BACKGROUND: Hepatitis B virus (HBV) and neonatal tetanus infections remain endemic in Nigeria despite the availability of safe, effective vaccines. We aimed to determine health facilities' capacity for hepatitis B vaccine birth dose (HepB-BD) and maternal tetanus-diphtheria (Td) vaccination and to assess knowledge, attitudes, and practices of HepB-BD and maternal Td vaccine administration among health facility staff in Nigeria. MATERIALS AND METHODS: This was a cross-sectional study assessing public primary and secondary health facilities in Adamawa and Enugu States. A multistage sampling approach was used to select 40 facilities and 79 health-care workers (HCWs) from each state. A structured facility assessment tool and standardized questionnaire evaluated facility characteristics and HCW knowledge, attitudes, and practices related to HepB-BD and maternal Td vaccination. Frequencies and proportions were reported as descriptive statistics. RESULTS: The survey of 80 facilities revealed that 73.8% implemented HepB-BD and maternal Td vaccination policies. HepB-BD was administered within 24 h of birth at 61.3% of facilities and at all times at 57.5%. However, administration seldom occurred in labor and delivery (35%) or maternity wards (16.3%). Nearly half of the facilities (46.3%) had HCWs believing there were contraindications to HepB-BD vaccination. Among 158 HCWs, 26.5% believed tetanus could be transmitted through unprotected sex, prevented by vaccination at birth (46.1%), or by avoiding sharing food and utensils. 65% of HCWs knew HBV infection had the worst outcome for newborns. CONCLUSIONS: The limited implementation of national policies on HepB-BD and maternal Td vaccination, coupled with knowledge gaps among HCWs, pose significant challenges to timely vaccination, necessitating interventions to address these gaps.

BACKGROUND: Nigeria has the largest number of children infected with hepatitis B virus (HBV) globally and has not yet achieved maternal and neonatal tetanus elimination. In Nigeria, maternal tetanus diphtheria (Td) vaccination is part of antenatal care and hepatitis B birth dose (HepB-BD) vaccination for newborns has been offered since 2004. We implemented interventions targeting healthcare workers (HCWs), community volunteers, and pregnant women attending antenatal care with the goal of improving timely (within 24 hours) HepB-BD vaccination among newborns and Td vaccination coverage among pregnant women. METHODS: We selected 80 public health facilities in Adamawa and Enugu states, with half intervention facilities and half control. Interventions included HCW and community volunteer trainings, engagement of pregnant women, and supportive supervision at facilities. Timely HepB-BD coverage and at least two doses of Td (Td2+) coverage were assessed at baseline before project implementation (January-June 2021) and at endline, one year after implementation (January-June 2022). We held focus group discussions at intervention facilities to discuss intervention strengths, challenges, and improvement opportunities. RESULTS: Compared to baseline, endline median vaccination coverage increased for timely HepB-BD from 2.6% to 61.8% and for Td2+ from 20.4% to 26.9% in intervention facilities (p < 0.05). In comparison, at endline in control facilities median vaccination coverage for timely HepB-BD was 7.9% (p < 0.0001) and Td2+ coverage was 22.2% (p = 0.14). Focus group discussions revealed that HCWs felt empowered to administer vaccination due to increased knowledge on hepatitis B and tetanus, pregnant women had increased knowledge that led to improved health seeking behaviors including Td vaccination, and transportation support was needed to reach those in far communities. CONCLUSION: Targeted interventions significantly increased timely HepB-BD and Td vaccination rates in intervention facilities. Continued support of these successful interventions could help Nigeria reach hepatitis B and maternal and neonatal tetanus elimination goals.

Nigeria is estimated to have the largest number of children worldwide, living with chronic hepatitis B virus (HBV) infection, the leading cause of liver cancer. Up to 90% of children infected at birth develop chronic HBV infection. A birth dose of the hepatitis B vaccine (HepB-BD) followed by at least two additional vaccine doses is recommended for prevention. This study assessed barriers and facilitators of HepB-BD administration and uptake, using structured interviews with healthcare providers and pregnant women in Adamawa and Enugu States, Nigeria. The Consolidated Framework for Implementation Sciences Research (CFIR) guided data collection and analysis. We interviewed 87 key informants (40 healthcare providers and 47 pregnant women) and created a codebook for data analysis. Codes were developed by reviewing the literature and reading a subsample of queries line-by-line. The overarching themes identified as barriers among healthcare providers were: the lack of hepatitis B knowledge, limited availability of HepB-BD to vaccination days only, misconceptions about HepB-BD vaccination, challenges in health facility staffing capacity, costs associated with vaccine transportation, and concerns related to vaccine wastage. Facilitators of timely HepB-BD vaccination included: vaccine availability, storage, and hospital births occurring during immunization days. Overarching themes identified as barriers among pregnant women were lack of hepatitis B knowledge, limited understanding of HepB-BD importance, and limited access to vaccines for births occurring outside of a health facility. Facilitators were high vaccine acceptance and willingness for their infants to receive HepB-BD if recommended by providers. Findings indicate the need for enhanced HepB-BD vaccination training for HCWs, educating pregnant women on HBV and the importance of timely HepB-BD, updating policies to enable HepB-BD administration within 24 hours of birth, expanding HepB-BD availability in public and private hospital maternity wards for all facility births, and outreach activities to reach home births.

The first three SARS-CoV-2 phylogenetic lineages classified as variants of concern (VOCs) in the United States (U.S.) from December 15, 2020 to February 28, 2021, Alpha (B.1.1.7), Beta (B.1.351), and Gamma (P.1) lineages, were initially detected internationally. This investigation examined available travel history of coronavirus disease 2019 (COVID-19) cases reported in the U.S. in whom laboratory testing showed one of these initial VOCs. Travel history, demographics, and health outcomes for a convenience sample of persons infected with a SARS-CoV-2 VOC from December 15, 2020 through February 28, 2021 were provided by 35 state and city health departments, and proportion reporting travel was calculated. Of 1,761 confirmed VOC cases analyzed, 1,368 had available data on travel history. Of those with data on travel history, 1,168 (85%) reported no travel preceding laboratory confirmation of SARS-CoV-2 and only 105 (8%) reported international travel during the 30 days preceding a positive SARS-CoV-2 test or symptom onset. International travel was reported by 92/1,304 (7%) of persons infected with the Alpha variant, 7/55 (22%) with Beta, and 5/9 (56%) with Gamma. Of the first three SARS-CoV-2 lineages designated as VOCs in the U.S., international travel was common only among the few Gamma cases. Most persons infected with Alpha and Beta variant reported no travel history, therefore, community transmission of these VOCs was likely common in the U.S. by March 2021. These findings underscore the importance of global surveillance using whole genome sequencing to detect and inform mitigation strategies for emerging SARS-CoV-2 VOCs.

PROBLEM/CONDITION: Gastrointestinal illness is common worldwide and can be transmitted by an infected person or contaminated food, water, or environmental surfaces. Outbreaks of gastrointestinal illness commonly occur in crowded living accommodations or communities where persons are physically close. Pathogens that cause gastrointestinal illness outbreaks can spread quickly in closed and semienclosed environments, such as cruise ships. CDC's Vessel Sanitation Program (VSP) is responsible for conducting public health inspections and monitoring acute gastroenteritis (AGE) illness on cruise ships entering the United States after visiting a foreign port. PERIOD COVERED: 2006-2019. DESCRIPTION OF SYSTEM: VSP maintains the Maritime Illness Database and Reporting System (MIDRS) for monitoring cases of AGE illness among passengers and crew sailing on cruise ships carrying ≥13 passengers and within 15 days of arrival at U.S. ports from foreign ports of call. Cruise ships under VSP jurisdiction are required to submit a standardized report (24-hour report) of AGE case counts for passengers and crew 24-36 hours before arrival at the first U.S. port after traveling internationally. If the cumulative number of AGE cases increases after submission of the 24-hour report, an updated report must be submitted no less than 4 hours before the ship arrives at the U.S. port. A special report is submitted to MIDRS when vessels are within 15 days of arrival at a U.S. port and cumulative case counts reach 2% of the passenger or crew population during a voyage. VSP declares an outbreak when 3% or more of the passengers or crew on a voyage report AGE symptom to the ship's medical staff. RESULTS: During 2006-2019, a total of 37,276 voyage reports from 252 cruise ships were submitted to MIDRS. Of the 252 cruise ships, 80.6% were extra large in size (60,001-120,000 gross registered tons [GRT]), 37.0% and 32.9% had voyages lasting 3-5 days and 8-10 days, respectively, and 53.2% were traveling to a port in the Southeast region of the United States at the time the final MIDRS report was submitted. During 2006-2019, VSP received 18,040 (48.4%) 24-hour routine reports, 18,606 (49.9%) 4-hour update reports, and 612 (1.6%) special reports (2% and 3% AGE reports). Incidence rates decreased from 32.5 cases per 100,000 travel days to 16.9 for passengers and from 13.5 to 5.2 for crew. Among passengers, AGE incidence rates increased with increasing ship size and voyage length. For crew members, rates were significantly higher on extra-large ships (19.8 per 100,000 travel-days) compared with small and large ships and on voyages lasting 6-7 days. Geographically, passenger incidence rates were highest among ships underway to ports in California, Alaska, Texas, New York, Florida, and Louisiana. Among passengers, AGE incidence rates were significantly higher on ships anchoring in California (32.1 per 100,000 travel-days [95% confidence interval (CI) = 31.7-32.4]); among crew, they were significantly higher in the South region of the United States (25.9 [CI = 25.1-26.7]). INTERPRETATION: This report is the first detailed summary of surveillance data from MIDRS during 2006-2019. AGE incidence rates decreased during this time. Incidence rates among passengers were higher on mega and super-mega ships and voyages lasting >7 days. AGE incidence among crew was higher on extra-large ships and voyages lasting 6-7 days. Ship size and voyage length are associated with AGE incidence rates, and more targeted effort is needed to prevent disproportionate AGE incidence rates among passengers and crew sailing in high-risk situations. PUBLIC HEALTH ACTIONS: Maritime AGE surveillance provides important information about the epidemiology of gastrointestinal illness among cruise ship populations traveling in U.S. jurisdictions. AGE illness is highly contagious and can be transmitted quickly within vessels. State and local public health departments in the United States can use data in this report to better inform the traveling public about the risk for AGE and the importance of their role in minimizing the risk for illness while traveling onboard cruise ships. Key elements for reducing exposure to AGE illness, limiting the spread of illness, and preventing AGE outbreaks are proper hand hygiene practices and prompt isolation of symptomatic persons. Passengers can work in collaboration with cruise lines to promote onboard public health by frequently washing their hands, promptly reporting AGE illness symptoms, and isolating themselves from other persons immediately after illness onset. Access to and proper use of handwashing stations can reduce the risk for illness transmission aboard cruise ships.

BACKGROUND: Cruise travel contributed to SARS-CoV-2 transmission when there were relatively few cases in the United States. By March 14, 2020, the Centers for Disease Control and Prevention (CDC) issued a No Sail Order suspending U.S. cruise operations; the last U.S. passenger ship docked on April 16. METHODS: We analyzed SARS-CoV-2 outbreaks on cruises in U.S. waters or carrying U.S. citizens and used regression models to compare voyage characteristics. We used compartmental models to simulate the potential impact of four interventions (screening for COVID-19 symptoms; viral testing on two days and isolation of positive persons; reduction of passengers by 40%, crew by 20%, and port visits to one) for 7-day and 14-day voyages. RESULTS: During January 19-April 16, 2020, 89 voyages on 70 ships had known SARS-CoV-2 outbreaks; 16 ships had recurrent outbreaks. There were 1,669 RT-PCR-confirmed SARS-CoV-2 infections and 29 confirmed deaths. Longer voyages were associated with more cases (adjusted incidence rate ratio, 1.10, 95% CI: 1.03-1.17, p < 0.0001). Mathematical models showed that 7-day voyages had about 70% fewer cases than 14-day voyages. On 7-day voyages, the most effective interventions were reducing the number of individuals onboard (43-49% reduction in total infections) and testing passengers and crew (42-43% reduction in total infections). All four interventions reduced transmission by 80%, but no single intervention or combination eliminated transmission. Results were similar for 14-day voyages. CONCLUSIONS: SARS-CoV-2 outbreaks on cruises were common during January-April 2020. Despite all interventions modeled, cruise travel still poses a significant SARS-CoV-2 transmission risk.

In December 2020, the B.1.1.7 genetic variant of SARS-CoV-2, the virus that causes COVID-19, was first reported after emergence and rapid circulation in the United Kingdom (1). Evidence suggests that the B.1.1.7 variant is more efficiently transmitted than are other SARS-CoV-2 variants, and widespread circulation could thereby increase SARS-CoV-2 infection and hospitalization rates (1,2). The first reported SARS-CoV-2 B.1.1.7 variant case in the United States was confirmed by sequencing in Colorado on December 29, 2020.* This report describes a person who traveled from the United Kingdom to the United States after experiencing COVID-19-compatible symptoms(†) and was eventually confirmed to be infected with the B.1.1.7 variant.

CrAssphage is a recently discovered human gut-associated bacteriophage. To validate the potential use of crAssphage for detecting human fecal contamination on environmental surfaces and hands, we tested stool samples (n = 60), hand samples (n = 30), and environmental swab samples (n = 201) from 17 norovirus outbreaks for crAssphage by real-time PCR. In addition, we tested stool samples from healthy persons (n = 173), respiratory samples (n = 113), and animal fecal specimens (n = 68) and further sequenced positive samples. Overall, we detected crAssphage in 71.4% of outbreak stool samples, 48%-68.5% of stool samples from healthy persons, 56.2% of environmental swabs, and 60% of hand rinse samples, but not in human respiratory samples or animal fecal samples. CrAssphage sequences could be grouped into 2 major genetic clusters. Our data suggest that crAssphage could be used to detect human fecal contamination on environmental surfaces and hands.

Norovirus is the leading cause of foodborne illness outbreaks in the United States, and restaurants are the most common setting of foodborne norovirus outbreaks. Therefore, prevention and control of restaurant-related foodborne norovirus outbreaks is critical to lowering the burden of foodborne illness in the United States. Data for 124 norovirus outbreaks and outbreak restaurants were obtained from Centers for Disease Control and Prevention (CDC) surveillance systems and analyzed to identify relationships between restaurant characteristics and outbreak size and duration. Findings showed that restaurant characteristics, policies, and practices were linked with both outbreak size and duration. Compared to their counterparts, restaurants that had smaller outbreaks had the following characteristics: managers received food safety certification; managers and workers received food safety training; food workers wore gloves; and restaurants had cleaning policies. In addition, restaurants that provided food safety training to managers, served food items requiring less complex food preparation, and had fewer managers had shorter outbreaks compared to their counterparts. These findings suggest that restaurant characteristics play a role in norovirus outbreak prevention and intervention; therefore, implementing food safety training, policies, and practices likely reduces norovirus transmission, leading to smaller or shorter outbreaks.

From July to September 2019, cruise line X experienced sudden, unexplained outbreaks (>3% of the passenger population) of acute gastroenteritis (AGE) among passengers on 10 cruise ships sailing in Europe. The rapid onset of vomiting and diarrhea followed by recovery within 24 hours were consistent with norovirus infection. Investigations by the cruise line throughout the summer yielded no clear source of the outbreaks even after extensive food testing. On September 18, 2019, CDC’s Vessel Sanitation Program (VSP) was notified of an outbreak of AGE on cruise ship A of cruise line X, sailing into U.S. jurisdiction (defined as passenger vessels carrying ≥13 passengers sailing to the United States from a foreign port) from Germany to New York City (1). By the end of the 19-day voyage on September 23, a total of 117 of 2,046 (5.7%) passengers and eight of 610 (1.3%) crew members met the case definition for AGE (three or more loose stools within a 24-hour period or more than normal for the patient, or vomiting plus one other sign or symptom including fever, diarrhea, bloody stool, myalgia, abdominal cramps, or headache). Four stool specimens were collected and tested for norovirus at CDC’s National Calicivirus Laboratory; three tested positive for norovirus by quantitative reverse transcription–polymerase chain reaction (RT-PCR). No outbreak source was determined after a field investigation by a VSP team on September 22.

An estimated 30 million passengers are transported on 272 cruise ships worldwide each year* (1). Cruise ships bring diverse populations into proximity for many days, facilitating transmission of respiratory illness (2). SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) was first identified in Wuhan, China, in December 2019 and has since spread worldwide to at least 187 countries and territories. Widespread COVID-19 transmission on cruise ships has been reported as well (3). Passengers on certain cruise ship voyages might be aged >/=65 years, which places them at greater risk for severe consequences of SARS-CoV-2 infection (4). During February-March 2020, COVID-19 outbreaks associated with three cruise ship voyages have caused more than 800 laboratory-confirmed cases among passengers and crew, including 10 deaths. Transmission occurred across multiple voyages of several ships. This report describes public health responses to COVID-19 outbreaks on these ships. COVID-19 on cruise ships poses a risk for rapid spread of disease, causing outbreaks in a vulnerable population, and aggressive efforts are required to contain spread. All persons should defer all cruise travel worldwide during the COVID-19 pandemic.

Environmental health specialists often perform environmental assessments (EAs) when a suspected or confirmed foodborne illness outbreak is linked to a food establishment. Information from EAs helps officials determine the cause of the outbreak and develop strategies to prevent future outbreaks; however, EAs are not always conducted. To determine facilitators and barriers to conducting EAs, we analyzed openended responses reported to the National Environmental Assessment Reporting System about these assessments. We found that EAs were conducted most often when illness was identified, a jurisdiction had a policy to investigate illnesses, and there were resources for such a response. EAs were not conducted in instances such as limited resources, insufficient training, uncooperative facility personnel, or if the establishment fell outside of health department jurisdiction. Identifying the facilitators and barriers to conducting EAs can enable health departments to develop strategies that improve their ability to conduct EAs.

In 2015, an estimated 257 million people were living with chronic hepatitis B virus (HBV) globally, with estimates in the United States as high as 2.2 million.1–3 Only 25% of infected individuals in the United States are aware of their HBV infection, and less than 10% are able to access care and treatment.2 If left untreated, chronic HBV infection can lead to serious liver complications, including liver cirrhosis and liver cancer, in up to 25% of infected individuals.4,5 Hepatitis B can be transmitted through direct contact with infected blood, unprotected sex with an infected individual, use of illicit drugs, contaminated or unsterile injecting equipment, and most commonly worldwide from an infected mother to her newborn during childbirth (or during pregnancy in women with high viral load).5 Likely attributed to the recent opioid epidemic, Centers for Disease Control and Prevention (CDC) has reported an increase in cases of acute HBV infections in 3 states among non-Hispanic whites aged 30 to 39 years who reported injection drug usage.6 The opioid epidemic increases the risk of potential exposure to hepatitis B, and our public health system must be ready to provide timely postexposure prophylaxis (PEP).

From 1990 to 2004, the reported rates of diarrheal disease (three or more loose stools or a greater than normal frequency in a 24-hour period) on cruise ships decreased 2.4%, from 29.2 cases per 100,000 travel days to 28.5 cases (1,2). Increased rates of acute gastroenteritis illness (diarrhea or vomiting that is associated with loose stools, bloody stools, abdominal cramps, headache, muscle aches, or fever) occurred in years that novel strains of norovirus, the most common etiologic agent in cruise ship outbreaks, emerged (3). To determine recent rates of acute gastroenteritis on cruise ships, CDC analyzed combined data for the period 2008-2014 that were submitted by cruise ships sailing in U.S. jurisdiction (defined as passenger vessels carrying ≥13 passengers and within 15 days of arriving in the United States) (4). CDC also reviewed laboratory data to ascertain the causes of acute gastroenteritis outbreaks and examined trends over time. During the study period, the rates of acute gastroenteritis per 100,000 travel days decreased among passengers from 27.2 cases in 2008 to 22.3 in 2014. Rates for crew members remained essentially unchanged (21.3 cases in 2008 and 21.6 in 2014). However, the rate of acute gastroenteritis was significantly higher in 2012 than in 2011 or 2013 for both passengers and crew members, likely related to the emergence of a novel strain of norovirus, GII.4 Sydney (5). During 2008-2014, a total of 133 cruise ship acute gastroenteritis outbreaks were reported, 95 (71%) of which had specimens available for testing. Among these, 92 (97%) were caused by norovirus, and among 80 norovirus specimens for which a genotype was identified, 59 (73.8%) were GII.4 strains. Cruise ship travelers experiencing diarrhea or vomiting should report to the ship medical center promptly so that symptoms can be assessed, proper treatment provided, and control measures implemented.

The drinking water infrastructure in the United States is ageing; extreme weather events place additional stress on water systems that can lead to interruptions in the delivery of safe drinking water. We investigated the association between household exposures to water service problems and acute gastrointestinal illness (AGI) and acute respiratory illness (ARI) in Alabama communities that experienced a freeze-related community-wide water emergency. Following the water emergency, investigators conducted a household survey. Logistic regression models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for self-reported AGI and ARI by water exposures. AGI was higher in households that lost water service for 7 days (aPR 2.4, 95% CI 1.1-5.2) and experienced low water pressure for 7 days (aPR 3.6, 95% CI 1.4-9.0) compared to households that experienced normal service and pressure; prevalence of AGI increased with increasing duration of water service interruptions. Investments in the ageing drinking water infrastructure are needed to prevent future low-pressure events and to maintain uninterrupted access to the fundamental public health protection provided by safe water supplies. Households and communities need to increase their awareness of and preparedness for water emergencies to mitigate adverse health impacts.

OBJECTIVES: We assessed changes in transit-associated walking in the United States from 2001 to 2009 and documented their importance to public health. METHODS: We examined transit walk times using the National Household Travel Survey, a telephone survey administered by the US Department of Transportation to examine travel behavior in the United States. RESULTS: People are more likely to transit walk if they are from lower income households, are non-White, and live in large urban areas with access to rail systems. Transit walkers in large urban areas with a rail system were 72% more likely to transit walk 30 minutes or more per day than were those without a rail system. From 2001 to 2009, the estimated number of transit walkers rose from 7.5 million to 9.6 million (a 28% increase); those whose transit-associated walking time was 30 minutes or more increased from approximately 2.6 million to 3.4 million (a 31% increase). CONCLUSIONS: Transit walking contributes to meeting physical activity recommendations. Study results may contribute to transportation-related health impact assessment studies evaluating the impact of proposed transit systems on physical activity, potentially influencing transportation planning decisions. (Am J Public Health. Published online ahead of print January 17, 2013: e1-e7. doi:10.2105/AJPH.2012.300912).

Successful aging takes on an array of attributes, including optimal health and community participation. Research indicates that (1) persons with disabilities, including age-related disabilities, report frequent barriers to community participation, including unsuitable building design (43%), transportation (32%), and sidewalks/curbs (31%), and (2) many seniors report an inability to cross roads safely near their homes. This paper attempts to define mobility-related elements that contribute to optimal health and quality of life, within the context of successful aging. It then examines the impacts of community design on individual mobility, delving into which traditional and nontraditional actors-including architects, urban planners, transportation engineers, occupational therapists, and housing authorities-play critical roles in ensuring that community environments serve as facilitators (rather than barriers) to mobility. As America ages, mobility challenges for seniors will only increase unless both traditional aging specialists and many nontraditional actors make a concerted effort to address the challenges.