Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
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Assessing mental health effects of eastern kentucky households after the state's deadliest flood: Using a Community Assessment for Public Health Emergency Response (CASPER)
Johnson O , Balasuriya L , Riley T , Lockard AS , Raleigh A , Ellis M , Schnall AH , Hanchey A , Thoroughman D . Disaster Med Public Health Prep 2025 18 e331 ![]() OBJECTIVES: On July 28, 2022, eastern Kentucky experienced the state's deadliest flood in recorded history. In response to ongoing mental health concerns from community members who survived the flood, local health department directors in affected communities requested technical assistance from the Kentucky Department for Public Health and the Centers for Disease Control and Prevention. METHODS: Two simultaneous Community Assessments for Public Health Emergency Response (CASPERs) were conducted 6 weeks after the flood. Four counties were assessed in each CASPER. EpiInfo7 was used to calculate the unweighted and weighted frequencies and percentages to estimate the number and percentage of households with a particular response in each CASPER. RESULTS: Approximately a third (30.5%) of households in CASPER 1 and approximately 40% of households in CASPER 2 reported experiencing ≥1 mental health problems. Individual-level mental health questions from a modified 3-stage CASPER found approximately 15% of persons in both CASPERs reported a Patient Health Questionnaire-2 (PHQ-2) score ≥3 and approximately 20% of persons in both CASPERs reported Generalized Anxiety Disorder-2 (GAD-2) score ≥3. CONCLUSIONS: These findings indicated households experienced mental health problems after the flood. Depression and anxiety were prevalent among persons living in flood-affected areas. If ever needed, households preferred to receive mental health services in-person and locally. |
Experiences of communities living in shelters during the 2022 Eastern Kentucky floods
Balasuriya L , Johnson O , Riley T , Lockard AS , McManus P , Raleigh A , Ellis M , Schnall AH , Hanchey A , Darling S , Bolen K , Thoroughman D . Disaster Med Public Health Prep 2024 18 e309 BACKGROUND: On July 28, 2022, floods in eastern Kentucky displaced over 600 individuals. With the goal of understanding mental health needs of affected families, we surveyed households living in flood evacuation shelters after the 2022 Kentucky floods. METHODS: Families experiencing displacement from the 2022 Kentucky floods currently living in three different temporary shelter locations were surveyed via convenience sampling. A rapid community needs assessment involving in-person interviews using modified two stage cluster methodology (CASPER) was conducted between September 6-9, 2022. RESULTS: Teams conducted 61 household interviews. Since the flood, 27.7% reported that their household received services from behavioral health and 19.6% received grief counseling. Experiencing agitation (36.7%), difficulty concentrating (47.5%), nightmares (62.3%), or suicidal thoughts/self-harm (6.6%) were reported by households surveyed. Over one-fourth (27.0%) of individuals surveyed reported being depressed nearly every day. Over 20% reported anhedonia (inability to feel pleasure) nearly every day. Over 75% of individuals surveyed reported being anxious several days or more over the last two weeks. Over one-third of individuals (34.0%) reported being unable to stop worrying nearly every day. Of those individuals surveyed, 36.1% reported barriers to mental health services. CONCLUSIONS: Symptoms of depressed mood, anhedonia, anxiety, and nightmares were prevalent in displaced families six weeks after the 2022 Kentucky floods. Providing and encouraging access to mental health services are important priorities during disaster recovery. |
The private well water climate impact index: Characterization of community-level climate-related hazards and vulnerability in the continental United States
Peer K , Hubbard B , Monti M , Kelen PV , Werner AK . Sci Total Environ 2024 177409 BACKGROUND: Private wells use groundwater as their source and their drinking water quality is unregulated in the United States at the federal level. Due to the lack of water quality regulations, those reliant on private wells have the responsibility of ensuring that the water is safe to drink. Where extreme weather is projected to increase with climate change, contamination due to climate-related hazards adds further layers of complexity for those relying on private wells. We sought to characterize community-level climate-related hazards and vulnerability for persons dependent on private wells in the continental United States (CONUS). Additional objectives of this work were to quantify the burden to private well water communities by climate regions and demographic groups. METHODS: Grounded in the latest climate change framework and private well water literature, we created the Private Well Water Climate Impact Index (PWWCII). We searched the literature and identified nationally consistent, publicly available, sub-county data to build Overall, Drought, Flood, and Wildfire PWWCIIs at the national and state scales. We adapted the technical construction of this relative index from the California Communities Environmental Health Screening Tool (CalEnviroScreen 4.0). RESULTS: The distribution of climate-related impact census tracts varied across CONUS by nationally-normed PWWCII type. Compared to the Southeast where the majority of the 2010 estimated U.S. private well water population lived, the estimated persons dependent upon private well water living in the West had an increased odds of living in higher impact census tracts for the Overall, Drought, and Wildfire PWWCIIs across CONUS. Compared to non-Hispanic White persons, non-Hispanic American Indian and Alaska Native (AI/AN) persons had an increased odds of living in higher impact census tracts for all four PWWCII types across CONUS. CONCLUSIONS: The PWWCII fills a gap as it provides a baseline understanding of potential climate-related impacts to communities reliant on private well water. |
Understanding natural disaster or weather-related drowning deaths among children
Hillers GM , Joy SC , Chatham-Stephens K , Collier A , Gentry B , Bélanger-Giguère K , Clemens T . Pediatrics 2024 154 OBJECTIVES: Drowning is the leading cause of death during flood disasters. Little is known about these deaths. Child death review teams review details of child deaths to understand circumstances and risk factors to inform prevention. METHODS: Using data entered in 2005 to 2021 for children ages 0 to 17 years from the National Fatality Review-Case Reporting System, we identified 130 drowning deaths directly attributed to natural disaster or weather incidents, and 14 deaths indirectly attributed to these incidents. Frequencies, proportions, and χ2 statistics were used to describe selected measures and compare with other drowning deaths. RESULTS: Children who drowned as a direct result of a natural disaster- or weather-related incident were more likely to be aged >4 years (81% vs 40%, P < .001) and located in a rural or frontier setting (63% vs 30%, P < .001). They were more likely to be supervised at the time of the incident (61% vs 38%, P < .001), and it was more likely for additional children (35% vs 5%, P < .001) or adults (33% vs 3%, P < .001) to have perished. The indirect deaths were commonly a result of damage to protective barriers. CONCLUSIONS: The characteristics of natural disaster- or weather-related drowning deaths among children differ from other drowning deaths. Natural disaster- or weather-related drowning may warrant tailored drowning prevention strategies. Improved surveillance of all water-related deaths may be a proactive action leading to the development of these prevention strategies, whereas poststorm remediation of protective barriers can be used as a reactive prevention after a storm has passed. |
Wastewater surveillance for influenza A virus and H5 subtype concurrent with the highly pathogenic avian influenza A(H5N1) virus outbreak in cattle and poultry and associated human cases - United States, May 12-July 13, 2024
Louis S , Mark-Carew M , Biggerstaff M , Yoder J , Boehm AB , Wolfe MK , Flood M , Peters S , Stobierski MG , Coyle J , Leslie MT , Sinner M , Nims D , Salinas V , Lustri L , Bojes H , Shetty V , Burnor E , Rabe A , Ellison-Giles G , Yu AT , Bell A , Meyer S , Lynfield R , Sutton M , Scholz R , Falender R , Matzinger S , Wheeler A , Ahmed FS , Anderson J , Harris K , Walkins A , Bohra S , O'Dell V , Guidry VT , Christensen A , Moore Z , Wilson E , Clayton JL , Parsons H , Kniss K , Budd A , Mercante JW , Reese HE , Welton M , Bias M , Webb J , Cornforth D , Santibañez S , Soelaeman RH , Kaur M , Kirby AE , Barnes JR , Fehrenbach N , Olsen SJ , Honein MA . MMWR Morb Mortal Wkly Rep 2024 73 (37) 804-809 ![]() ![]() As part of the response to the highly pathogenic avian influenza A(H5N1) virus outbreak in U.S. cattle and poultry and the associated human cases, CDC and partners are monitoring influenza A virus levels and detection of the H5 subtype in wastewater. Among 48 states and the District of Columbia that performed influenza A testing of wastewater during May 12-July 13, 2024, a weekly average of 309 sites in 38 states had sufficient data for analysis, and 11 sites in four states reported high levels of influenza A virus. H5 subtype testing was conducted at 203 sites in 41 states, with H5 detections at 24 sites in nine states. For each detection or high level, CDC and state and local health departments evaluated data from other influenza surveillance systems and partnered with wastewater utilities and agriculture departments to investigate potential sources. Among the four states with high influenza A virus levels detected in wastewater, three states had corresponding evidence of human influenza activity from other influenza surveillance systems. Among the 24 sites with H5 detections, 15 identified animal sources within the sewershed or adjacent county, including eight milk-processing inputs. Data from these early investigations can help health officials optimize the use of wastewater surveillance during the upcoming respiratory illness season. |
Comparison of tuberculin skin testing and interferon-γ release assays in predicting tuberculosis disease
Ayers T , Hill AN , Raykin J , Mohanty S , Belknap RW , Brostrom R , Khurana R , Lauzardo M , Miller TL , Narita M , Pettit AC , Pyan A , Salcedo KL , Polony A , Flood J . JAMA Netw Open 2024 7 (4) e244769 IMPORTANCE: Elimination of tuberculosis (TB) disease in the US hinges on the ability of tests to detect individual risk of developing disease to inform prevention. The relative performance of 3 available TB tests-the tuberculin skin test (TST) and 2 interferon-γ release assays (IGRAs; QuantiFERON-TB Gold In-Tube [QFT-GIT] and SPOT.TB [TSPOT])-in predicting TB disease development in the US remains unknown. OBJECTIVE: To compare the performance of the TST with the QFT-GIT and TSPOT IGRAs in predicting TB disease in high-risk populations. DESIGN, SETTING, AND PARTICIPANTS: This prospective diagnostic study included participants at high risk of TB infection (TBI) or progression to TB disease at 10 US sites between 2012 and 2020. Participants of any age who had close contact with a case patient with infectious TB, were born in a country with medium or high TB incidence, had traveled recently to a high-incidence country, were living with HIV infection, or were from a population with a high local prevalence were enrolled from July 12, 2012, through May 5, 2017. Participants were assessed for 2 years after enrollment and through registry matches until the study end date (November 15, 2020). Data analysis was performed in June 2023. EXPOSURES: At enrollment, participants were concurrently tested with 2 IGRAs (QFT-GIT from Qiagen and TSPOT from Oxford Immunotec) and the TST. Participants were classified as case patients with incident TB disease when diagnosed more than 30 days from enrollment. MAIN OUTCOMES AND MEASURES: Estimated positive predictive value (PPV) ratios from generalized estimating equation models were used to compare test performance in predicting incident TB. Incremental changes in PPV were estimated to determine whether predictive performance significantly improved with the addition of a second test. Case patients with prevalent TB were examined in sensitivity analysis. RESULTS: A total of 22 020 eligible participants were included in this study. Their median age was 32 (range, 0-102) years, more than half (51.2%) were male, and the median follow-up was 6.4 (range, 0.2-8.3) years. Most participants (82.0%) were born outside the US, and 9.6% were close contacts. Tuberculosis disease was identified in 129 case patients (0.6%): 42 (0.2%) had incident TB and 87 (0.4%) had prevalent TB. The TSPOT and QFT-GIT assays performed significantly better than the TST (PPV ratio, 1.65 [95% CI, 1.35-2.02] and 1.47 [95% CI, 1.22-1.77], respectively). The incremental gain in PPV, given a positive TST result, was statistically significant for positive QFT-GIT and TSPOT results (1.64 [95% CI, 1.40-1.93] and 1.94 [95% CI, 1.65-2.27], respectively). CONCLUSIONS AND RELEVANCE: In this diagnostic study assessing predictive value, IGRAs demonstrated superior performance for predicting incident TB compared with the TST. Interferon-γ release assays provided a statistically significant incremental improvement in PPV when a positive TST result was known. These findings suggest that IGRA performance may enhance decisions to treat TBI and prevent TB. |
Tuberculosis diagnostic delays and treatment outcomes among patients with COVID-19, California, USA, 2020
Han E , Nabity SA , Dasgupta-Tsinikas S , Guevara RE , Moore M , Kadakia A , Henry H , Cilnis M , Buhain S , Chitnis A , Chakrabarty M , Ky A , Nguyen Q , Low J , Jain S , Higashi J , Barry PM , Flood J . Emerg Infect Dis 2024 30 (1) 136-140 We assessed tuberculosis (TB) diagnostic delays among patients with TB and COVID-19 in California, USA. Among 58 persons, 43% experienced TB diagnostic delays, and a high proportion (83%) required hospitalization for TB. Even when viral respiratory pathogens circulate widely, timely TB diagnostic workup for at-risk persons remains critical for reducing TB-related illness. |
Notes from the field: Supply interruptions of first- and second-line oral drugs to treat tuberculosis during the previous 12 months - California, January-March, 2023
Nabity SA , Agraz-Lara R , Bravo A , Benjamin R , Fong V , Lam CK , Keh C , Mase S , Flood J . MMWR Morb Mortal Wkly Rep 2024 72 (5253) 1390-1391 Tuberculosis (TB) drug supply disruptions are a recurring concern in the United States (1). Contributors to these disruptions include loss of manufacturers to the U.S. market, inefficient supply chains, and lack of active ingredients available for import.* The last severe U.S. TB drug shortage occurred in 2012, when isoniazid (INH) was temporarily unavailable for several months (2). INH and rifampin (RIF) are the cornerstones for treatment of drug-susceptible TB, and rifapentine (RPT), a long acting rifamycin, has been incorporated into shorter first-line regimens† to treat both latent TB infection (LTBI) (3) and TB disease§ (4). In recent years, the U.S. supply of several TB drugs has again been disrupted. The Food and Drug Administration has declared shortages of RPT (on March 25, 2020), RIF (on December 22, 2021), and INH (on May 17, 2023).¶ Approximately one fifth of all U.S. TB cases are reported from California (5). TB drug procurement is decentralized among the state’s 61 local TB programs,** mirroring the decentralization among U.S. states and territories. The California Department of Public Health and the California TB Controllers Association assessed the impact of the shortage on California’s TB programs. |
Incidence of TB disease among persons who use drugs in California
Frazier C , Nabity SA , Flood J . Int J Tuberc Lung Dis 2023 27 (10) 781-783 TB may disproportionately affect persons who use drugs (PWUD),1–3 but the TB incidence rate among PWUD has not been estimated in the United States (U.S). California has the highest TB case burden and the highest frequency of current drug use: in 2019, 23.5% of incident TB cases in the U.S. occurred in California (5.3/100,000), and the state has an estimated 4.7 million PWUD.4,5 A better understanding of the intersection between drug use and TB will promote equity-informed interventions that account for social aspects of TB risk.6 In the study presented here, we estimate the incidence of TB disease among PWUD in California, describe the characteristics of TB patients who use drugs, and evaluate drug use as a risk factor for adverse treatment outcomes. | | We analyzed surveillance data of incident TB disease reported to the California Department of Public Health (CDPH; Richmond, CA, USA) TB registry in persons ≥12 years of age from 2015–2019. The denominator population of PWUD (who reported drug use in the past year) was derived from the National Survey of Drug Use and Mental Health (NSDUH) of noninstitutionalized civilians who were aged ≥12 years and resided in fixed-address households. We accessed prevalence estimates derived from the NSDUH through the Restricted Online Data Access System.7 NSDUH prevalence estimates are based on 2 years of pooled sample data and, because each year had two estimates (e.g., for 2018 data for 2017–2018 and 2018–2019), we used the average for the annual denominator value. We considered persons with TB who use drugs (PWUD-TB) as patients who reported any injecting or noninjecting drug use in the year preceding TB diagnosis. We used the NSDUH past-year variable ‘Any illicit drug use’ as the PWUD population denominator. We determined whether cases were attributable to recent transmission using a plausible source-case algorithm that associates genetic isolates with likely TB source cases.8 We defined TB treatment noncompletion as premature treatment cessation due to loss to follow-up, refusal, or nonadherence. We defined treatment extension as the completion of an appropriate regimen in more than 12 months, excluding patients with multidrug-resistant TB. We calculated the annual incidence of TB disease among PWUD aged ≥12 years from 2015 to 2019 by dividing the annual frequency of PWUD-TB by the corresponding NSDUH prevalence estimate of past-year drug use for California, stratified by place of birth. We used the χ2 test for comparison of categorical variables and the Wilcoxon rank-sum test for continuous variables (α = 0.05). Finally, we constructed multivariable log-binomial models to determine the independent association of drug use with treatment extension and treatment noncompletion (α = 0.05). This activity was determined to meet the requirements of public health surveillance by the Centers for Disease Control and Prevention (CDC) as defined in 45 CFR 46.102(l)(2), and thus did not require institutional board review. CDPH also determined this work to be non-research. Informed consent was not required. |
Changes in spina bifida lesion level after folic acid fortification in the US
Mai CT , Evans J , Alverson CJ , Yue X , Flood T , Arnold K , Nestoridi E , Denson L , Adisa O , Moore CA , Nance A , Zielke K , Rice S , Shan X , Dean JH , Ethen M , Hansen B , Isenburg J , Kirby RS . Obstet Gynecol Surv 2023 78 (4) 189-191 following which a substantial decline in neural tube defects at birth occurred. Studies also have suggested that lesion levels in cases of spina bifida are directly affected by folic acid fortification. Locations of such lesions contribute to outcome and prognosis of the condition. When compared with sacral and lower lumbar lesions, the greatest risks of disability and mortality are associated with cervical, thoracic, and high lumbar lesions. Individuals with thoracic or high lumbar lesions require a wheelchair and orthosis in adulthood for ambulation 70% to 99% of the time. As lesion levels therefore determine function and overall quality of life, assessment of whether folic acid fortification significantly impacts lesion levels is important. This study aimed to examine patterns of lesion levels in spina bifida following mandatory folic acid fortification in the United States. | | A call was issued by the National Birth Defects Prevention Network for State Birth Defects Programs' spina bifida lesion data before and after fortification mandate. To be eligible, programs needed to provide verbatim medical record text descriptions of spina bifida diagnoses. The 6 participating programs were from the states of Arizona, California (covering 8 counties), Oklahoma, South Carolina, Utah, and metropolitan Atlanta (Georgia). Birth years examined included the prefortification years of 1992–1996 and the postfortification period of 1999–2016. Central processing and analysis occurred as each program provided case-level data (deidentified) based on the exclusion/inclusion criteria to the Centers for Disease Control and Prevention. Medical and record text description of the spina bifida diagnosis and codes were the basis of case information, using the International Classification of Diseases, Ninth Edition, Clinical Modification or the Centers for Disease Control and Prevention and Prevention/British Pediatric Association coding system. Types of spina bifida included in the study were spinal rachischisis, myelomeningocele/meningomyelocele, meningocele, and spina bifida not otherwise specified. Cases excluded were cranial lesions, lipomyelomeningocele/lipomeningomyelocele, dysraphism related to split cord malformations, and spina bifida occulta. | | Lesion-level information was provided based on the highest lesion using nonradiographic clinical assessment. Classification of severe upper-level lesions included cervical or thoracic lesion-level cases, whereas lower-level lesions included cases with lumbar or sacral. The study defined open lesion as leaking spinal fluid or membrane covered only, whereas closed lesions were defined as having intact-skin covering and lacking fluid leakage. Spina bifida cases were considered isolated when no other anomalies related to the primary cause of abnormal neural tube closure were present (nor were secondary to the neurologic complications caused by it). Examining associations between fortification period and the outcomes (lesion level and spina bifida) occurred using the generalized estimating approach to logistic (case severity analyses) and log-linear (PR analyses) regression, which accounted for clustering of cases by state. | | From a total of 7,816,062 live births, 2593 cases of spina bifida met the case inclusion criteria. Overall, 573 cases were included in the prefortification period (birth prevalence of 4.07 per 10,000 live births), and 2020 cases were included in the postfortification period (birth prevalence of 3.15 per 10,000 live births). Overall, 80.2% of cases resulted in live births, and most cases of spina bifida involved lower-level lesions (81.3%). Most lesions were lumbar, and the proportions prefortification and postfortification were 61.4% and 72.0%, respectively, with a higher proportion of lumbar lesions seen in the postfortification period. The odds of upper-level to lower-level lesions decreased by 70% after fortification. The spina bifida live birth prevalence decreased significantly and remained consistently low throughout the early, mid, and recent postfortification periods. The study found a 72% decrease overall in prevalence of severe, upper-level lesions following mandatory folic acid fortification in the United States. | | The limitations of the study include the shortcomings of relying on diagnostic codes, the difficulty of coding lesion level using the International Classification of Diseases, Ninth Edition, Clinical Modification coding scheme, the lack of recorded functional outcome for children in medical records (indirect indicators of severity), the lack of preconception and prenatal folic acid data, and the possible variation of case ascertainment within programs contributing studies. A major study strength is its potential to address additional important questions regarding epidemiology and spina bifida. The classification of spinal defects is complex, and this study adds to the limited distribution data that exist for prefortification and postfortification subtypes. | | The study concluded that the overall prevalence of severe upper-level lesions in spina bifida cases experienced a steep reduction following mandatory folic acid fortification institution within the United States, whereas no change in the prevalence of less severe lower-level lesions took place. Additional examinations are warranted to better understand the magnitude and mechanism of spina bifida severity in relation to folic acid intake. |
Correction: Building capacity for injury prevention: a process evaluation of a replication of the Cardiff Violence Prevention Programme in the Southeastern USA
Mercer Kollar LM , Sumner SA , Bartholow B , Wu DT , More JC , Mays EW , Atkins EV , Fraser DA , Flood CE , Shepherd JP . Inj Prev 2021 27 (1) 101 The article is previously published with incorrect and missing information. The updates are as follows: | | The last sentence in the third paragraph of ‘Building hospital capacity for data collection’ in ‘Results’ section has been updated as ‘A one-way ANOVA revealed a significant difference between April 2015 and April 2016 triage times, F(1,2734)=5.33, p=0.02. Triage times were on average 16.2 s longer in April 2016 compared with April 2015. No post-hoc analyses were done to control for other, non-CMST-related changes that occurred during the triage process (eg, additional triage screen) from April 2015 to April 2016.’ | Below statement has been added in the sixth paragraph of the ‘Discussion’ section after ‘Nurse participation in the satisfaction … a different US hospital.’ | The statistically significant increase in triage time of 16.2 s, which is unlikely to be clinically significant, may reflect other non-CMST-related triage process changes - such as addition of another triage screen - that were not accounted for in the analyses. |
Association of area-based socioeconomic measures with tuberculosis incidence in California
Bakhsh Y , Readhead A , Flood J , Barry P . J Immigr Minor Health 2022 1-10 We assessed the association of area-based socio-economic status (SES) measures with tuberculosis (TB) incidence in California. We used TB disease data for 2012-2016 (n=9901), population estimates, and SES measures to calculate incidence rates, rate ratios, and 95% confidence intervals (95% CI) by SES and birth country. SES was measured by census tract and was categorized by quartiles for education, crowding, and the California Healthy Places Index (HPI)and by specific cutoffs for poverty. The lowest SES areas defined by education, crowding, poverty, and HPI had 39%, 40%, 41%, and 33% of TB cases respectively. SES level was inversely associated with TB incidence across all SES measures and birth countries. TB rates were 3.2 (95% CI 3.0-3.4), 2.1 (95% CI 1.9-2.2), 3.6 (95% CI 3.3-3.8), and 2.0 (95% CI 1.9-2.1) times higher in lowest SES areas vs. highest SES areas as defined by education, crowding, poverty and HPI respectively. Area-based SES measures are associated with TB incidence in California. This information could inform TB prevention efforts in terms of materials, partnerships, and prioritization. |
Changes in spina bifida lesion level after folic acid fortification in the United States
Mai CT , Evans J , Alverson CJ , Yue X , Flood T , Arnold K , Nestoridi E , Denson L , Adisa O , Moore CA , Nance A , Zielke K , Rice S , Shan X , Dean JH , Ethen M , Hansen B , Isenburg J , Kirby RS . J Pediatr 2022 249 59-66 e1 OBJECTIVE: To assess whether the severity of cases of spina bifida changed after mandatory folic acid fortification in the United States. STUDY DESIGN: Six active population-based birth defects programs provided data on cases of spina bifida for 1992-1996 (pre-fortification) and 1999-2016 (post-fortification); programs contributed varying years of data. Case information included both medical record verbatim text description of the spina bifida diagnosis and spina bifida codes (International Classification of Diseases, Clinical Modification, or a modified birth defects surveillance coding system). Comparing pre- with post-fortification periods, adjusted odds ratios (aOR) for case severity [upper-level (cervical, thoracic) to lower-level (lumbar, sacral) lesion cases] and prevalence ratios (PR) were estimated. RESULTS: A total of 2,593 cases of spina bifida (7,816,062 live births) met inclusion criteria, with 573 and 2,020 cases from the pre- and post-fortification periods respectively. Case severity decreased 70% (aOR: 0.30; 95% confidence interval [CI] 0.26, 0.35) between the fortification periods. The decrease was most pronounced for non-Hispanic white mothers. Overall spina bifida prevalence declined 23% (PR=0.77, 95% CI=0.71, 0.85), with similar reduction seen across early, mid, and recent post-fortification periods. A statistically significant decrease in upper-level lesions occurred in the post-fortification compared with pre-fortification periods (PR=0.28, 95% CI=0.22, 0.34), while prevalence of lower-level lesions remained relatively similar (PR: 0.94, 95% CI: 0.84, 1.05). CONCLUSIONS: Severity of cases of spina bifida decreased after mandatory folic acid fortification in the United States. Further examination is warranted to understand better the potential effect of folic acid on spina bifida severity. |
Flooding and emergency department visits: Effect modification by the CDC/ATSDR Social Vulnerability Index
Ramesh B , Jagger MA , Zaitchik B , Kolivras KN , Swarup S , Deanes L , Hallisey E , Sharpe JD , Gohlke JM . Int J Disaster Risk Reduct 2022 76 The Centers for Disease Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry (ATSDR) Social Vulnerability Index (SVI) is a census-based metric that includes 15 socioeconomic and demographic factors split into four themes relevant to disaster planning, response, and recovery. Using CDC/ATSDR SVI, health outcomes, and remote sensing data, we sought to understand the differences in the occurrence of overall and cause-specific emergency department (ED) visits before and after a 2017 flood event in Texas following Hurricane Harvey, modified by different levels of social vulnerability. We used a controlled before-after study design to estimate the association between flooding and overall and cause-specific ED visits after adjusting for the baseline period, seasonal trends, and individual-level characteristics. We estimated rate ratios stratified by CDC/ATSDR SVI quartiles (overall and 4 themes separately) and tested for the presence of effect modification. Positive effect modification was found such that total ED visits from flooded census tracts with moderate, high, and very high levels of social vulnerability were less reduced compared to tracts with the least vulnerability during flooding and the month following the flood event. The CDC/ATSDR SVI socioeconomic status theme, household composition and disability theme, and housing and transportation type theme explained this result. We found predominantly negative effect modification with higher ED visits among tracts with the least vulnerability for ED visits related to insect bites, dehydration, and intestinal infectious diseases. © 2022 |
Invasive mould infections in patients from floodwater- damaged areas after Hurricane Harvey - a closer look at an immunocompromised cancer patient population
Wurster S , Paraskevopoulos T , Toda M , Jiang Y , Tarrand JJ , Williams S , Chiller TM , Jackson BR , Kontoyiannis DP . J Infect 2022 84 (5) 701-709 OBJECTIVES: Extensive floodwater damage following hurricane Harvey raised concerns of increase in invasive mould infections (IMIs), especially in immunocompromised patients. To more comprehensively characterize the IMI landscape pre- and post- Harvey, we used a modified, less restrictive clinical IMI (mcIMI) definition by incorporating therapeutic-intent antifungal drug prescriptions combined with an expanded list of host and clinical features. METHODS: We reviewed 103 patients at MD Anderson Cancer Center (Houston, Texas), who lived in Harvey-affected counties and had mould-positive cultures within 12 months pre-/post-Harvey (36 and 67 patients, respectively). Cases were classified as proven or probable IMI (EORTC/MSG criteria), mcIMI, or colonization/ contamination. We also compared in-hospital mortality and 42- day survival outcomes of patients with mcIMI pre-/ post- Harvey. RESULTS: The number of patients with mould- positive cultures from Harvey- affected counties almost doubled from 36 pre- Harvey to 67 post- Harvey (p < 0.01). In contrast, no significant changes in (mc) IMI incidence post- Harvey nor changes in the etiological mould genera were noted. However, patients with mcIMIs from flood affected areas had significantly higher in- hospital mortality (p = 0.01). CONCLUSIONS: We observed increased colonization but no excess cases of (mc)IMIs in immunosuppressed cancer patients from affected areas following a large flooding event such as hurricane Harvey. |
A Trans-Governmental Collaboration to Independently Evaluate SARS-CoV-2 Serology Assays.
Pinto LA , Shawar RM , O'Leary B , Kemp TJ , Cherry J , Thornburg N , Miller CN , Gallagher PS , Stenzel T , Schuck B , Owen SM , Kondratovich M , Satheshkumar PS , Schuh A , Lester S , Cassetti MC , Sharpless NE , Gitterman S , Lowy DR . Microbiol Spectr 2022 10 (1) e0156421 The emergence of SARS-CoV-2 created a crucial need for serology assays to detect anti-SARS-CoV-2 antibodies, which led to many serology assays entering the market. A trans-government collaboration was created in April 2020 to independently evaluate the performance of commercial SARS-CoV-2 serology assays and help inform U.S. Food and Drug Administration (FDA) regulatory decisions. To assess assay performance, three evaluation panels with similar antibody titer distributions were assembled. Each panel consisted of 110 samples with positive (n = 30) serum samples with a wide range of anti-SARS-CoV-2 antibody titers and negative (n = 80) plasma and/or serum samples that were collected before the start of the COVID-19 pandemic. Each sample was characterized for anti-SARS-CoV-2 antibodies against the spike protein using enzyme-linked immunosorbent assays (ELISA). Samples were selected for the panel when there was agreement on seropositivity by laboratories at National Cancer Institute's Frederick National Laboratory for Cancer Research (NCI-FNLCR) and Centers for Disease Control and Prevention (CDC). The sensitivity and specificity of each assay were assessed to determine Emergency Use Authorization (EUA) suitability. As of January 8, 2021, results from 91 evaluations were made publicly available (https://open.fda.gov/apis/device/covid19serology/, and https://www.cdc.gov/coronavirus/2019-ncov/covid-data/serology-surveillance/serology-test-evaluation.html). Sensitivity ranged from 27% to 100% for IgG (n = 81), from 10% to 100% for IgM (n = 74), and from 73% to 100% for total or pan-immunoglobulins (n = 5). The combined specificity ranged from 58% to 100% (n = 91). Approximately one-third (n = 27) of the assays evaluated are now authorized by FDA for emergency use. This collaboration established a framework for assay performance evaluation that could be used for future outbreaks and could serve as a model for other technologies. IMPORTANCE The SARS-CoV-2 pandemic created a crucial need for accurate serology assays to evaluate seroprevalence and antiviral immune responses. The initial flood of serology assays entering the market with inadequate performance emphasized the need for independent evaluation of commercial SARS-CoV-2 antibody assays using performance evaluation panels to determine suitability for use under EUA. Through a government-wide collaborative network, 91 commercial SARS-CoV-2 serology assay evaluations were performed. Three evaluation panels with similar overall antibody titer distributions were assembled to evaluate performance. Nearly one-third of the assays evaluated met acceptable performance recommendations, and two assays had EUAs revoked and were removed from the U.S. market based on inadequate performance. Data for all serology assays evaluated are available at the FDA and CDC websites (https://open.fda.gov/apis/device/covid19serology/, and https://www.cdc.gov/coronavirus/2019-ncov/covid-data/serology-surveillance/serology-test-evaluation.html). |
Sociodemographic Characteristics, Comorbidities, and Mortality Among Persons Diagnosed With Tuberculosis and COVID-19 in Close Succession in California, 2020.
Nabity SA , Han E , Lowenthal P , Henry H , Okoye N , Chakrabarty M , Chitnis AS , Kadakia A , Villarino E , Low J , Higashi J , Barry PM , Jain S , Flood J . JAMA Netw Open 2021 4 (12) e2136853 IMPORTANCE: Tuberculosis (TB) and COVID-19 are respiratory diseases that disproportionately occur among medically underserved populations; little is known about their epidemiologic intersection. OBJECTIVE: To characterize persons diagnosed with TB and COVID-19 in California. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional analysis of population-based public health surveillance data assessed the sociodemographic, clinical, and epidemiologic characteristics of California residents who were diagnosed with TB (including cases diagnosed and reported between September 3, 2019, and December 31, 2020) and COVID-19 (including confirmed cases based on positive results on polymerase chain reaction tests and probable cases based on positive results on antigen assays reported through February 2, 2021) in close succession compared with those who were diagnosed with TB before the COVID-19 pandemic (between January 1, 2017, and December 31, 2019) or diagnosed with COVID-19 alone (through February 2, 2021). This analysis included 3 402 713 California residents with COVID-19 alone, 6280 with TB before the pandemic, and 91 with confirmed or probable COVID-19 diagnosed within 120 days of a TB diagnosis (ie, TB/COVID-19). EXPOSURES: Sociodemographic characteristics, medical risk factors, factors associated with TB severity, and health equity index. MAIN OUTCOMES AND MEASURES: Frequency of reported successive TB and COVID-19 (TB/COVID-19) diagnoses within 120 days, frequency of deaths, and age-adjusted mortality rates. RESULTS: Among the 91 persons with TB/COVID-19, the median age was 58.0 years (range, 3.0-95.0 years; IQR, 41.0-73.0 years); 52 persons (57.1%) were male; 81 (89.0%) were born outside the US; and 28 (30.8%) were Asian or Pacific Islander, 4 (4.4%) were Black, 55 (60.4%) were Hispanic or Latino, 4 (4.4%) were White. The frequency of reported COVID-19 among those who received a TB diagnosis between September 3, 2019, and December 31, 2020, was 225 of 2210 persons (10.2%), which was similar to that of the general population (3 402 804 of 39 538 223 persons [8.6%]). Compared with persons with TB before the pandemic, those with TB/COVID-19 were more likely to be Hispanic or Latino (2285 of 6279 persons [36.4%; 95% CI, 35.2%-37.6%] vs 55 of 91 persons [60.4%; 95% CI, 49.6%-70.5%], respectively; P < .001), reside in low health equity census tracts (1984 of 6027 persons [32.9%; 95% CI, 31.7%-34.1%] vs 40 of 89 persons [44.9%; 95% CI, 34.4%-55.9%]; P = .003), live in the US longer before receiving a TB diagnosis (median, 19.7 years [IQR, 7.2-32.3 years] vs 23.1 years [IQR, 15.2-31.5 years]; P = .03), and have diabetes (1734 of 6280 persons [27.6%; 95% CI, 26.5%-28.7%] vs 42 of 91 persons [46.2%; 95% CI, 35.6%-56.9%]; P < .001). The frequency of deaths among those with TB/COVID-19 successively diagnosed within 30 days (8 of 34 persons [23.5%; 95% CI, 10.8%-41.2%]) was more than twice that of persons with TB before the pandemic (631 of 5545 persons [11.4%; 95% CI, 10.6%-12.2%]; P = .05) and 20 times that of persons with COVID-19 alone (42 171 of 3 402 713 persons [1.2%; 95% CI, 1.2%-1.3%]; P < .001). Persons with TB/COVID-19 who died were older (median, 81.0 years; IQR, 75.0-85.0 years) than those who survived (median, 54.0 years; IQR, 37.5-68.5 years; P < .001). The age-adjusted mortality rate remained higher among persons with TB/COVID-19 (74.2 deaths per 1000 persons; 95% CI, 26.2-122.1 deaths per 1000 persons) compared with either disease alone (TB before the pandemic: 56.3 deaths per 1000 persons [95% CI, 51.2-61.4 deaths per 1000 persons]; COVID-19 only: 17.1 deaths per 1000 persons [95% CI, 16.9-17.2 deaths per 1000 persons]). CONCLUSIONS AND RELEVANCE: In this cross-sectional analysis, TB/COVID-19 was disproportionately diagnosed among California residents who were Hispanic or Latino, had diabetes, or were living in low health equity census tracts. These results suggest that tuberculosis and COVID-19 occurring together may be associated with increases in mortality compared with either disease alone, especially among older adults. Addressing health inequities and integrating prevention efforts could avert the occurrence of concurrent COVID-19 and TB and potentially reduce deaths. |
Polycyclic aromatic hydrocarbons in Houston parks after Hurricane Harvey
Casillas GA , Johnson NM , Chiu WA , Ramirez J , McDonald TJ , Horney JA . Environ Justice 2021 14 (4) 277-287 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. |
State-level prevalence estimates of latent tuberculosis infection in the United States by medical risk factors, demographic characteristics and nativity.
Mirzazadeh A , Kahn JG , Haddad MB , Hill AN , Marks SM , Readhead A , Barry PM , Flood J , Mermin JH , Shete PB . PLoS One 2021 16 (4) e0249012 ![]() INTRODUCTION: Preventing tuberculosis (TB) disease requires treatment of latent TB infection (LTBI) as well as prevention of person-to-person transmission. We estimated the LTBI prevalence for the entire United States and for each state by medical risk factors, age, and race/ethnicity, both in the total population and stratified by nativity. METHODS: We created a mathematical model using all incident TB disease cases during 2013-2017 reported to the National Tuberculosis Surveillance System that were classified using genotype-based methods or imputation as not attributed to recent TB transmission. Using the annual average number of TB cases among US-born and non-US-born persons by medical risk factor, age group, and race/ethnicity, we applied population-specific reactivation rates (and corresponding 95% confidence intervals [CI]) to back-calculate the estimated prevalence of untreated LTBI in each population for the United States and for each of the 50 states and the District of Columbia in 2015. RESULTS: We estimated that 2.7% (CI: 2.6%-2.8%) of the U.S. population, or 8.6 (CI: 8.3-8.8) million people, were living with LTBI in 2015. Estimated LTBI prevalence among US-born persons was 1.0% (CI: 1.0%-1.1%) and among non-US-born persons was 13.9% (CI: 13.5%-14.3%). Among US-born persons, the highest LTBI prevalence was in persons aged ≥65 years (2.1%) and in persons of non-Hispanic Black race/ethnicity (3.1%). Among non-US-born persons, the highest LTBI prevalence was estimated in persons aged 45-64 years (16.3%) and persons of Asian and other racial/ethnic groups (19.1%). CONCLUSIONS: Our estimations of the prevalence of LTBI by medical risk factors and demographic characteristics for each state could facilitate planning for testing and treatment interventions to eliminate TB in the United States. Our back-calculation method feasibly estimates untreated LTBI prevalence and can be updated using future TB disease case counts at the state or national level. |
Social Vulnerability and Access of Local Medical Care During Hurricane Harvey: A Spatial Analysis
Rickless DS , Wilt GE , Sharpe JD , Molinari N , Stephens W , LeBlanc TT . Disaster Med Public Health Prep 2021 17 1-9 OBJECTIVES: When Hurricane Harvey struck the coastline of Texas in 2017, it caused 88 fatalities and over US $125 billion in damage, along with increased emergency department visits in Houston and in cities receiving hurricane evacuees, such as the Dallas-Fort Worth metroplex (DFW).This study explored demographic indicators of vulnerability for patients from the Hurricane Harvey impact area who sought medical care in Houston and in DFW. The objectives were to characterize the vulnerability of affected populations presenting locally, as well as those presenting away from home, and to determine whether more vulnerable communities were more likely to seek medical care locally or elsewhere. METHODS: We used syndromic surveillance data alongside the Centers for Disease Control and Prevention Social Vulnerability Index to calculate the percentage of patients seeking care locally by zip code tabulation area. We used this variable to fit a spatial lag regression model, controlling for population density and flood extent. RESULTS: Communities with more patients presenting for medical care locally were significantly clustered and tended to have greater socioeconomic vulnerability, lower household composition vulnerability, and more extensive flooding. CONCLUSIONS: These findings suggest that populations remaining in place during a natural disaster event may have needs related to income, education, and employment, while evacuees may have more needs related to age, disability, and single-parent household status. |
Proximity to freshwater blue space and type 2 diabetes onset: The importance of historical and economic context
Poulsen MN , Schwartz BS , DeWalle J , Nordberg C , Pollak JS , Silva J , Mercado CI , Rolka DB , Siegel KR , Hirsch AG . Landsc Urban Plann 2021 209 Salutogenic effects of living near aquatic areas (blue space) remain underexplored, particularly in non-coastal and non-urban areas. We evaluated associations of residential proximity to inland freshwater blue space with new onset type 2 diabetes (T2D) in central and northeast Pennsylvania, USA, using medical records to conduct a nested case-control study. T2D cases (n = 15,888) were identified from diabetes diagnoses, medication orders, and laboratory test results and frequency-matched on age, sex, and encounter year to diabetes-free controls (n = 79,435). We calculated distance from individual residences to the nearest lake, river, tributary, or large stream, and residence within the 100-year floodplain. Logistic regression models adjusted for community socioeconomic deprivation and other confounding variables and stratified by community type (townships [rural/suburban], boroughs [small towns], city census tracts). Compared to individuals living ≥ 1.25 miles from blue space, those within 0.25 miles had 8% and 17% higher odds of T2D onset in townships and boroughs, respectively. Among city residents, T2D odds were 38–39% higher for those living 0.25 to < 0.75 miles from blue space. Residing within the floodplain was associated with 16% and 14% higher T2D odds in townships and boroughs. A post-hoc analysis demonstrated patterns of lower residential property values with nearer distance to the region's predominant waterbody, suggesting unmeasured confounding by socioeconomic disadvantage. This may explain our unexpected findings of higher T2D odds with closer proximity to blue space. Our findings highlight the importance of historic and economic context and interrelated factors such as flood risk and lack of waterfront development in blue space research. |
Using search-constrained inverse distance weight modeling for near real-time riverine flood modeling: Harris County, Texas, USA before, during, and after Hurricane Harvey
Berens AS , Palmer T , Dutton ND , Lavery A , Moore M . Nat Hazards (Dordr) 2020 105 (1) 277-292 Flooding poses a serious public health hazard throughout the world. Flood modeling is an important tool for emergency preparedness and response, but some common methods require a high degree of expertise or may be unworkable due to poor data quality or data availability issues. The conceptually simple method of inverse distance weight modeling offers an alternative. Using stream gauges as inputs, this study interpolated stream elevation via inverse distance weight modeling under 15 different model input parameter scenarios for Harris County, Texas, USA, from August 25th to September 15th, 2017 (before, during, and after Hurricane Harvey inundated the county). A digital elevation model was used to identify areas where modeled stream elevation exceeded ground elevation, indicating flooding. Imagery and observed high water marks were used to validate the models’ outputs. There was a high degree of agreement (between 79 and 88%) between imagery and model outputs of parameterizations visually validated. Quantitative validations based on high water marks were also positive, with a Nash–Sutcliffe efficiency of in excess of.6 for all parameterizations relative to a Nash–Sutcliffe efficiency of the benchmark of 0.56. Inverse distance weight modeling offers a simple, accurate method for first-order estimations of riverine flooding in near real-time using readily available data, and outputs are robust to some alterations to input parameters. |
Policy implications of mathematical modeling of latent tuberculosis infection testing and treatment strategies to accelerate tuberculosis elimination
Marks SM , Dowdy DW , Menzies NA , Shete PB , Salomon JA , Parriott A , Shrestha S , Flood J , Hill AN . Public Health Rep 2020 135 38s-43s Tuberculosis (TB) disease is the leading cause of death globally from a single infectious organism.1 However, TB is both curable and preventable. In the United States during the past 2 decades, a national coordinated multi-agency policy response implemented in 1992, along with other influences (eg, new federal and state funding), led to a decrease in the number of TB cases reported in the United States, from 26 673 in 1992 to 9105 in 2017, a 65.9% decline.2,3 The 1992 national policy response was launched as a result of multidrug-resistant TB outbreaks that occurred during 1985-1992. That response included support for improved TB diagnostics, infection control, monitoring of TB treatment, and investigation of persons who had recent contact with persons who had infectious TB.4 Mathematical modeling of TB during 1995-2014 in the United States estimated that approximately 145 000 to 319 000 TB cases were averted, yielding societal benefits (in 2014 US dollars) of $3.1 billion to $14.5 billion.4 |
Treatment outcomes in global systematic review and patient meta-analysis of children with extensively drug-resistant tuberculosis
Osman M , Harausz EP , Garcia-Prats AJ , Schaaf HS , Moore BK , Hicks RM , Achar J , Amanullah F , Barry P , Becerra M , Chiotan DI , Drobac PC , Flood J , Furin J , Gegia M , Isaakidis P , Mariandyshev A , Ozere I , Shah NS , Skrahina A , Yablokova E , Seddon JA , Hesseling AC . Emerg Infect Dis 2019 25 (3) 441-450 Extensively drug-resistant tuberculosis (XDR TB) has extremely poor treatment outcomes in adults. Limited data are available for children. We report on clinical manifestations, treatment, and outcomes for 37 children (<15 years of age) with bacteriologically confirmed XDR TB in 11 countries. These patients were managed during 1999-2013. For the 37 children, median age was 11 years, 32 (87%) had pulmonary TB, and 29 had a recorded HIV status; 7 (24%) were infected with HIV. Median treatment duration was 7.0 months for the intensive phase and 12.2 months for the continuation phase. Thirty (81%) children had favorable treatment outcomes. Four (11%) died, 1 (3%) failed treatment, and 2 (5%) did not complete treatment. We found a high proportion of favorable treatment outcomes among children, with mortality rates markedly lower than for adults. Regimens and duration of treatment varied considerably. Evaluation of new regimens in children is required. |
Comparative modelling of tuberculosis epidemiology and policy outcomes in California
Menzies NA , Parriott A , Shrestha S , Dowdy DW , Cohen T , Salomon JA , Marks SM , Hill AN , Winston CA , Asay G , Barry P , Readhead A , Flood J , Kahn JG , Shete PB . Am J Respir Crit Care Med 2019 201 (3) 356-365 Rationale Mathematical modelling is used to understand disease dynamics, forecast trends, and inform public health prioritization. We conducted a comparative analysis of tuberculosis (TB) epidemiology and potential intervention effects in California, using three previously developed epidemiologic models of TB. Measurements and Methods We compared model results between 2005 and 2050 under a base case scenario representing current TB services, and alternative scenarios including: (i) sustained interruption of Mycobacterium tuberculosis (Mtb) transmission, (ii) sustained resolution of latent TB infection (LTBI) and TB prior to entry of new residents, and (iii) one-time targeted testing and treatment of LTBI among 25% of non-US-born individuals residing in California. Results Model estimates of TB cases and deaths in California were in close agreement over the historical period but diverged for LTBI prevalence and new Mtb infections-outcomes for which definitive data are unavailable. Between 2018 and 2050, models projected average annual declines of 0.58-1.42% in TB cases, without additional interventions. A one-time LTBI testing and treatment intervention among non-US-born residents was projected to produce sustained reductions in TB incidence. Models found prevalent Mtb infection and migration to be more significant drivers of future TB incidence than local transmission. Conclusions All models projected a stagnation in the decline of TB incidence, highlighting the need for additional interventions including greater access to LTBI diagnosis and treatment for non-US-born individuals. Differences in model results reflect gaps in historical data and uncertainty in the trends of key parameters, demonstrating the need for high-quality, up-to-date TB determinant and outcome data. |
Impact and effectiveness of state-level tuberculosis interventions in California, Florida, New York and Texas: A model-based analysis
Shrestha S , Cherng S , Hill AN , Reynolds S , Flood J , Barry PM , Readhead A , Oxtoby M , Lauzardo M , Privett T , Marks SM , Dowdy DW . Am J Epidemiol 2019 188 (9) 1733-1741 The incidence of tuberculosis (TB) disease in the United States has stabilized, and additional interventions are needed to make progress toward TB elimination. But the impact of such interventions depends on local demography and heterogeneity in populations at risk. Using state-level individual-based TB transmission models, calibrated to California, Florida, New York, and Texas, we modeled two TB interventions: (i) Increased targeted testing and treatment (TTT) of high-risk populations, including people who are non-US-born, diabetic, HIV-positive, homeless, or incarcerated; and (ii) Enhanced TB contact investigation (ECI), including higher completion of preventive therapy. For each intervention, we projected reductions in active TB incidence over 10 years (2016-2026) and numbers needed to screen and treat to avert one case. TTT delivered to half of the non-US-born adult population could lower TB incidence by 19.8%-26.7% over ten years. TTT delivered to smaller populations with higher TB risk (e.g., HIV-positive, homeless) and ECI were generally more efficient, but had less overall impact on incidence. TTT targeted to smaller, highest-risk populations, and ECI can be highly efficient; however, major reductions in incidence will only be achieved by also targeting larger, moderate-risk populations. Ultimately, to eliminate TB in the US, a combination of these approaches is necessary. |
Hurricane-associated mold exposures among patients at risk for invasive mold infections after Hurricane Harvey - Houston, Texas, 2017
Chow NA , Toda M , Pennington AF , Anassi E , Atmar RL , Cox-Ganser JM , Da Silva J , Garcia B , Kontoyiannis DP , Ostrosky-Zeichner L , Leining LM , McCarty J , Al Mohajer M , Murthy BP , Park JH , Schulte J , Shuford JA , Skrobarcek KA , Solomon S , Strysko J , Chiller TM , Jackson BR , Chew GL , Beer KD . MMWR Morb Mortal Wkly Rep 2019 68 (21) 469-473 In August 2017, Hurricane Harvey caused unprecedented flooding and devastation to the Houston metropolitan area (1). Mold exposure was a serious concern because investigations after Hurricanes Katrina and Rita (2005) had documented extensive mold growth in flood-damaged homes (2,3). Because mold exposure can cause serious illnesses known as invasive mold infections (4,5), and immunosuppressed persons are at high risk for these infections (6,7), several federal agencies recommend that immunosuppressed persons avoid mold-contaminated sites (8,9). To assess the extent of exposure to mold and flood-damaged areas among persons at high risk for invasive mold infections after Hurricane Harvey, CDC and Texas health officials conducted a survey among 103 immunosuppressed residents in Houston. Approximately half of the participants (50) engaged in cleanup of mold and water-damaged areas; these activities included heavy cleanup (23), such as removing furniture or removing drywall, or light cleanup (27), such as wiping down walls or retrieving personal items. Among immunosuppressed persons who performed heavy cleanup, 43% reported wearing a respirator, as did 8% who performed light cleanup. One participant reported wearing all personal protective equipment (PPE) recommended for otherwise healthy persons (i.e., respirator, boots, goggles, and gloves). Immunosuppressed residents who are at high risk for invasive mold infections were exposed to mold and flood-damaged areas after Hurricane Harvey; recommendations from health care providers to avoid exposure to mold and flood-damaged areas could mitigate the risk to immunosuppressed persons. |
Outlook for tuberculosis elimination in California: An individual-based stochastic model
Goodell AJ , Shete PB , Vreman R , McCabe D , Porco TC , Barry PM , Flood J , Marks SM , Hill A , Cattamanchi A , Kahn JG . PLoS One 2019 14 (4) e0214532 RATIONALE: As part of the End TB Strategy, the World Health Organization calls for low-tuberculosis (TB) incidence settings to achieve pre-elimination (<10 cases per million) and elimination (<1 case per million) by 2035 and 2050, respectively. These targets require testing and treatment for latent tuberculosis infection (LTBI). OBJECTIVES: To estimate the ability and costs of testing and treatment for LTBI to reach pre-elimination and elimination targets in California. METHODS: We created an individual-based epidemic model of TB, calibrated to historical cases. We evaluated the effects of increased testing (QuantiFERON-TB Gold) and treatment (three months of isoniazid and rifapentine). We analyzed four test and treat targeting strategies: (1) individuals with medical risk factors (MRF), (2) non-USB, (3) both non-USB and MRF, and (4) all Californians. For each strategy, we estimated the effects of increasing test and treat by a factor of 2, 4, or 10 from the base case. We estimated the number of TB cases occurring and prevented, and net and incremental costs from 2017 to 2065 in 2015 U.S. dollars. Efficacy, costs, adverse events, and treatment dropout were estimated from published data. We estimated the cost per case averted and per quality-adjusted life year (QALY) gained. MEASUREMENTS AND MAIN RESULTS: In the base case, 106,000 TB cases are predicted to 2065. Pre-elimination was achieved by 2065 in three scenarios: a 10-fold increase in the non-USB and persons with MRF (by 2052), and 4- or 10-fold increase in all Californians (by 2058 and 2035, respectively). TB elimination was not achieved by any intervention scenario. The most aggressive strategy, 10-fold in all Californians, achieved a case rate of 8 (95% UI 4-16) per million by 2050. Of scenarios that reached pre-elimination, the incremental net cost was $20 billion (non-USB and MRF) to $48 billion. These had an incremental cost per QALY of $657,000 to $3.1 million. A more efficient but somewhat less effective single-lifetime test strategy reached as low as $80,000 per QALY. CONCLUSIONS: Substantial gains can be made in TB control in coming years by scaling-up current testing and treatment in non-USB and those with medical risks. |
Prevalence of selected birth defects by maternal nativity status, United States, 1999-2007
Kirby RS , Mai CT , Wingate MS , Janevic T , Copeland GE , Flood TJ , Isenburg J , Canfield MA . Birth Defects Res 2019 111 (11) 630-639 OBJECTIVES: We investigated differences in prevalence of major birth defects by maternal nativity within racial/ethnic groups for 27 major birth defects. METHODS: Data from 11 population-based birth defects surveillance systems in the United States including almost 13 million live births (approximately a third of U.S. births) during 1999-2007 were pooled. We calculated prevalence estimates for each birth defect for five racial/ethnic groups. Using Poisson regression, crude and adjusted prevalence ratios (aPRs) were also calculated using births to US-born mothers as the referent group in each racial/ethnic group. RESULTS: Approximately 20% of case mothers and 26% of all mothers were foreign-born. Elevated aPRs for infants with foreign-born mothers were found for spina bifida and trisomy 13, 18, and 21, while lower prevalence patterns were found for pyloric stenosis, gastroschisis, and hypospadias. CONCLUSIONS: This study demonstrates that birth defects prevalence varies by nativity within race/ethnic groups, with elevated prevalence ratios for some specific conditions and lower prevalence for others. More detailed analyses focusing on a broader range of maternal behaviors and characteristics are required to fully understand the implications of our findings. |
Getting the message out: Social media and word-of-mouth as effective communication methods during emergencies
Wolkin AF , Schnall AH , Nakata NK , Ellis EM . Prehosp Disaster Med 2018 34 (1) 1-6 Effective communication is a critical part of managing an emergency. During an emergency, the ways in which health agencies normally communicate warnings may not reach all of the intended audience. Not all communities are the same, and households within communities are diverse. Because different communities prefer different communication methods, community leaders and emergency planners need to know their communities' preferred methods for seeking information about an emergency. This descriptive report explores findings from previous community assessments that have collected information on communication preferences, including television (TV), social media, and word-of-mouth (WoM) delivery methods. Data were analyzed from 12 Community Assessments for Public Health Emergency Response (CASPERs) conducted from 2014-2017 that included questions regarding primary and trusted communication sources. A CASPER is a rapid needs assessment designed to gather household-based information from a community. In 75.0% of the CASPERs, households reported TV as their primary source of information for specific emergency events (range = 24.0%-83.1%). Households reporting social media as their primary source of information differed widely across CASPERs (3.2%-41.8%). In five of the CASPERs, nearly one-half of households reported WoM as their primary source of information. These CASPERs were conducted in response to a specific emergency (ie, chemical spill, harmful algal bloom, hurricane, and flood). The CASPERs conducted as part of a preparedness activity had lower percentages of households reporting WoM as their primary source of information (8.3%-10.4%). The findings in this report demonstrate the need for emergency plans to include hybrid communication models, combining traditional methods with newer technologies to reach the broadest audience. Although TV was the most commonly reported preferred source of information, segments of the population relied on social media and WoM messaging. By using multiple methods for risk communication, emergency planners are more likely to reach the whole community and engage vulnerable populations that might not have access to, trust in, or understanding of traditional news sources. Multiple communication channels that include user-generated content, such as social media and WoM, can increase the timeliness of messaging and provide community members with message confirmation from sources they trust encouraging them to take protective public health actions.Wolkin AF, Schnall AH, Nakata NK, Ellis EM. Getting the message out: social media and word-of-mouth as effective communication methods during emergencies. |
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