Black women are disproportionately affected by HIV. We analyzed data from two Centers for Disease Control and Prevention's HIV surveillance systems to better understand HIV prevention strategies used by Black women at risk for and with HIV to help inform efforts to end HIV. Among sexually active Black women, we analyzed 2019 National HIV Behavioral Surveillance data on women without HIV (n = 4,033) and 2018-2020 Medical Monitoring Project data on women with HIV (n = 967). We reported percentages of HIV prevention strategies and services used and assessed differences between groups using Rao-Scott chi-square tests. Among Black women without HIV, 39% were aware of pre-exposure prophylaxis (PrEP); of these, 7% discussed PrEP with a healthcare provider, and 1% used PrEP in the past 12 months. Approximately 16% used a condom with their last sex partner; 36% reported that their last sex partner did not have HIV. Among Black women with HIV, 58% had condom-protected sex, 56% reported having sex while having sustained viral suppression, 3% had condomless sex with a partner on PrEP, and 24% had sex with a partner with HIV; 12% engaged in sex without using any HIV prevention strategy. HIV prevention strategies and services differed by selected demographic characteristics and social determinants of health. Although many sexually active Black women reported using HIV prevention strategies, there is room for improvement among those at risk for or with HIV. Tailoring prevention efforts based on individual needs and circumstances is essential for ending the HIV epidemic.

BACKGROUND: Hemoglobin and hematocrit are the two most common biomarkers used to identify anemia in clinical settings, but their results do not always agree. OBJECTIVE: To examine agreement between hemoglobin and hematocrit in identifying anemia among children aged 1-<5 years and pregnant persons. METHODS: Pregnant persons and children aged 1-<5 years with hemoglobin and hematocrit results from the same whole blood sample in National Health and Nutrition Examination Survey (NHANES,1999-2020) were included. We used the Centers for Disease Control and Prevention (CDC) anemia cutoff values for children, pregnancy status, trimester, and smoking adjustments. We examined concordance of anemia, sensitivity, and specificity among those with anemia based on at least one test overall and by race/ethnicity, sex, and income level. Cohen's kappa was used to measure concordance. RESULTS: Analytic samples included 7,052 children and 1,437 pregnant persons, of which 1,119 had trimester data. Among children, anemia prevalence was 3.7% (95% CI: 3.1-4.3) based on hemoglobin and 5.5% (95% CI: 4.7-6.3) based on hematocrit. Among pregnant persons, anemia prevalence based on hemoglobin was 7.7% (95% CI: 5.9-9.5) and 12.4% (95% CI: 10.1-14.6) based on hematocrit. Kappa scores overall and by sociodemographic characteristics ranged from 0.64-0.75 (moderate concordance) among children and 0.53-0.78 (weak to moderate concordance) among pregnant persons. Among those with anemia on at least one test, 53.5% of children and 61.5% of pregnant persons had anemia based on both tests. CONCLUSIONS: We found substantial discordance between the two biomarkers; about 50% of children and 40% of pregnant women were identified by only one of the two biomarkers. Because hemoglobin and hematocrit may be used interchangeably in the clinical setting, individuals with anemia may be missed, not receive treatment, and therefore be at higher risk of adverse pregnancy, birth, and developmental outcomes.

BACKGROUND: Highly pathogenic avian influenza A(H5N1) viruses have caused widespread infections in dairy cows and poultry in the United States, with sporadic human cases. We describe characteristics of human A(H5N1) cases identified from March through October 2024 in the United States. METHODS: We analyzed data from persons with laboratory-confirmed A(H5N1) virus infection using a standardized case-report form linked to laboratory results from the Centers for Disease Control and Prevention influenza A/H5 subtyping kit. RESULTS: Of 46 case patients, 20 were exposed to infected poultry, 25 were exposed to infected or presumably infected dairy cows, and 1 had no identified exposure; that patient was hospitalized with nonrespiratory symptoms, and A(H5N1) virus infection was detected through routine surveillance. Among the 45 case patients with animal exposures, the median age was 34 years, and all had mild A(H5N1) illness; none were hospitalized, and none died. A total of 42 patients (93%) had conjunctivitis, 22 (49%) had fever, and 16 (36%) had respiratory symptoms; 15 (33%) had conjunctivitis only. The median duration of illness among 16 patients with available data was 4 days (range, 1 to 8). Most patients (87%) received oseltamivir; oseltamivir was started a median of 2 days after symptom onset. No additional cases were identified among the 97 household contacts of case patients with animal exposures. The types of personal protective equipment (PPE) that were most commonly used by workers exposed to infected animals were gloves (71%), eye protection (60%), and face masks (47%). CONCLUSIONS: In the cases identified to date, A(H5N1) viruses generally caused mild illness, mostly conjunctivitis, of short duration, predominantly in U.S. adults exposed to infected animals; most patients received prompt antiviral treatment. No evidence of human-to-human A(H5N1) transmission was identified. PPE use among occupationally exposed persons was suboptimal, which suggests that additional strategies are needed to reduce exposure risk. (Funded by the Centers for Disease Control and Prevention.).

Shifts in colorectal cancer (CRC) screening, including guidance from the United States Preventive Services Task Force lowering the recommended screening age from 50 to 45 years in 2021, may leave gaps in clinicians' understanding of related barriers and beliefs held by patients. This study uses the National Institute on Minority Health and Health Disparities Research Framework to analyze factors influencing CRC screening uptake among individuals aged 44-54 years and identifies how gaps in knowledge intersect with screening barriers, particularly as they relate to the health care system and sociocultural environment. In 2022, the Centers for Disease Control and Prevention's Division of Cancer Prevention and Control's Screen for Life campaign conducted 12 online focus groups to gather audience insights and test materials. Researchers conducted the focus groups in English and Spanish with individuals aged 44-54 years who had never had CRC and had never received a CRC screening. Focus groups gauged participants' knowledge, awareness, and behavior pertaining to CRC and CRC screening. Results show that participants often lacked knowledge about risk factors and screening modalities and appreciated emotionally resonant communication approaches that addressed gaps in knowledge using demystifying, destigmatizing language and representative imagery. Findings also indicate a need to help patients overcome barriers related to insurance coverage, treatment options, and discrimination. Results may guide the development of future health promotion efforts and empower health care providers to approach conversations with their patients with additional context regarding patients' needs.

We compared the number of Aedes aegypti females per trap and the number of detections of this mosquito species per week during 8 wk in 3 types of autocidal gravid traps, the Centers for Disease Control and Prevention (CDC) Autocidal Gravid Ovitrap (AGO), Biogents Gravid Aedes Trap (GAT), and Singapore Gravitrap (SGT), in central Puerto Rico. These traps use the same principles for attracting gravid Ae. aegypti females as traditional ovitraps, such as dark colors, standing water, and decomposing plant materials. The traps differ in size, AGO being the biggest and SGT the smallest. Average captures of female Ae. aegypti per trap per week were 11.1, 7.2, and 1.7 in AGO, GAT, and SGT traps, respectively, a pattern consistent with the sizes of the traps. These results indicated that GAT traps and SGT traps captured 35.5% and 84.7% fewer females of Ae. aegypti, respectively, than AGO traps. Although Ae. aegypti was present in all 20 sites during the 8 wk of observations, AGO, GAT, and SGT traps did not catch specimens in 1, 9, and 58 out of 160 observations per trap type (trap-wk), respectively. Trap failures were 1, 6, and 1 for the AGO, GAT, and SGT traps, respectively. Despite the absence of females of Ae. aegypti at some sites and weeks in each of the traps, all 3 traps were able to detect the presence of this mosquito at each of the 20 sites during the 8 wk of observations and could be used for Ae. aegypti surveillance.

In 2015, the United States Public Health Service (USPHS) set a target fluoride level for drinking water at 0.7 mg/L to maximize oral health benefits while minimizing any potential harms. Using water fluoridation operational data reported by water systems to the Centers for Disease Control and Prevention (CDC) Water Fluoridation Reporting System (WFRS) during 2016–2021, this study assesses how water systems performed around this target. The authors summarize completeness of data reporting, assess the distribution of monthly average fluoride readings (MAFR) values, and evaluate precision in maintaining fluoride levels. About 69% of adjusting systems provided data, with an average completeness of 63.8% among them. MAFR mean was 0.71 mg/L (SD: 0.20 mg/L), indicating that water systems have primarily adopted the USPHS target. About 76% of MAFRs fell ± 0.1 mg/L around the reporting system point's mean, indicating feasibility in maintaining precision around a target. State programs and water systems could work together to improve data quality and educate operators on best practices. Published 2024. This article is a U.S. Government work and is in the public domain in the USA.

BACKGROUND: On June 8, 2021, a new 20-valent pneumococcal conjugate vaccine (PCV20, PREVNAR 20(®), Pfizer, Inc.) was licensed for use in adults aged ≥ 18 years by the US Food and Drug Administration (FDA). OBJECTIVE: To describe reports to the Vaccine Adverse Event Reporting System (VAERS) after administration of the 20-valent pneumococcal conjugate vaccine in adults. METHODS: We searched the VAERS for reports of adverse events involving persons aged ≥ 19 years who received PCV20 during October 20, 2021, through December 31, 2023. Our evaluation included automated analysis of reports, clinical review of serious reports and pre-specified events of special interest, empirical Bayesian data mining to assess for disproportionate reporting, and estimation of reporting rates for reports of Guillain-Barré syndrome (GBS). RESULTS: The VAERS received 1976 reports after PCV20 administration in persons aged ≥ 19 years (6% of reports involved serious events). The most common adverse events among persons aged 19-64 years (n = 798) were injection-site reactions (231, 29%), pain (134, 17%), erythema (118, 15%), and fever (117, 15%). For persons aged ≥ 65 years (n = 1178), the most common adverse events were injection-site reactions (417, 35%), pain (180, 15%), pain in extremity (162, 14%), and erythema (158, 13%). A data mining alert (EB05 = 3.812) for the MedDRA Preferred Term "Guillain-Barre syndrome" was observed for serious reports. Clinical review verified 11 of 20 GBS reports; 7/11 vaccine recipients were aged ≥ 65 years. Among the 11 verified cases, the median time from vaccination to symptom onset was 14 days. Five persons received another vaccine on the same visit. The reporting rate of GBS after PCV20 receipt was 0.5 cases per million doses distributed. No other safety concern was identified. CONCLUSIONS: During the period of this post-licensure review of PCV20, we found most reports were non-serious and comprised mostly local and systemic (e.g., fever) reactions consistent with prelicensure studies. In serious reports, we also identified a data mining alert for GBS after receipt of PCV20, which Centers for Disease Control and Prevention and the FDA are investigating further. No other new or unexpected safety concern was identified.

BACKGROUND: Egg-based inactivated quadrivalent seasonal influenza vaccine (eIIV4), cell culture-based inactivated quadrivalent seasonal influenza vaccine (ccIIV4), and recombinant haemagglutinin (HA)-based quadrivalent seasonal influenza vaccine (RIV4) have been licensed for use in the USA. In this study, we used antigen-specific serum proteomics analysis to assess how the molecular composition and qualities of the serological antibody repertoires differ after seasonal influenza immunisation by each of the three vaccines and how different vaccination platforms affect the HA binding affinity and breadth of the serum antibodies that comprise the polyclonal response. METHODS: In this comparative, prospective, observational cohort study, we included female US health-care personnel (mean age 47·6 years [SD 8]) who received a single dose of RIV4, eIIV4, or ccIIV4 during the 2018-19 influenza season at Baylor Scott & White Health (Temple, TX, USA). Eligible individuals were selected based on comparable day 28 serum microneutralisation titres and similar vaccination history. Laboratory investigators were blinded to assignment until testing was completed. The preplanned exploratory endpoints were assessed by deconvoluting the serological repertoire specific to A/Singapore/INFIMH-16-0019/2016 (H3N2) HA before (day 0) and after (day 28) immunisation using bottom-up liquid chromatography-mass spectrometry proteomics (referred to as Ig-Seq) and natively paired variable heavy chain-variable light chain high-throughput B-cell receptor sequencing (referred to as BCR-Seq). Features of the antigen-specific serological repertoire at day 0 and day 28 for the three vaccine groups were compared. Antibodies identified with high confidence in sera were recombinantly expressed and characterised in depth to determine the binding affinity and breadth to time-ordered H3 HA proteins. FINDINGS: During September and October of the 2018-19 influenza season, 15 individuals were recruited and assigned to receive RIV4 (n=5), eIIV4 (n=5), or ccIIV4 (n=5). For all three cohorts, the serum antibody repertoire was dominated by back-boosted antibody lineages (median 98% [95% CI 88-99]) that were present in the serum before vaccination. Although vaccine platform-dependent differences were not evident in the repertoire diversity, somatic hypermutation, or heavy chain complementarity determining region 3 biochemical features, antibodies boosted by RIV4 showed substantially higher binding affinity to the vaccine H3/HA (median half-maximal effective concentration [EC50] to A/Singapore/INFIMH-16-0019/2016 HA: 0·037 μg/mL [95% CI 0·012-0·12] for RIV4; 4·43 μg/mL [0·030-100·0] for eIIV4; and 18·50 μg/mL [0·99-100·0] μg/mL for ccIIV4) and also the HAs from contemporary H3N2 strains than did those elicited by eIIV4 or ccIIV4 (median EC50 to A/Texas/50/2012 HA: 0·037 μg/mL [0·017-0·32] for RIV4; 1·10 μg/mL [0·045-100] for eIIV4; and 12·6 μg/mL [1·8-100] for ccIIV4). Comparison of B-cell receptor sequencing repertoires on day 7 showed that eIIV4 increased the median frequency of canonical egg glycan-targeting B cells (0·20% [95% CI 0·067-0·37] for eIIV4; 0·058% [0·050-0·11] for RIV4; and 0·035% [0-0·062] for ccIIV4), whereas RIV4 vaccination decreased the median frequency of B-cell receptors displaying stereotypical features associated with membrane proximal anchor-targeting antibodies (0·062% [95% CI 0-0·084] for RIV4; 0·12% [0·066-0·16] for eIIV4; and 0·18% [0·016-0·20] for ccIIV4). In exploratory analysis, we characterised the structure of a highly abundant monoclonal antibody that binds to both group 1 and 2 HAs and recognises the HA trimer interface, despite its sequence resembling the stereotypical sequence motif found in membrane-proximal anchor binding antibodies. INTERPRETATION: Although all three licensed seasonal influenza vaccines elicit serological antibody repertoires with indistinguishable features shaped by heavy imprinting, the RIV4 vaccine selectively boosts higher affinity monoclonal antibodies to contemporary strains and elicits greater serum binding potency and breadth, possibly as a consequence of the multivalent structural features of the HA immunogen in this vaccine formulation. Collectively, our findings show advantages of RIV4 vaccines and more generally highlight the benefits of multivalent HA immunogens in promoting higher affinity serum antibody responses. FUNDING: Centers for Disease Control and Prevention, National Institutes of Health, and Bill & Melinda Gates Foundation.

There is a pressing need for innovative strategies to control arboviruses transmitted by Aedes aegypti. The modification of indoor residual spraying to target Ae. aegypti is one such strategy. A clinical trial quantifying the epidemiologic impact of targeted indoor residual spraying for Ae. aegypti control used a product with pirimiphos-methyl as the active ingredient in the city of Mérida, Mexico. To monitor the susceptibility of local Ae. aegypti populations over the course of the trial, we calculated a diagnostic dose for pirimiphos-methyl using the Centers for Disease Control and Prevention bottle assay. Two independent laboratories tested a series of 8 concentrations of pirimiphos-methyl, eliciting a range of mortality between 0% and 100% in an insecticide-susceptible reference strain of Ae. aegypti. The results suggested a diagnostic dose of 25 μg/ml at a diagnostic time of 30 min. This diagnostic dose of pirimiphos-methyl was used to monitor pirimphos-methyl susceptibility in Ae. aegypti throughout the trial.

In response to notable increases in tick-associated illnesses in the United States, recent public health policies encouraged multi-sector collaborative approaches to preventing vector-borne diseases. Primary prevention strategies focus on educating the public about risks for tick-borne diseases and encouraging adoption of personal protection strategies. Accurate descriptions of when and where people are at risk for tick-borne diseases aid in the optimization of prevention messaging. Tick and tick-borne pathogen data can be used to fill gaps in epidemiological surveillance. However, the utility of acarological data is limited by their completeness. National maps showing the distribution of medically important tick species and the pathogens they carry are often incomplete or non-existent. Recent policies encourage accelerated efforts to monitor changes in the distribution and abundance of medically important ticks and the presence and prevalence of human pathogens that they carry, and to provide actionable, evidence-based information to the public, health care providers and public health policy makers. In 2018, the Centers for Disease Control and Prevention initiated a national tick surveillance program focused on Ixodes ticks. The national program coordinated and expanded upon existing efforts led by public health departments and academic institutions. Here, we describe experiences of state public health departments engaged in Ixodes tick surveillance, including information on why they initiated Ixodes surveillance programs, programmatic objectives, and strategies for maintaining tick surveillance programs. We share experiences and challenges in interpreting or communicating tick surveillance data to stakeholders and explore how the acarological data are used to complement epidemiological data.

BACKGROUND: Population-based incidence data on young-adult-onset type 1 diabetes and type 2 diabetes are limited. We aimed to examine secular trends in the incidence of diagnosed type 1 diabetes and type 2 diabetes with an age of onset between 15 and 39 years. METHODS: In this multicountry aggregate data analysis, we assembled eight administrative datasets from high-income jurisdictions and countries (Australia, Denmark, Finland, Hungary, Japan, Scotland, South Korea, and Spain [Catalonia]) that had appropriate data available from an international diabetes consortium (GLOBODIAB) describing incidence by diabetes type among people aged 15-39 years from 2000 to 2020. We modelled type 1 diabetes and type 2 diabetes incidence rates using Poisson regression including age and calendar time by sex. FINDINGS: During the years 2000-20, there were 349 591 incident diabetes (both types) cases from 346 million person-years of follow-up among people aged 15-39 years. Over time, there was no statistically significant change in the incidence of type 1 diabetes in Hungary and Japan. The incidence of type 1 diabetes significantly increased in Australia, Denmark, Finland, Scotland, South Korea, and Spain, with annual changes ranging from 0·5% to 6·0%. The incidence of type 2 diabetes significantly increased in four of eight jurisdictions (Denmark, Finland, Japan, and South Korea), with annual increases from 2·0% to 8·5%. The magnitude of increase in incidence of type 2 diabetes was greater in Asian than non-Asian jurisdictions. There was no statistically significant change in type 2 diabetes incidence in Australia and Hungary. The incidence of type 2 diabetes significantly decreased in Scotland and Spain, with annual changes of -0·7% and -1·5%, respectively. INTERPRETATION: There is variability in the trajectory of the incidence of young-adult-onset type 2 diabetes among high-income countries or jurisdictions, with a greater evidence of increase in Asian than non-Asian countries. Evolving trends in the incidence of type 1 and type 2 diabetes in young adults call for the ongoing surveillance of diabetes incidence and a greater research focus on this population. FUNDING: US Centers for Disease Control and Prevention, Diabetes Australia Research Programme, and Victoria State Government Operational Infrastructure Support Programme.

OBJECTIVE: The Centers for Disease Control and Prevention sexually transmitted infection (STI) treatment guidelines state that the decision to provide STI/human immunodeficiency virus (HIV) testing and presumptive treatment after sexual assault (SA) should be made on an individual basis to minimize retraumatization of the patient. However, little is known about STI screening, presumptive treatment, and positivity in the emergency department (ED) setting. The objective of this study was to evaluate STI testing rates and positivity, presumptive gonorrhea and chlamydia treatment, pregnancy testing, and emergency contraception offered to SA survivors in the ED in the United States. METHODS: The Premier Healthcare Database, a national administrative data set containing health care information from inpatient and hospital-based outpatient encounters, was used. Approximately 30% of encounters have available laboratory test results. ED visits for SA (identified by ICD-10-CM codes) among female patients aged 15-44 years between 2019 and 2023 were included. For patients presenting multiple times to the ED, only the first ED visit after SA was included. RESULTS: Of 49,047 total visits where females ages 15-44 years presented to the ED for SA, chlamydia, gonorrhea, syphilis, and HIV tests were conducted in 18.6%, 18.6%, 13.4%, and 16.9%, respectively, and pregnancy tests in 33.1% of visits. Presumptive gonorrhea and chlamydia treatment was provided in 53.7% and 52.2%, respectively, and emergency contraception in 27.2% of visits. Approximately 40% of patients were neither tested nor treated for either chlamydia or gonorrhea. Of patients with available laboratory test results, chlamydia, gonorrhea, and syphilis positivity rates were 10.0%, 3.8%, and 1.0%, respectively. CONCLUSIONS: Low STI testing and treatment rates and high STI positivity identified in this study suggest that an important opportunity exists for improving STI screening and presumptive treatment for female patients presenting to the ED after SA.

In 2022, the U.S. Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), and state partners conducted a sample-initiated investigation of a multistate outbreak of Salmonella Senftenberg illnesses linked to peanut butter. Twenty-one illnesses and four hospitalizations were reported in 17 states, with a significant epidemiological signal for peanut butter from Firm A. Whole genome sequence (WGS) data from a Salmonella-positive environmental swab sample collected at Firm A in 2010 yielded the outbreak strain that was a match to the WGS data from the 2022 clinical isolates. Lot code information collected from patients indicated Firm A's facility in Kentucky as a common manufacturing source, and FDA and state partners initiated an inspection. In 2021, Firm A installed two new roasters with at least one of the cooling air supply vents leaking, allowing unfiltered air and rainwater to enter the cooling section after the roasting process. Investigators noted the limitations of Firm A's finished product testing program to identify contamination. Investigative partners from five states collected and analyzed 14 product samples, and FDA collected 205 environmental swabs, and all were negative. Although the exact source and route of the contamination were not determined, epidemiological and traceback evidence confirmed peanut butter consumed by patients was produced by Firm A. Firm A voluntarily recalled all implicated products and provided a plan for corrective actions and restart to FDA. This was the first major domestic investigation of a multistate-foodborne illness outbreak linked to peanut butter since 2012. This investigation demonstrates the importance of caution with reliance on finished product testing, taking appropriate corrective actions when detection occurs, and potential benefits for industry to incorporate WGS as a tool in their environmental monitoring program.

The Department of Defense (DoD) remains committed to mitigating harmful behaviors that harm personnel and hinder military readiness. DoD's Sexual Assault Prevention and Response Office (SAPRO) and the Division of Violence Prevention (DVP) within the Centers for Disease Control and Prevention (CDC) established a partnership to build capacity for primary prevention though a wide-ranging training and technical assistance (TTA) system, The Integrated Prevention Technical Assistance Center (IPTAC). The system serves as a support system within the Interactive Systems Framework (ISF). The goal for IPTAC's TTA support is to build capacity for integrated primary prevention and build sustainability for prevention in complex military environments. To assess the effectiveness of IPTAC, the system is evaluated on what TTA is delivered, the skills and knowledge increase in TTA participants, participant satisfaction with TTA received, and participant application or intent for application of skills. Early results are positive; however, these results could be improved partly through ensuring a larger focus on tailoring to military contexts within all TTA activities. This article describes the creation of IPTAC, the role of the ISF in the implementation of TTA, and the evaluation of IPTAC. Implications for TTA delivery in the military and civilian sectors are discussed.

The benefits of training and technical assistance (TTA) have been well documented. There is limited literature that explores how complex systems of TTA are implemented and evaluated particularly in the violence prevention field. The Violence Prevention Practice and Translation Branch (VPPTB) within the Centers for Disease Control and Prevention's (CDC) Division of Violence Prevention funds multiple technical assistance providers who are tasked with building the capacity of program recipients to implement comprehensive approaches to prevent multiple forms of violence. VPPTB designed the Violence Prevention Technical Assistance Center (VPTAC) with the goal of implementing and evaluating comprehensive TTA efforts that integrates the work of multiple TTA providers to build the capacity of recipients to plan, implement, and evaluate violence prevention efforts. The VPTAC evaluation incorporates data from program recipients, TTA providers, and TTA modalities enabling the VPPTB staff to show improvement in technical knowledge, gather examples of enhanced implementation, and facilitate proactive TTA planning. An important step in the process of evaluating VPTAC from a system-level perspective required an expansion beyond evaluating a single TTA event, provider, or engagement. This is essential to understand how a diverse set of TTA activities and partners work together in their efforts to build capacity.

The consumption of alcohol and other substances during pregnancy can impair prenatal development. While scientifically informed public health measures have raised awareness of the risks of harmful prenatal substance exposures, the use of alcohol and other substances during pregnancy continues to rise. The successful dissemination of consistent messaging, health care professional education and training, and universal implementation of clinical interventions may help reduce drinking in pregnancy and prevent fetal alcohol spectrum disorders (FASDs), a constellation of developmental disabilities and birth defects caused by alcohol use during pregnancy. Alcohol screening and brief intervention (alcohol SBI) is an evidence-based preventive practice that enables early identification of excessive drinking and intervention prior to serious consequences. Routine clinical implementation of alcohol SBI has been shown to effectively reduce excessive alcohol consumption among adults, including pregnant people. Many barriers prevent widespread implementation of the practice: a lack of health care professional knowledge of the prevalence and implications of prenatal alcohol exposure, stigma surrounding individuals who use substances potentially harmful to their pregnancy, resistance to public health messages encouraging alcohol avoidance during pregnancy, and discomfort and hesitancy with alcohol SBI procedures among practitioners. The Centers for Disease Control and Prevention (CDC) leads the public health effort to prevent alcohol use during pregnancy and improve identification of and care for children living with FASDs. CDC partners with health systems, health care professional associations, universities, and community-based networks to promote alcohol SBI as an effective but underused preventive health service. This special section consisting of 6 articles including this introductory commentary represents the efforts of 11 CDC projects and their partners to demonstrate the rationale for FASD prevention and intervention, engage health care disciplines to expand prevention messaging and education for providers, develop practical approaches for implementing alcohol SBI in diverse clinical settings, and prevent alcohol use in pregnancy and FASDs.

In 2022, the U.S. Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), U.S. state and local partners, the Public Health Agency of Canada (PHAC), and the Canadian Food Inspection Agency (CFIA), conducted a bi-national sample-initiated retrospective outbreak investigation (SIROI) of Listeria monocytogenes illnesses linked to enoki mushrooms. The FDA and CDC investigated the first known L. monocytogenes outbreak linked to enoki mushrooms from 2016-2020, making the 2022 outbreak the second time this pathogen-commodity pair was investigated by FDA and CDC. The 2022 outbreak included six ill people, all of whom were hospitalized. Epidemiologic, laboratory, and traceback evidence led to multiple public health actions, including voluntary recalls by firms, public communications about the outbreak, and FDA's country-wide Import Alert for enoki mushrooms from China. This SIROI illustrates the importance of surveillance sampling, national and international coordination of efforts, and rapid information sharing to identify and stop foodborne outbreaks on a global scale. To reduce the risk of listeriosis illnesses linked to contaminated enoki mushrooms, public health and regulatory agencies in the United States and Canada remain committed to conducting comprehensive surveillance for Listeria in foods and in people, efficiently investigating identified outbreaks, and implementing control measures to potentially minimize the impact of future outbreaks.

Objectives: Yellow fever (YF) remains a public health threat in Sub-Saharan Africa and South America, with an estimated 200,000 cases and 30,000 deaths annually. Although the World Health Organization considers Tanzania to be at low risk for YF because no YF cases have been reported, the country remains at alert to importation of the virus due to ecological factors and high connectivity to high-risk YF areas in other countries. This study aimed to identify points of interest with connectivity to high-risk YF areas to guide preparedness efforts in Tanzania. Methods: Using the Population Connectivity Across Borders (PopCAB) toolkit, the Nelson Mandela African Institution of Science and Technology (Department of Health and Biomedical Sciences), in collaboration with the Tanzania Ministry of Health and the Centers for Disease Control and Prevention, implemented 12 focus group discussions with participatory mapping in two high-risk borders of Mutukula and Namanga. Results: Participants identified 147 and 90 points of interest with connectivity to YF risk areas in Kenya and Uganda, respectively. The identified locations are important for trade, fishing, pastoralism, tourism, health-seeking, agriculture, mining, religious activities, education, and cross-border marriages. Conclusions: The Tanzania Ministry of Health used the results to update cross-border surveillance and risk communication strategies and vaccination guidelines to prevent the importation of YF into Tanzania. © 2024 The Authors

BACKGROUND: In June 2019, the U.S. Advisory Committee on Immunization Practices recommended shared clinical decision making regarding potential human papillomavirus (HPV) vaccination of men and women aged 27 to 45 years ("mid-adults"). OBJECTIVE: To examine the incremental cost-effectiveness ratios (ICERs) and number needed to vaccinate (NNV) to prevent 1 HPV-related cancer case of expanding HPV vaccination to subgroups of mid-adults at increased risk for HPV-related diseases in the United States. DESIGN: Individual-based transmission dynamic modeling of HPV transmission and associated diseases using HPV-ADVISE (Agent-based Dynamic model for VaccInation and Screening Evaluation). DATA SOURCES: Published data. TARGET POPULATION: All U.S. mid-adults and higher-risk subgroups within this population. TIME HORIZON: 100 years. PERSPECTIVE: Health care sector. INTERVENTION: Expanding 9-valent HPV vaccination to mid-adults and higher-risk subgroups. OUTCOME MEASURES: ICERs and NNVs. RESULTS OF BASE-CASE ANALYSIS: Expanding 9-valent HPV vaccination to all mid-adults, those with more lifetime partners, and those who have just separated was projected to cost an additional $2 005 000, $763 000, and $1 164 000 per quality-adjusted life-year (QALY) gained, respectively. The NNVs to prevent 1 additional HPV-related cancer case were 7670, 3190, and 5150, respectively, compared with 223 for vaccination of persons aged 9 to 26 years (vs. no vaccination). RESULTS OF SENSITIVITY ANALYSIS: The mid-adult strategy with the lowest ICER and NNV was vaccinating infrequently screened mid-adult women who have just separated and have a higher number of lifetime sex partners (ICER, $86 000 per QALY gained; NNV, 470). LIMITATION: Uncertainty about rate of new sex partners and natural history of HPV among mid-adults. CONCLUSION: Vaccination of mid-adults against HPV is substantially less cost-effective and produces higher NNVs than vaccination of persons younger than 26 years under all scenarios investigated. However, cost-effectiveness and NNV are projected to improve when higher-risk mid-adult subgroups are vaccinated, such as mid-adults with more sex partners and who have recently separated, and women who are underscreened. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention.

This cross-sectional study examines reactogenicity among children of participants in the Centers for Disease Control and Prevention COVID-19 Vaccine Pregnancy Registry from November 2022 to September 2023 to understand the frequency and types of reactions experienced. | eng

Nearly a decade after the National Academy of Medicine released the "Improving Diagnosis in Health Care" report, diagnostic errors remain common, often leading to physical, psychological, emotional, and financial harm. Despite a robust body of research on potential solutions and next steps, the translation of these efforts to patient care has been limited. Improvement initiatives are still narrowly focused on selective themes such as diagnostic stewardship, preventing overdiagnosis, and enhancing clinical reasoning without comprehensively addressing vulnerable systems and processes surrounding diagnosis. To close this implementation gap, the US Centers for Disease Control and Prevention (CDC) released the Core Elements of Hospital Diagnostic Excellence programs on September 17, 2024. This initiative aligns with the World Health Organization's (WHO) 2024 World Patient Safety Day focus on improving diagnosis. These Core Elements provide guidance for the formation of hospital programs to improve diagnosis and aim to integrate various disparate efforts in hospitals. By creating a shared mental model of diagnostic excellence, the Core Elements of Diagnostic Excellence supports actions to break down silos, guide hospitals toward multidisciplinary diagnostic excellence teams, and provide a foundation for building diagnostic excellence programs in hospitals.

BACKGROUND: On 20 September 2022, the Ugandan Ministry of Health declared an outbreak of Ebola disease caused by Sudan ebolavirus. METHODS: From 6 October 2022 to 10 January 2023, Centers for Disease Control and Prevention (CDC) staff conducted public health assessments at five US ports of entry for travellers identified as having been in Uganda in the past 21 days. CDC also recommended that state, local and territorial health departments ('health departments') conduct post-arrival monitoring of these travellers. CDC provided traveller contact information, daily to 58 health departments, and collected health department data regarding monitoring outcomes. RESULTS: Among 11 583 travellers screened, 132 (1%) required additional assessment due to potential exposures or symptoms of concern. Fifty-three (91%) health departments reported receiving traveller data from CDC for 10 114 (87%) travellers, of whom 8499 (84%) were contacted for monitoring, 1547 (15%) could not be contacted and 68 (1%) had no reported outcomes. No travellers with high-risk exposures or Ebola disease were identified. CONCLUSION: Entry risk assessment and post-arrival monitoring of travellers are resource-intensive activities that had low demonstrated yield during this and previous outbreaks. The efficiency of future responses could be improved by incorporating an assessment of risk of importation of disease, accounting for individual travellers' potential for exposure, and expanded use of methods that reduce burden to federal agencies, health departments, and travellers.

The first Ebola Virus Disease (EVD) cases in the 2021 Ebola outbreak were reported by the Democratic Republic of the Congo (DRC) Ministry of Health in February. However, 1 week later, the Guinea Ministry of Health reported its first EVD outbreak since April 2016. U.S. Centers for Disease Control (CDC) in-country operational and workforce capacity were built during the 2014-2016 Ebola outbreak response in West Africa and leveraged during the 2021 EVD outbreaks. During the 2014-2016 West Africa response and the 2021 EVD outbreaks, capacity and capability improvements in laboratory systems, risk communication, surveillance, epidemiology, infection prevention, and control were needed for a successful response. The overarching goal of CDC's operational and workforce capacity improvements was to strengthen countries' abilities to prevent, detect, and respond to outbreaks quickly. The Ebola outbreaks are examples of enhanced public health interventions where CDC has contributed as a partner with in-country ministries of health to save lives and control disease outbreaks. Lessons learned from the recent Ebola outbreaks indicate that a capacity-building approach has the potential application to other public health emergencies and contributes to strengthening global health security.

BACKGROUND: Applicants seeking entry into the United States are examined overseas for TB by panel physicians and international immigration clinicians guided by Centers for Disease Control and Prevention (CDC) TB Technical Instructions. To support this effort, CDC-funded TB Centers of Excellence (COEs) provide web-based expert consultation, with documentation stored in a medical consultation database (MCD). MCD analysis can reveal inquiry trends among panel physicians worldwide. METHODS: TB-related queries in the COE MCD from January 1, 2018, to December 31, 2022, were analyzed using a descriptive coding scheme developed through inductive analysis, allowing multiple themes per entry. RESULTS: A total of 215 queries from 126 patients in 28 countries were analyzed. Major themes included evaluating diagnostic criteria, tailoring treatment, and managing comorbidities or adverse reactions. Diagnostic questions (n = 104, 48.4%) included mycobacterial culture, smear, and radiology interpretation. Treatment tailoring inquiries involved optimizing the initial regimen (n = 89, 41.4%) or modifying existing regimens (n = 26, 12.1%). Additionally, 50 consultations (23.2%) mentioned comorbidities, while 47 (21.9%) described adverse reactions. CONCLUSION: The MCD analysis identified topics where TB expertise was provided in overseas medical evaluation. These topics highlight opportunities for targeted panel physician education to improve the health of individual applicants and advance U.S. TB elimination efforts.

Evaluation generates critical evidence about the effectiveness of health-focused climate adaptation, who receives what benefits, and how to improve program quality. However, using evaluation to improve climate adaptation outcomes with timeliness and context-specificity is uniquely challenging. The United States Centers for Disease Control and Prevention supports health departments to implement adaptation initiatives through the Climate-Ready States and Cities Initiative (CRSCI) grant and minimize negative health impacts of climate change via the Building Resilience Against Climate Effects (BRACE) framework, which includes evaluation. In this paper, we present current evaluation practice by describing the health-focused adaptation actions that were evaluated among CRSCI recipients, the evaluation approaches they used, and the barriers and enablers encountered. Using a mixed methods approach, we abstracted annual progress report and standardized performance measure data to characterize evaluation activities across 18 grant recipients using basic quantitative descriptive analysis. Through structured interviews with three grant recipients and standard team-based qualitative coding and analysis techniques, we developed qualitative case studies to explore evaluation barriers and enablers in richer context. Recipients reported 76 evaluations over the reporting period (2018-2021). Evaluated programs commonly addressed extreme weather (50.0%), followed by heat (27.6%). The most common purpose was to monitor implementation or improve delivery (57.9%). Case studies highlighted barriers to successful evaluation such as limited specialized evaluation expertise and staff time. Enablers included staff motivation to justify program expansion, strong relationships with community partners, and use of evaluation plans. Case studies revealed diverse strategies to seek input from stakeholders disproportionately impacted by climate change and to reduce health disparities. The experiences of CDC grant recipients provide an opportunity to better understand the barriers and enablers of climate and health evaluation practice and to identify practical strategies to expand the value of evaluation in this nascent field.

Hospital surfaces are known to contribute to the spread of healthcare-associated antimicrobial pathogens. Environmental sampling can help locate reservoirs and determine intervention strategies, although sampling and detection can be labor intensive. Composite approaches may help reduce time and costs associated with sampling and detection. We investigated optimum surface areas for sampling antimicrobial-resistant organisms (AROs) with a single side of cellulose sponge, created theoretical composites (TC) by adding recovery results from multiple optimum areas, then compared the TC to the standard Centers for Disease Control and Prevention sampling method (one sponge using all sides, whole tool; (WT)). Five AROs were evaluated: carbapenemase-producing KPC+ Klebsiella pneumoniae (KPC), Acinetobacter baumannii (AB), methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecalis (VRE) and Clostridioides difficile spores (CD). Steel coupons comprising four surface areas (323; 645; 1,290 and 2,258 cm2) were inoculated, dried, and sampled with one sampling pass using the larger side (face) or the smaller side (edge) of a pre-moistened cellulose sponge tool. Based on the optimum areas determined for each organism, composite areas were 1,290 cm2 for MRSA and VRE, 1,936 cm2 for AB, 2,580 cm2 for CD spores and 3,870 cm2 for KPC. Total colony forming units (CFU) recovered using a composite approach was greater or comparable than using multiple WT samplings (over the same area as the composite) for MRSA, VRE and AB (130%; 144% and 95%) yet less than if using multiple WT samplings for KP and CD (47% and 66%). We propose a conservative composite sampling strategy if the target organism is unknown; 323 cm2 sampling area for each of the four sides of the sponge, (1290 cm2 total). The conservative composite sampling strategy improved the recovery of KP (from 47% to 85% of multiple WT samplings), while MRSA, VRE, AB and CD (131%; 144%; 97% and 66%) remained within 5% to that of the optimum area TC.

Travel-related malaria is regularly encountered in the United States, and the U.S. Centers for Disease Control and Prevention (CDC) characterizes Plasmodium falciparum drug-resistance genotypes routinely for travel-related cases. An important aspect of antimalarial drug resistance is understanding its geographic distribution. However, specimens submitted to CDC laboratories may have missing, incomplete, or inaccurate travel data. To complement genotyping for drug-resistance markers Pfcrt, Pfmdr1, Pfk13, Pfdhps, Pfdhfr, and PfcytB at CDC, amplicons of Pfs47 and Pfcpmp are also sequenced as markers of geographic origin. Here, a bi-allele likelihood (BALK) classifier was trained using Pfs47 and Pfcpmp sequences from published P. falciparum genomes of known geographic origin to classify clinical genotypes to a continent. Among P. falciparum-positive blood samples received at CDC for drug-resistance genotyping from 2018 to 2021 (n = 380), 240 included a travel history with the submission materials, though 6 were excluded due to low sequence quality. Classifications obtained for the remaining 234 were compared to their travel histories. Classification results were over 96% congruent with reported travel for clinical samples, and with collection sites for field isolates. Among travel-related samples, only two incongruent results occurred; a specimen submitted citing Costa Rican travel classified to Africa, and a specimen with travel referencing Sierra Leone classified to Asia. Subsequently, the classifier was applied to specimens with unreported travel histories (n = 140; 5 were excluded due to low sequence quality). For the remaining 135 samples, geographic classification data were paired with results generated using CDC's Malaria Resistance Surveillance (MaRS) protocol, which detects single-nucleotide polymorphisms in and generates haplotypes for Pfcrt, Pfmdr1, Pfk13, Pfdhps, Pfdhfr, and PfcytB. Given the importance of understanding the geographic distribution of antimalarial drug resistance, this work will complement domestic surveillance efforts by expanding knowledge on the geographic origin of drug-resistant P. falciparum entering the USA.

AIM: Lipoprotein (a) [Lp(a)] is a well-established risk factor for cardiovascular disease independent of low-density lipoprotein-cholesterol (LDL-C). The Lp(a) concentrations were inconsistent between the immunoassays. This study aimed to investigate whether harmonization of Lp(a) measurements can be achieved using a serum panel value assigned with the IFCC-endorsed mass spectrometry-based reference measurement procedure (IFCC-MS-RMP). METHODS: We measured the Lp(a) concentrations using five Lp(a) immunoassays in 40 panel sera provided by the Centers for Disease Control and Prevention (CDC), and 500 Japanese subjects enrolled in the Bunkyo Health Study. Of the five immunoassays, only the Roche Lp(a) assay was traceable to the WHO-IFCC reference material SRM2B. Lp(a) concentrations in CDC samples were also determined by IFCC-MS-RMP, provisionally calibrated to SRM2B. Lp(a) concentrations were expressed in mass units (mg/dL) for most reagents, but in SI units (nmol/L) for Roche's reagent and IFCC-MS-RMP. RESULTS: In the CDC panel sera, all immunoassays, including Roche's reagent, showed good correlations with IFCC-MS-RMP. In the Bunkyo Health Study samples, all immunoassays showed good correlations with Roche's reagent (r(s), 0.986-0.998) although the slopes of the regression lines ranged from 0.292 to 0.579. After recalibration with the CDC's panel sera, Lp(a) results of Bunkyo Health Study samples were converted to the equivalent values determined by the IFCC-MS-RMP, thus resulting in a marked reduction in the intermethod CV among the assays. CONCLUSION: We achieved harmonization of Lp(a) measurements with five immunoassays using a serum panel value assigned with the IFCC-MS-RMP.

OBJECTIVES: To describe sudden unexpected infant deaths (SUIDs) occurring in safe sleep environments and explore differences in selected characteristics. METHODS: We examined SUID from 22 jurisdictions from 2011 to 2020 and classified them as unexplained, no unsafe sleep factors (U-NUSF). Data were derived from the Sudden Unexpected Infant Death and Sudden Death in the Young Case Registry, a population-based Centers for Disease Control and Prevention surveillance system built on the National Center for Fatality Review and Prevention's child death review program. SUID classified as U-NUSF included infants who were (1) awake, under supervision, and witnessed to become unresponsive or (2) found unresponsive in a safe sleep environment after sleep (unwitnessed). We calculated frequencies and percentages for demographics, birth and environmental characteristics, medical history, and death investigation findings. RESULTS: Most of the 117 U-NUSF SUID occurred before 4 months of age. Witnessed deaths most commonly occurred at <1 month of age (28%), whereas unwitnessed deaths most commonly occurred at ages 2 to 3 months (44%) Among all U-NUSF, 69% occurred in the infant's home (62% witnessed, 77% unwitnessed). All unwitnessed deaths occurred in a crib; most witnessed deaths occurred while being held (54%) or in a car seat traveling (18%). Most infants (84%) had no history of abuse or neglect. Abnormal autopsy findings were reported in 46% of deaths (49% witnessed, 42% unwitnessed). CONCLUSIONS: Characterizing these deaths is key to advancing our knowledge of SUID etiology. Our study revealed a heterogeneous group of infants, suggesting physiologic, genetic, or environmental etiologies.

Legionella pneumophila serogroup 1 sequence types (ST) 213 and 222, a single-locus variant of ST213, were first detected in the early 1990s in the Midwest United States (U.S.) and the late 1990s in the Northeast U.S. and Canada. Since 1992, these STs have increasingly been implicated in community-acquired sporadic and outbreak-associated Legionnaires' disease (LD) cases. We were interested in understanding the change in LD frequency due to these STs and identifying genetic features that differentiate these STs from one another. For the geographic area examined here (Mountain West to Northeast) and over the study period (1992-2020), ST213/222-associated LD cases identified by the Centers for Disease Control and Prevention increased by 0.15 cases per year, with ST213/222-associated LD cases concentrated in four states: Michigan (26%), New York (18%), Minnesota (16%), and Ohio (10%). Additionally, between 2002 and 2021, ST222 caused at least five LD outbreaks in the U.S.; no known outbreaks due to ST213 occurred in the U.S. during this time. We compared the genomes of 230 ST213/222 isolates and found that the mean of the average nucleotide identity (ANI) within each ST was high (99.92% for ST222 and 99.92% for ST213), with a minimum between ST ANI of 99.50% and a maximum of 99.87%, indicating low genetic diversity within and between these STs. While genomic features were identified (e.g., plasmids and CRISPR-Cas systems), no association explained the increasing geographic distribution and prevalence of ST213 and ST222. Yet, we provide evidence of the expanded geographical distribution of ST213 and ST222 in the U.S.IMPORTANCESince the 1990s, cases of Legionnaires' disease (LD) attributed to a pair of closely related Legionella pneumophila variants, ST213 and ST222, have increased in the U.S. Furthermore, between 2002 and 2021, ST222 caused at least five outbreaks of LD in the U.S., while ST213 has not been linked to any U.S. outbreak. We wanted to understand how the rate of LD cases attributed to these variants has changed over time and compare the genetic features of the two variants. Between 1992 and 2020, we determined an increase of 0.15 LD cases ascribed to ST213/222 per year in the geographic region studied. Our research shows that these STs are spreading within the U.S., yet most of the cases occurred in four states: Michigan, New York, Minnesota, and Ohio. Additionally, we found little genetic diversity within and between these STs nor could specific genetic features explain their geographic spread.