Just over 50 years ago, the Lead-Based Paint Poisoning Prevention Act of 1971 led to the establishment of the Childhood Lead Poisoning Prevention Program (CLPPP) at the Centers for Disease Control and Prevention (CDC). Since then, a broad, multifaceted environmental public health effort involving a wide array of government agencies and key stakeholders has led to marked declines in exposure levels and blood lead levels (BLLs) in the United States. Nevertheless, the effect of lead on young children and the resultant public health challenge remains. The scientific advances that have led to a better understanding of the deleterious effects of current lead exposures compel the ongoing public health efforts, with new shifts in emphasis and focus, to eliminate childhood lead poisoning. Although widely distributed in the environment, it is significantly related to poverty and inequity, particularly affecting Black and other minority children. Prevention has been a challenge only partially met, and lead poisoning still endures and remains to be fully eliminated.

OBJECTIVE: To develop, implement, and assess implementation outcomes for a developmental monitoring and referral program for children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). METHODS: Based on Centers for Disease Control and Prevention's Learn the Signs. Act Early. campaign, the program was developed and replicated in two phases at 20 demographically diverse WIC clinics in eastern Missouri. Parents were asked to complete developmental milestone checklists for their children, ages 2months to 4years, during WIC eligibility recertification visits; WIC staff referred children with potential concerns to their healthcare providers for developmental screening. WIC staff surveys and focus groups were used to assess initial implementation outcomes. RESULTS: In both phases, all surveyed staff (n=46) agreed the program was easy to use. Most (80%) agreed that checklists fit easily into clinic workflow and required5min to complete. Staff (55%) indicated using checklists with75% of their clients. 92% or more reported referring one or more children with potential developmental concerns. According to 80% of staff, parents indicated checklists helped them learn about development and planned to share them with healthcare providers. During thesecond phase, 18 of 20 staff surveyed indicated the program helped them learn when to refer children and how to support parents, and 19 felt the program promoted healthy development. Focus groups supported survey findings, and all clinics planned to sustain the program. CONCLUSIONS: Initial implementation outcomes supported this approach to developmental monitoring and referral in WIC. The program has potential to help low-income parents identify possible concerns and access support.

Data on the detailed clinical progression of COVID-19 in conjunction with epidemiological and virological characteristics are limited. In this case series, we describe the first 12 US patients confirmed to have COVID-19 from 20 January to 5 February 2020, including 4 patients described previously(1-3). Respiratory, stool, serum and urine specimens were submitted for SARS-CoV-2 real-time reverse-transcription polymerase chain reaction (rRT-PCR) testing, viral culture and whole genome sequencing. Median age was 53 years (range: 21-68); 8 patients were male. Common symptoms at illness onset were cough (n = 8) and fever (n = 7). Patients had mild to moderately severe illness; seven were hospitalized and demonstrated clinical or laboratory signs of worsening during the second week of illness. No patients required mechanical ventilation and all recovered. All had SARS-CoV-2 RNA detected in respiratory specimens, typically for 2-3 weeks after illness onset. Lowest real-time PCR with reverse transcription cycle threshold values in the upper respiratory tract were often detected in the first week and SARS-CoV-2 was cultured from early respiratory specimens. These data provide insight into the natural history of SARS-CoV-2. Although infectiousness is unclear, highest viral RNA levels were identified in the first week of illness. Clinicians should anticipate that some patients may worsen in the second week of illness.

The literature on sero-epidemiological studies of flaviviral infections in the African continent is quite scarce. Much of the viral epidemiology studies have been focussing on diseases such as HIV/AIDS because of their sheer magnitude and impact on the lives of people in the various affected countries. Increasingly disease outbreaks caused by arboviruses such as the recent cases of chikungunya virus, dengue virus and yellow fever virus have prompted renewed interest in studying these viruses. International agencies from the US, several EU nations and China are starting to build collaborations to build capacity in many African countries together with established institutions to conduct these studies. The Tofo Advanced Study Week (TASW) was established to bring the best scientists from the world to the tiny seaside town of Praia do Tofo to rub shoulders with African virologists and discuss cutting-edge science and listen to the work of researchers in the field. In 2015 the 1st TASW focussed on Ebola virus. The collections of abstracts from participants at the 2nd TASW which focused on Dengue and Zika virus as well as presentations on other arboviruses are collated in this chapter.

The Epidemic Intelligence Service officers (EISOs) at the National Center for Environmental Health (NCEH)/Agency for Toxic Substances and Disease Registry (ATSDR) respond to public health outbreaks, assist public health surveillance, and recommend public health actions. We summarize the breadth of work done by EISOs assigned to NCEH/ATSDR during 2006-2015. We used the Web of Science, Scopus, and PubMed databases to identify articles authored by the EISOs, number and types of epidemiologic assistance field investigations (Epi-AIDS), and interviewed NCEH/ATSDR programs with EISO assignees. The largest number of NCEH/ATSDR EISO publications (n = 61) and Epi-AIDS (n = 110) related to toxic chemicals (23 and 37, respectively), followed by natural disasters and those caused by humans (19 and 25, respectively), extreme temperature-related illness (9), and chronic diseases (8). The investigations raised awareness, identified risk factors and public health needs, and introduced better prevention and protection measures for human health. Through field investigations and other technical assistance, NCEH/ATSDR provided leadership and staff scientists to assist in the field, as well as knowledge transfer to local, state, territorial, and international health departments. © The Author(s).

Health effects following low doses of ionizing radiation are uncertain. Military veterans at the Nevada test site (NTS) during the SMOKY atmospheric nuclear weapons test in 1957 were reported to be at increased risk for leukemia in 1979, but this increase was not evaluated with respect to radiation dose. The SMOKY test was one of 30 tests in 1957 within the PLUMBBOB test series. These early studies led to public laws where atomic veterans could qualify for compensation for presumptive radiogenic diseases. A retrospective cohort study was conducted of 12219 veterans at the PLUMBBOB test series, including 3020 at the SMOKY nuclear test. Mortality follow-up was through 2010 and observed causes of death were compared with expected causes based on general population rates. Radiation dose to red bone marrow was based on individual dose reconstructions, and Cox proportional hazards models were used to evaluate dose response for all leukemias other than chronic lymphocytic leukemia (non-CLL leukemia). Vital status was determined for 95.3% of the 12 219 veterans. The dose to red bone marrow was low (mean 3.2 mGy, maximum 500 mGy). Military participants at the PLUMBBOB nuclear test series remained relatively healthy after 53 years and died at a lower rate than the general population. In contrast, and in comparison with national rates, the SMOKY participants showed significant increases in all causes of death, respiratory cancer, leukemia, nephritis and nephrosis, and accidents, possibly related in part to lifestyle factors common to enlisted men who made up 81% of the SMOKY cohort. Compared with national rates, a statistically significant excess of non-CLL leukemia was observed among SMOKY participants (Standardized Mortality Ratio = 1.89, 95% 1.24-2.75, n = 27) but not among PLUMBBOB participants after excluding SMOKY (SMR = 0.87, 95% 0.64-1.51, n = 47). Leukemia risk, initially reported to be significantly increased among SMOKY participants, remained elevated, but this risk diminished over time. Despite an intense dose reconstruction, the risk for leukemia was not found to increase with increasing levels of radiation dose to the red bone marrow. Based on a linear model, the estimated excess relative risk per mGy is -0.05 (95% CI -0.14, 0.04). An explanation for the observed excess of leukemia remains unresolved but conceivably could be related to chance due to small numbers, subtle biases in the study design and/or high tobacco use among enlisted men. Larger studies should elucidate further the possible relationship between fallout radiation, leukemia and cancer among atomic veterans.

BACKGROUND: Limited and fragmented data collection systems exist for burn injury. A global registry may lead to better injury estimates and identify risk factors. A collaborative effort involving the WHO, the Global Alliance for Clean Cookstoves, the CDC and the International Society for Burn Injuries was undertaken to simplify and standardise inpatient burn data collection. An expert panel of epidemiologists and burn care practitioners advised on the development of a new Global Burn Registry (GBR) form and online data entry system that can be expected to be used in resource-abundant or resource-limited settings. METHODS: International burn organisations, the CDC and the WHO solicited burn centre participation to pilot test the GBR system. The WHO and the CDC led a webinar tutorial for system implementation. RESULTS: During an 8-month period, 52 hospitals in 30 countries enrolled in the pilot and were provided the GBR instrument, guidance and a data visualisation tool. Evaluations were received from 29 hospitals (56%). KEY FINDINGS: Median time to upload completed forms was <10 min; physicians most commonly entered data (64%), followed by nurses (25%); layout, clarity, accuracy and relevance were all rated high; and a vast majority (85%) considered the GBR 'highly valuable' for prioritising, developing and monitoring burn prevention programmes. CONCLUSIONS: The GBR was shown to be simple, flexible and acceptable to users. Enhanced regional and global understanding of burn epidemiology may help prioritise the selection, development and testing of primary prevention interventions for burns in resource-limited settings.

Answer: Acanthanmoeba spp. Hematoxylin and eosin (H/E)-stained tissue sections revealed edematous mucose with evidence of moderate acute and chronic inflammation and confluent areas of necrosis. Within the necrotic tissue were scattered double-walled wrinkled cystic structures and trophozoites were identified within a vessel wall, indicitave of angioinvasion. Gomori Methenamine silver (GMS) and periodic acid Schiff stains highlighted the cysts and trophozoites.

PURPOSE: To determine whether a bacteriophage antimicrobial-lock technique can reduce bacterial colonization and biofilm formation on indwelling central venous catheters in a rabbit model. MATERIALS AND METHODS: Cuffed central venous catheters were inserted into the jugular vein of female New Zealand White rabbits under image guidance. Catheters were inoculated for 24 hours with broth culture of methicillin-sensitive Staphylococcus aureus. The inoculum was aspirated, and rabbits were randomly assigned to two equal groups for 24 hours: (i) untreated controls (heparinized saline lock), (ii) bacteriophage antimicrobial-lock (staphylococcal bacteriophage K, propagated titer > 108/mL). Blood cultures were obtained via peripheral veins, and the catheters were removed for quantitative culture and scanning electron microscopy. RESULTS: Mean colony-forming units (CFU) per cm2 of the distal catheter segment, as a measure of biofilm, were significantly decreased in experimental animals compared with controls (control, 1.2 x 105 CFU/cm2; experimental, 7.6 x 103; P = .016). Scanning electron microscopy demonstrated that biofilms were present on the surface of five of five control catheters but only one of five treated catheters (P = .048). Blood culture results were not significantly different between the groups. CONCLUSIONS: In a rabbit model, treatment of infected central venous catheters with a bacteriophage antimicrobial-lock technique significantly reduced bacterial colonization and biofilm presence. Our data represent a preliminary step toward use of bacteriophage therapy for prevention and treatment of central venous catheter-associated infection.

This paper summarizes environmental investigations (n = 458) conducted during the first 60 years of the epidemic-assistance investigation program at the Centers for Disease Control and Prevention. These investigations were grouped into 10 categories: toxic chemicals (n = 102), indoor air quality and outdoor air toxics (n = 21), new or rare epidemic diseases and unexplained syndromes (n = 29), natural disasters (n = 81), terrorism and unintentional human-made disasters (n = 9), substance use and abuse (n = 13), environmental aspects of infectious disease (n = 132), those affecting neonates and infants (n = 11), violence and injuries (n = 51), and miscellaneous (n = 9). Among the most important or prominent were studies of lead and arsenic toxicity at smelters, mercury in paint and beauty creams, dioxin in waste oil in Missouri, polychlorinated biphenyls and multiple other toxic chemicals, global pesticide poisoning outbreaks, hepatic angiosarcoma among vinyl chloride workers, toxic oil syndrome in Spain, eosinophilia-myalgia syndrome from contaminated L-tryptophan, diethylene glycol poisoning in Haiti, aflatoxicosis in Kenya, Gulf War illness among veterans, impact and needs assessments during natural disasters (e.g., Hurricane Katrina (2005) and the Mount St. Helens volcano eruptions (1980)), risk factors for heat-related mortality, domestic and international terrorist attacks, Parkinsonism related to 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine in California, and unintentional injury- and violence-related events.

As an epidemiology bulletin, MMWR has unique strengths and attributes. These include weekly publication (highlighting timeliness and frequency of reporting), rapid turnaround, a close relation with government practitioners of public health (federal, state, and local), and a clear mission of informing the public health community and the general public about new, reemerging, and ongoing threats to the public's health. With its integral relationship to CDC, MMWR also is a means of publishing major internal CDC reports, particularly surveillance reports. | | The field of environmental health is particularly heterogeneous and diverse. Environmental threats can be categorized singly as particular toxins, chemicals, or risks (e.g., lead, mercury, dioxin, rats, and poisons), grouped by environmental media (e.g., air pollutants, water pollutants, and hazardous wastes), broadly demarcated by environmental place or setting (e.g., homes, communities, and rural environments), or more broadly by national versus global concerns. Similarly, environmental diseases can be categorized as diseases essentially caused by a specific environmental factor (e.g., heat stroke and carbon monoxide [CO] poisoning); diseases caused, triggered, or exacerbated by environmental risk factors (e.g., asthma); or chronic multifactorial diseases for which environmental risk factors are just one category of multiple risk factors (e.g., heart disease or cancer). Beyond disease, natural and human-made disasters (e.g., chemical, biologic, and nuclear/radiation), including terrorist events, are an essential focus of environmental health. | | Given the attributes of MMWR and the breadth of environmental health, readers might anticipate that MMWR environmental health reports focus heavily on new or reemerging epidemic diseases, disaster situations, chemicals and toxins causing acute clinical illness, newly identified risk factors and threats for acute illness, and surveillance updates for tracking environmental disease. Indeed, such has been the case, particularly in MMWR's early years; however, in recent years, coverage has broadened. This report provides an overview of MMWR as it related to environmental health during 1961--2010; the presentation of results follows the outline of the environmental framework (Table 1) and highlights the public health problems addressed in MMWR.

As we approach the 10th anniversary of the terrorist attacks of September 11, 2001, we are aware of the dramatic changes that have resulted from a decade of sharply increased terrorist activity, mostly in the form of explosive devices in a variety of high-profile settings. This has led to heightened vigilance to prevent such attacks and to much greater attention to disaster preparedness and emergency medical response capabilities. | One of the challenges in the United States for disaster preparedness and response planning is that almost all of the terrorist explosive events have occurred overseas (eg, the London, Madrid, and Bali attacks and the hundreds of bombings and explosions in Israel, Pakistan, India, Iraq, Afghanistan). Although planning is ongoing in US cities, many US cities have had no significant experience with such terrorist events. | The Tale of Cities project was designed to bridge this gap by bringing together key leaders from selected countries with deep experience in responding to terrorist explosive events with public health, health care, first responders, homeland security, and military representatives in the United States who are actively planning for such events, in a setting that provides considerable opportunity for sharing experiences, along with dialogue and interaction. The 6 American cities that have participated in these workshops and conferences are New York, Washington, Boston, Chicago, Los Angeles, and San Francisco; these cities would be considered potentially high risk, and all are actively engaged in preparedness and response planning. The selected foreign participants, all of whom had critical leadership roles in responding to major terrorist explosive attacks, have had a range of responsibilities including the chief superintendent for the London police, New Scotland Yard for the London train/bus bombings of 2005; emergency medical services (EMS) and hospital clinical leads for the Madrid train bombings of 2004; the director general of the Pakistan Ministry of Health; the former surgeon general of the Israel Defense Forces Home Front Command; and several clinical hospital and trauma center leads for terrorist attacks in New Delhi and Mumbai, India (a complete list is provided in the Acknowledgments).

STUDY OBJECTIVE: We developed recommendations for antidote stocking at hospitals that provide emergency care. METHODS: An expert panel representing diverse perspectives (clinical pharmacology, clinical toxicology, critical care medicine, clinical pharmacy, emergency medicine, internal medicine, pediatrics, poison centers, pulmonary medicine, and hospital accreditation) was formed to create recommendations for antidote stocking. Using a standardized summary of the medical literature, the primary reviewer for each antidote proposed guidelines for antidote stocking to the full panel. The panel used a formal iterative process to reach their recommendation for the quantity of an antidote that should be stocked and the acceptable period for delivery of each antidote. RESULTS: The panel recommended consideration of 24 antidotes for stocking. The panel recommended that 12 of the antidotes be available for immediate administration on patient arrival. In most hospitals, this period requires that the antidote be stocked in the emergency department. Another 9 antidotes were recommended for availability within 1 hour of the decision to administer, allowing the antidote to be stocked in the hospital pharmacy if the hospital has a mechanism for prompt delivery of antidotes. The panel identified additional antidotes that should be stocked by the hospital but are not usually needed within the first hour of treatment. The panel recommended that each hospital perform a formal antidote hazard vulnerability assessment to determine the need for antidote stocking in that hospital. CONCLUSION: The antidote expert recommendations provide a tool to be used in creating practices for appropriate and adequate antidote stocking in hospitals that provide emergency care.