). During July 2016-May 2017, the Alaska Division of Public Health (ADPH) investigated two outbreaks of trichinellosis in the Norton Sound region associated with consumption of raw or undercooked walrus (Odobenus rosmarus) meat; five cases were identified in each of the two outbreaks. These were the first multiple-case outbreaks of walrus-associated trichinellosis in Alaska since 1992 (Figure 2). Health care providers should inquire about consumption of commercially prepared and personally harvested meats when evaluating suspected trichinellosis cases, especially in areas where consumption of wild game is commonplace.

During 2012-2014, five cases of Rickettsia parkeri rickettsiosis were identified by a single urgent care practice in Georgia, located approximately 40 miles southwest of Atlanta. Symptom onset occurred during June-October, and all patients had a known tick bite. Patients ranged in age from 27 to 72 years (median = 53 years), and all were male. The most commonly reported initial signs were erythema (n = 3) and swelling (n = 2) at the site of the bite. Two patients reported fever and a third patient reported a rash and lymphadenopathy without fever. Other symptoms included myalgia (n = 3), chills (n = 3), fatigue (n = 2), arthralgia (n = 2), and headache (n = 2). Eschar biopsy specimens were collected from each patient using a 4-mm or 5-mm punch and placed in 10% neutral buffered formalin or sterile saline. These specimens were tested by immunohistochemical (IHC) stains, quantitative polymerase chain reaction (qPCR) assays, or cell culture isolation to determine if there was evidence of infection with a Rickettsia species (1). IHC evidence of spotted fever group rickettsiae was found in the eschar biopsy specimens in all five cases. In four cases, the biopsy specimens were also positive for R. parkeri by qPCR. The fifth case (specimen positive only by IHC testing) was considered a probable R. parkeri case based on clinical signs and symptoms. R. parkeri was grown in cell culture from one specimen from which isolation was attempted. All patients were treated with oral doxycycline (100 mg twice daily) for a minimum of 10 days, and all recovered.

Partnership for Health (PfH) is an evidence-based, clinician-delivered HIV prevention program conducted in the United States for HIV-positive patients. This intervention strives to reduce risky sexual behaviors through provider-patient discussions on safer sex and HIV status disclosure. A cross-sectional, mixed-methods design was used to evaluate the dissemination and implementation of PfH, including training evaluations, an online trainee survey, and interviews with national trainers for PfH. Descriptive statistics were calculated with the categorical data, whereas thematic analysis was completed with the qualitative data. Between 2007 and 2013, PfH was disseminated to 776 individuals from 104 different organizations in 21 states/territories. The smallest proportion of trainees was physicians (6.9%). More than three-fourths of survey respondents (78.6%) reported using PfH, but less than one-third (31.8%) used the intervention with every patient. The PfH training supports the implementation of the intervention; however, challenges were experienced in clinician engagement. Tailored strategies to recruit and train clinicians providing care to HIV-positive patients are required.

CONTEXT: Latino and black adolescents are disproportionately affected by STDs, including HIV, and unintended pregnancies. Few parent-based interventions have targeted these youth, focused on early adolescence and had high participation rates. METHODS: Between 2003 and 2009, a randomized clinical trial was conducted with 2,016 Latino and black mother-adolescent dyads in New York City. Adolescents were eligible if they were in grade 6 or 7. Dyads were assigned to one of three conditions: a parent-based intervention, Families Talking Together (FTT); an adolescent-only intervention, Making a Difference! (MAD); or a combined FTT+MAD intervention. Respondents completed questionnaires at baseline and 12 months later. Single-degree-of-freedom contrasts and logistic regression analysis were used to evaluate differences in outcomes by intervention. RESULTS: The proportion of youth who reported ever having engaged in vaginal intercourse increased over the study period by eight percentage points among those in the MAD group, five points in the FTT group and three points in the combined group; the differences among these increases were not statistically significant. Adolescents in the two FTT groups were significantly more likely than those in the MAD group to indicate that their mother had talked to them about not having intercourse (79% vs. 68%). They also scored higher than youth in the MAD group on measures of communication and perceived maternal attributes, and lower on activities that might lead to risky behaviors. CONCLUSIONS: The proportions of adolescents who initiated intercourse during the study period were not significantly different across groups, implying that the interventions were comparable. Findings suggest that FTT may have led to improved parenting behaviors.