BACKGROUND: clinical guidelines recommend initiation of antiviral therapy as soon as possible for patients hospitalized with confirmed or suspected influenza. METHODS: A multicenter US observational sentinel surveillance network prospectively enrolled adults (aged ≥18 years) hospitalized with laboratory-confirmed influenza at 24 hospitals during October 1, 2022-July 21, 2023. A multivariable proportional odds model was used to compare peak pulmonary disease severity (no oxygen support, standard supplemental oxygen, high-flow oxygen/non-invasive ventilation, invasive mechanical ventilation, or death) after the day of hospital admission among patients starting oseltamivir treatment on the day of admission (early) versus those who did not (late or not treated), adjusting for baseline (admission day) severity, age, sex, site, and vaccination status. Multivariable logistic regression models were used to evaluate the odds of intensive care unit (ICU) admission, acute kidney replacement therapy or vasopressor use, and in-hospital death. RESULTS: A total of 840 influenza-positive patients were analyzed, including 415 (49%) who started oseltamivir treatment on the day of admission, and 425 (51%) who did not. Compared with late or not treated patients, those treated early had lower peak pulmonary disease severity (proportional aOR: 0.60, 95% CI: 0.49-0.72), and lower odds of intensive care unit admission (aOR: 0.24, 95% CI: 0.13-0.47), acute kidney replacement therapy or vasopressor use (aOR: 0.40, 95% CI: 0.22-0.67), and in-hospital death (aOR: 0.36, 95% CI: 0.18-0.72). CONCLUSION: Among adults hospitalized with influenza, treatment with oseltamivir on day of hospital admission was associated reduced risk of disease progression, including pulmonary and extrapulmonary organ failure and death.

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

INTRODUCTION: Food and nutrition security is crucial for health, but many U.S. households experience food insecurity. This systematic review conducted in support of the Community Preventive Services Task Force (CPSTF) examines the effectiveness of Fruit and Vegetable Incentive (FVI) programs in reducing food insecurity, increasing fruit and vegetable (FV) consumption, and improving health outcomes among households with lower incomes. METHODS: Community Guide systematic review methods were applied. Studies were identified through a literature search (inception of each database to February 2023). U.S. studies were included if they evaluated programs offering participants financial incentives to purchase FV; were designed for or implemented among populations with lower incomes; reported health-related outcomes; and were published in English as peer-reviewed articles or government reports. RESULTS: This review included 30 studies. Thirteen of 14 datapoints from 12 studies indicated FVI programs reduced household food insecurity. Twenty-one of 29 datapoints from 23 studies showed increased FV consumption. Programs providing incentives to participants at risk for or with diet-related health conditions improved blood glucose levels by a median of 0.64 percentage points. DISCUSSION: Based on the review findings, CPSTF recommends FVI programs for populations with lower incomes to reduce household food insecurity, increase household FV consumption, and improve blood glucose levels in participants at risk for or with diet-related health conditions. Although the review did not find direct evidence of reducing health disparities, the CPSTF expects that these programs will improve health equity across the US by improving the affordability and accessibility of healthier foods for households with lower incomes.

BACKGROUND: In test-negative studies of vaccine effectiveness (VE), including patients with co-circulating, vaccine-preventable, respiratory pathogens in the control group for the pathogen of interest can introduce a downward bias on VE estimates. METHODS: A multicenter sentinel surveillance network in the US prospectively enrolled adults hospitalized with acute respiratory illness from September 1, 2022-March 31, 2023. We evaluated bias in estimates of VE against influenza-associated and COVID-19-associated hospitalization based on: inclusion vs exclusion of patients with a co-circulating virus among VE controls; observance of VE against the co-circulating virus (rather than the virus of interest), unadjusted and adjusted for vaccination against the virus of interest; and observance of influenza or COVID-19 against a sham outcome of respiratory syncytial virus (RSV). RESULTS: Overall VE against influenza-associated hospitalizations was 6 percentage points lower when patients with COVID-19 were included in the control group, and overall VE against COVID-19-associated hospitalizations was 2 percentage points lower when patients with influenza were included in the control group. Analyses of VE against the co-circulating virus and against the sham outcome of RSV showed that downward bias was largely attributable the correlation of vaccination status across pathogens, but also potentially attributable to other sources of residual confounding in VE models. CONCLUSION: Excluding cases of confounding respiratory pathogens from the control group in VE analysis for a pathogen of interest can reduce downward bias. This real-world analysis demonstrates that such exclusion is a helpful bias mitigation strategy, especially for measuring influenza VE, which included a high proportion of COVID-19 cases among controls.

This cohort study examines the association of reuse of N95 filtering facepiece respirators and N95 filtration efficiency. | eng

ABSTRACTWhile international guidelines recommend integration of family planning (FP) and HIV services, limited research has been done to explore how healthcare providers perceive the feasibility and utility of integrated services. To address this gap, we administered a standardized questionnaire to 85 providers from 6 HIV clinics in Lusaka, Zambia, before (April-May 2018) and after (May-June 2019) implementing an enhanced model of FP/HIV service integration. We tested for differences in FP knowledge, attitudes and practices between the two time periods with tests appropriate for paired observations. The proportion of providers self-reporting direct provision of contraceptives increased significantly for several methods including oral contraceptives (14% vs. 26%, p = 0.03), injectables (9% vs. 25%, p < 0.001), implants (2% vs. 13%, p = 0.007) and intra-uterine devices (2% vs. 13%, p = 0.007). In-depth interviews were also conducted post-integration with 109 providers to solicit their feedback on the benefits and challenges of offering integrated services. While providers were highly supportive of integrated services, they identified several challenges including widespread belief in FP myths among female clients, the need to consult a male partner prior to starting FP, lack of trained staff and space, and frequent stockouts of contraceptives and equipment. Addressing these challenges will be critical in designing future services.

PURPOSE: This study examined the use of behavioral design strategies to improve healthier food sales. DESIGN: A quasi-experimental, one-group, repeated measures design examined changes in food sales following behavioral design adjustments. SETTING: United States military base hospital dining facility. SUBJECTS: U.S. military service members, retirees, and civilian employees. INTERVENTION: Behavioral design changes included placement, layout, messaging, default healthy bundling, a stoplight rating system, strategic positioning of healthy items on menu boards, and an increase in healthier snacks. MEASURES: Food sales were assessed by point-of-sales data. ANALYSIS: T-tests examined total sales of each food adjusted weekly between baseline and intervention and intervention and post-intervention. 16 food items targeted by the intervention were examined. Weekly food sales were calculated for the 18-week baseline, 18-week intervention, and 9-week post-intervention. Further, analysis estimated negative binomial models for food item sales. RESULTS: The hospital dining facility served 600 to 900 meals per day. Weekly foods sales decreased during the intervention for desserts, cooked starches, hummus, and yogurt (P < 0.01). Sales increased during the intervention for fruit cups, cooked vegetables, vegetable and turkey burgers, grilled chicken, packaged salads, French fries, hamburgers, and hot dogs (P < 0.02). CONCLUSION: This study demonstrates that a mixture of behavioral design strategies can be operationalized with reasonable fidelity and can lead to increases in the sales of some healthy foods in military worksites.

BACKGROUND: In September 2022, Uganda experienced an outbreak of Sudan virus disease (SVD), mainly in central Uganda. As a result of enhanced surveillance activities for Ebola disease, samples from several patients with suspected viral hemorrhagic fever (VHF) were sent to the VHF Program at Uganda Virus Research Institute (UVRI), Entebbe, Uganda, and identified with infections caused by other viral etiologies. Herein, we report the epidemiologic and laboratory findings of Crimean-Congo hemorrhagic fever (CCHF) cases that were detected during the SVD outbreak response. METHODOLOGY: Whole blood samples from VHF suspected cases were tested for Sudan virus (SUDV) by real-time reverse transcription-polymerase chain reaction (RT-PCR); and if negative, were tested for CCHF virus (CCHFV) by RT-PCR. CCHFV genomic sequences generated by metagenomic next generation sequencing were analyzed to ascertain strain relationships. PRINCIPAL FINDINGS: Between September 2022 and January 2023, a total of 2,626 samples were submitted for VHF testing at UVRI. Overall, 13 CCHF cases (including 7 deaths; case fatality rate of 53.8%), aged 4 to 60 years, were identified from 10 districts, including several districts affected by the SVD outbreak. Four cases were identified within the Ebola Treatment Unit (ETU) at Mubende Hospital. Most CCHF cases were males engaged in livestock farming or had exposure to wildlife (n = 8; 61.5%). Among confirmed cases, the most common clinical symptoms were hemorrhage (n = 12; 92.3%), fever (n = 11; 84.6%), anorexia (n = 10; 76.9%), fatigue (n = 9; 69.2%), abdominal pain (n = 9; 69.2%) and vomiting (n = 9; 69.2%). Sequencing analysis showed that the majority of identified CCHFV strains belonged to the Africa II clade previously identified in Uganda. Two samples, however, were identified with greater similarity to a CCHFV strain that was last reported in Uganda in 1958, suggesting possible reemergence. CONCLUSIONS/SIGNIFICANCE: Identifying CCHFV from individuals initially suspected to be infected with SUDV emphasizes the need for comprehensive VHF testing during filovirus outbreak responses in VHF endemic countries. Without expanded testing, CCHFV-infected patients would have posed a risk to health care workers and others while receiving treatment after a negative filovirus diagnosis, thereby complicating response dynamics. Additionally, CCHFV-infected cases could acquire an Ebola infection while in the ETU, and upon release because of a negative Ebola virus result, have the potential to spread these infections in the community.

The Youth Risk Behavior Surveillance System (YRBSS) is a set of surveys that tracks a broad range of behaviors, experiences, and conditions that can lead to poor health among high school students. The system includes a nationally representative Youth Risk Behavior Survey (YRBS) and separate school-based YRBSs conducted by states, tribes, territories, and local school districts. For the 2023 national YRBS, CDC made changes to the sampling method, survey administration mode, and questionnaire. Specifically, the sampling design added an American Indian or Alaska Native (AI/AN) supplemental sample so that separate, precise estimates could be made for AI/AN high school students, in addition to the usual sample designed to provide nationally representative data for the population of students in grades 9-12. To decrease the time needed to collect and process data, CDC changed the survey administration mode from paper-and-pencil scannable booklets to a tablet-based electronic survey. To provide national data on topics of emerging interest, CDC added new questions to the questionnaire. These new questions assessed social media use, experiences of racism at school, adverse childhood experiences, transgender identity, consent for sexual contact, and unfair discipline at school. Public health practitioners and researchers can use YRBSS data to examine the prevalence of youth health behaviors, experiences, and conditions; monitor trends; and guide interventions. This overview report describes 2023 YRBSS survey methodology, including sampling, data collection, data processing, weighting, and data analyses. The 2023 YRBS participation map, survey response rates, and a detailed examination of student demographic characteristics are included in this report. During 2023, in addition to the national YRBS, 68 site-level surveys were administered to high school students in 39 states, three tribal governments, five territories, and 21 local school districts. These site-level surveys use site-specific questionnaires that are similar to the national YRBS questionnaire but are modified to meet sites' needs. This overview and methods report is one of 11 featured in this MMWR supplement, which reports results from the 2023 national YRBS but does not include data from the 68 site-level surveys. Each report is based on data collected using methods presented in this overview report. A full description of YRBSS results and downloadable data are available (https://www.cdc.gov/yrbs/index.html).

BACKGROUND: On September 20, 2022, Uganda declared an Sudan Virus Disease (SVD) outbreak in Mubende District. Another eight districts were infected September-November 2022. We examined how Ugandan community beliefs and practices spread Sudan Ebola Virus (SUDV) in 2022. METHODS: A qualitative study was conducted in Mubende, Kassanda, and Kyegegwa districts in February 2023. Nine focus group discussions and six key informant interviews were held. We investigated whether community beliefs and practices contributed to spreading Sudan Ebola Virus (SUDV). Interviews were recorded, translated, transcribed, and thematically analyzed. RESULTS: The community deaths, later found to be due to Sudan Virus Disease(SVD), were often attributed to witchcraft or poisoning. Key informants reported that SVD patients often sought traditional healers or spiritual leaders before or after formal healthcare failed. They also found that traditional healers treated SVD patients without precautions. Religious leaders praying for SVD patients and their symptomatic contacts, SVD patients hiding in friends' homes, and exhuming SVD patients from safe and dignified burials to allow traditional burials were other themes. CONCLUSION: Diversity in community beliefs and culture likely contributed to spreading the 2022 Ugandan SVD outbreak. Public health systems, traditional healers, and religious leaders can help Uganda control ebolavirus outbreaks by identifying socially acceptable and scientifically supported infection control methods.

OBJECTIVE: We reviewed recent reports of recalled children's products contaminated with lead to learn more about what could be done to inform public health partners about the recalls in a timely manner to assist with broader consumer notification for proactive lead poisoning prevention efforts. METHODS: Centers for Disease Control and Prevention staff reviewed lead-related recall notices for children's products issued during June 2022 through April 2024. Recall notices were extracted from the Consumer Product Safety Commission using Really Simple Syndication feed technology to identify and capture the most current recall information. Specific product details in the database were extracted and analyzed descriptively to identify response trends and best practices. RESULTS: Centers for Disease Control and Prevention's automated tool identified 30 recalls from Consumer Product Safety Commission. Lead-contaminated toys were the most frequent type of product recalled (n = 11, 37%). Most products were manufactured in China (n = 24, 86%). Products were on the market for an average of 25 months before they were recalled. No injuries were reported. The 30 recalls resulted in a combined number of 914 598 recalled units sold. CONCLUSIONS: The current approach to protecting children from lead hazards in consumer products could be augmented by timely notifying the public health community about recalls so they can broadly disseminate information through their channels to reduce lead exposure in children. Additional steps to reduce lead contamination in children's products when sourcing raw materials and components may help to decrease the number of recalls.

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.

BACKGROUND: Uganda has had seven Ebola disease outbreaks, between 2000 and 2022. On Sept 20, 2022, the Ministry of Health declared a Sudan virus disease outbreak in Mubende District, Central Uganda. We describe the epidemiological characteristics and transmission dynamics. METHODS: For this descriptive study, cases were classified as suspected, probable, or confirmed using Ministry of Health case definitions. We investigated all reported cases to obtain data on case-patient demographics, exposures, and signs and symptoms, and identified transmission chains. We conducted a descriptive epidemiological study and also calculated basic reproduction number (R(o)) estimates. FINDINGS: Between Aug 8 and Nov 27, 2022, 164 cases (142 confirmed, 22 probable) were identified from nine (6%) of 146 districts. The median age was 29 years (IQR 20-38), 95 (58%) of 164 patients were male, and 77 (47%) patients died. Symptom onsets ranged from Aug 8 to Nov 27, 2022. The case fatality rate was highest in children younger than 10 years (17 [74%] of 23 patients). Fever (135 [84%] of 160 patients), vomiting (93 [58%] patients), weakness (89 [56%] patients), and diarrhoea (81 [51%] patients) were the most common symptoms; bleeding was uncommon (21 [13%] patients). Before outbreak identification, most case-patients (26 [60%] of 43 patients) sought care at private health facilities. The median incubation was 6 days (IQR 5-8), and median time from onset to death was 10 days (7-23). Most early cases represented health-care-associated transmission (43 [26%] of 164 patients); most later cases represented household transmission (109 [66%]). Overall R(o) was 1·25. INTERPRETATION: Despite delayed detection, the 2022 Sudan virus disease outbreak was rapidly controlled, possibly thanks to a low R(o). Children (aged <10 years) were at the highest risk of death, highlighting the need for targeted interventions to improve their outcomes during Ebola disease outbreaks. Initial care-seeking occurred at facilities outside the government system, showing a need to ensure that private and public facilities receive training to identify possible Ebola disease cases during an outbreak. Health-care-associated transmission in private health facilities drove the early outbreak, suggesting gaps in infection prevention and control. FUNDING: None.

The Advisory Committee on Immunization Practices (ACIP) recommended that dengue pre-vaccination screening tests for Dengvaxia administration have at least 98% specificity and 75% sensitivity. This study evaluates the performance of commercial anti-DENV IgG tests to identify tests that could be used for pre-vaccination screening. First, for seven tests, we evaluated sensitivity and specificity in early convalescent dengue virus (DENV) infection, using 44 samples collected 7-30 days after symptom onset and confirmed by RT-PCR. Next, for the five best-performing tests and two additional tests (with and without an external test reader) that became available later, we evaluated performance to detect past dengue infection among a panel of 44 specimens collected in 2018-2019 from healthy 9- to 16-year-old children from Puerto Rico. Finally, a full-scale evaluation was done with the four best-performing tests using 400 specimens from the same population. We used virus focus reduction neutralization test and an in-house DENV IgG ELISA as reference standards. Of seven tests, five showed ≥75% sensitivity in detecting anti-DENV IgG in early convalescent specimens with low cross-reactivity to the Zika virus. For the detection of previous DENV infections, the tests with the highest performance were the Euroimmun NS1 IgG ELISA (sensitivity 84.5%, specificity 97.1%) and CTK Dengue IgG rapid test R0065C with the test reader (sensitivity 76.2% specificity 98.1%). There are IgG tests available that can be used to accurately classify individuals with previous DENV infection as eligible for dengue vaccination to support safe vaccine implementation. IMPORTANCE: The Advisory Committee on Immunization Practices (ACIP) has set forth recommendations that dengue pre-vaccination screening tests must exhibit at least 98% specificity and 75% sensitivity. Our research rigorously assesses the performance of various commercial tests against these benchmarks using well-characterized specimens from Puerto Rico. The findings from our study are particularly relevant given FDA approval and ACIP recommendation of Sanofi Pasteur's Dengvaxia vaccine, highlighting the need for accurate pre-vaccination screening tools.

BACKGROUND AND AIMS: A functional cure and therapeutic end point of chronic HBV infection is defined as the clearance of HBsAg from serum. Little is known about the long-term durability of HBsAg loss in the Alaskan Native population. APPROACH AND RESULTS: We performed a retrospective cohort study of Alaska Native patients with chronic HBV-monoinfection from January 1982 through December 2019. The original group in this cohort was identified during a 1982 to 1987 population-based screening for 3 HBV serologic markers in 53,000 Alaska Native persons. With close to 32,000 years of follow-up, we assessed the frequency and duration of HBsAg seroclearance (HBsAg-negative for > 6 mo). We examined factors associated with HBsAg clearance and followed persons for a median of 13.1 years afterward to assess the durability of HBsAg clearance. Among 1079 persons with an average length of follow-up of 33 years, 260 (24%) cleared HBsAg at a constant rate of 0.82% per person/per year. Of the 260 persons who cleared, 249 (96%) remained HBsAg-negative, while 11 persons had ≥ 2 transient HBsAg-positive results in subsequent follow-up. CONCLUSIONS: Of the patients with chronic HBV monoinfection, 0.82% of people per year achieved a functional cure. HBsAg seroclearance was durable for treated and nontreated patients and lasted, on average, over 13 years without seroreversion.

Monkeypox virus (MPXV) is zoonotic and capable of infecting many mammal species. However, whether common companion animals are susceptible to MPXV infection is unclear. During July 2022-March 2023, we collected animal and environmental swab samples within homes of confirmed human mpox case-patients and tested for MPXV and human DNA by PCR. We also used ELISA for orthopoxvirus antibody detection. Overall, 12% (22/191) of animal and 25% (14/56) of environmental swab samples from 4 households, including samples from 4 dogs and 1 cat, were positive for MPXV DNA, but we did not detect viable MPXV or orthopoxvirus antibodies. Among MPXV PCR-positive swab samples, 82% from animals and 93% the environment amplified human DNA with a statistically significant correlation in observed cycle threshold values. Our findings demonstrate likely DNA contamination from the human mpox cases. Despite the high likelihood for exposure, however, we found no indications that companion animals were infected with MPXV.

INTRODUCTION: Health equity science examines underlying social determinants, or drivers, of health inequities by building an evidence base to guide action across programs, public health surveillance, policy, and communications efforts. A Social Vulnerability Index (SVI) was utilized during the COVID-19 response to identify areas where inequities exist and support communities with vaccination. We set out to assess COVID-19 vaccination coverage by two SVI themes, Racial and Ethnicity Minority Status and Housing Type and Transportation to examine disparities. METHODS: US county-level COVID-19 vaccine administration data among persons aged 5 years and older reported to the Centers for Disease Control and Prevention from December 14, 2020 to December 14, 2022, were analyzed. Counties were categorized 1) into tertiles (low, moderate, high) according to each SVI theme's level of vulnerability or 2) dichotomized by urban or rural classification. Primary series vaccination coverage per age group were assessed for SVI social factors by SVI theme tertiles or urbanicity. RESULTS: Older adults aged 65 years and older had the highest vaccination coverage across all vulnerability factors compared with children aged 5-17 years and adults aged 18-64 years. Overall, children and adults had higher vaccination coverage in counties of high vulnerability. Greater vaccination coverage differences were observed by urbanicity as rural counties had some of the lowest vaccination coverage for children and adults. CONCLUSION: COVID-19 vaccination efforts narrowed gaps in coverage for adults aged 65 years and older but larger vaccination coverage differences remained among younger populations. Moreover, greater disparities in coverage existed in rural counties. Health equity science approaches to analyses should extend beyond identifying differences by basic demographics such as race and ethnicity and include factors that provide context (housing, transportation, age, and geography) to assist with prioritization of vaccination efforts where true disparities in vaccination coverage exist.

BACKGROUND: Assessing variant-specific COVID-19 vaccine effectiveness (VE) and severity can inform public health risk assessments and decisions about vaccine composition. BA.2.86 and its descendants, including JN.1 (referred to collectively as "JN lineages"), emerged in late 2023 and exhibited substantial divergence from co-circulating XBB lineages. METHODS: We analyzed patients hospitalized with COVID-19-like illness at 26 hospitals in 20 U.S. states admitted October 18, 2023-March 9, 2024. Using a test-negative, case-control design, we estimated effectiveness of an updated 2023-2024 (Monovalent XBB.1.5) COVID-19 vaccine dose against sequence-confirmed XBB and JN lineage hospitalization using logistic regression. Odds of severe outcomes, including intensive care unit (ICU) admission and invasive mechanical ventilation (IMV) or death, were compared for JN versus XBB lineage hospitalizations using logistic regression. RESULTS: 585 case-patients with XBB lineages, 397 case-patients with JN lineages, and 4,580 control-patients were included. VE in the first 7-89 days after receipt of an updated dose was 54.2% (95% CI = 36.1%-67.1%) against XBB lineage hospitalization and 32.7% (95% CI = 1.9%-53.8%) against JN lineage hospitalization. Odds of ICU admission (adjusted odds ratio [aOR] 0.80; 95% CI = 0.46-1.38) and IMV or death (aOR 0.69; 95% CI = 0.34-1.40) were not significantly different among JN compared to XBB lineage hospitalizations. CONCLUSIONS: Updated 2023-2024 COVID-19 vaccination provided protection against both XBB and JN lineage hospitalization, but protection against the latter may be attenuated by immune escape. Clinical severity of JN lineage hospitalizations was not higher relative to XBB.

BACKGROUND: Early detection of outbreaks requires robust surveillance and reporting at both community and health facility levels. Uganda implements Integrated Disease Surveillance and Response (IDSR) for priority diseases and uses the national District Health Information System (DHIS2) for reporting. However, investigations after the first case in the 2022 Uganda Sudan virus outbreak was confirmed on September 20, 2022 revealed many community deaths among persons with Ebola-like symptoms as far back as August. Most had sought care at private facilities. We explored possible gaps in surveillance that may have resulted in late detection of the Sudan virus disease (SVD) outbreak in Uganda. METHODS: Using a standardized tool, we evaluated core surveillance capacities at public and private health facilities at the hospital level and below in three sub-counties reporting the earliest SVD cases in the outbreak. Key informant interviews (KIIs) were conducted with 12 purposively-selected participants from the district local government. Focus group discussions (FGDs) were conducted with community members from six villages where early probable SVD cases were identified. KIIs and FGDs focused on experiences with SVD and Viral Hemorrhagic Fever (VHF) surveillance in the district. Thematic data analysis was used for qualitative data. RESULTS: Forty-six (85%) of 54 health facilities surveyed were privately-owned, among which 42 (91%) did not report to DHIS2 and 39 (85%) had no health worker trained on IDSR; both metrics were 100% in the eight public facilities. Weak community-based surveillance, poor private facility engagement, low suspicion index for VHF among health workers, inability of facilities to analyze and utilize surveillance data, lack of knowledge about to whom to report, funding constraints for surveillance activities, lack of IDSR training, and lack of all-cause mortality surveillance were identified as gaps potentially contributing to delayed outbreak detection. CONCLUSION: Both systemic and knowledge-related gaps in IDSR surveillance in SVD-affected districts contributed to the delayed detection of the 2022 Uganda SVD outbreak. Targeted interventions to address these gaps in both public and private facilities across Uganda could help avert similar situations in the future.

In 2022, the Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), and state health and regulatory partners investigated an outbreak of Salmonella enterica serovar Typhimurium infections linked to cantaloupes from southwest Indiana, resulting in 87 ill persons and 32 hospitalizations reported in 11 states. Epidemiologic and traceback evidence confirmed cantaloupe as the vehicle for these infections. Based on records collected by FDA, traceback of cantaloupe exposures for 14 ill people converged on a packing house in southwest Indiana, which supplied cantaloupe to eight of the 11 points of service where ill people purchased cantaloupe. Salmonella isolates were recovered from environmental samples collected by FDA from three growers and a packing house in southwest Indiana. Whole genome sequencing analyses of these isolates found that isolates collected from one grower matched the Salmonella Typhimurium outbreak strain, and samples collected from the other two growers and the packing house matched a 2020 Salmonella Newport outbreak strain. State and federal public health and agricultural partners identified potential conditions and practices that could have possibly resulted in the contamination of cantaloupe, including the presence of Salmonella spp. in on-farm, post-harvest, and off-farm environments. This is the third outbreak of salmonellosis confirmed to be linked to melons, sourced from southwest Indiana in the last decade. The 2012, 2020, and 2022 outbreaks of reoccurring and persisting strains of Salmonella illustrate the need for additional efforts to determine the source and extent of environmental contamination in the melon growing region of southwest Indiana and for outreach and education to help promote practices to reduce contamination of melons. © 2024

Objective: To (1) estimate the lifetime prevalence of suspected and diagnosed traumatic brain injury (TBI) based on parent report overall and select sociodemographic characteristics; and (2) describe differences in prevalence of health conditions and health-related risk factors by whether a child had a lifetime history of diagnosed TBI. Study design: We analyzed data from the 2020 National Survey of Children's Health, a cross-sectional address-based survey of US households. A categorical variable was created on the basis of parent responses to 3 questions inquiring about their suspicion of their child having a brain injury, if they sought medical care, and if the health care provider provided a diagnosis. Parents also were asked to report on their child's additional health conditions, functional indicators, school and social factors, and health care access and service use. Results: The prevalence of lifetime diagnosed TBI was 4.2% (95% CI 3.8-4.5). Children with a parent-reported lifetime history of diagnosed TBI were more likely to have a variety of health conditions, special health care needs, disabilities, activity limitations, missed days of school, and unmet care coordination needs, compared with those without a history. However, they were more likely to have a usual source of sick care and to receive more health-related services. Conclusions: For school-aged children, a history of TBI is associated with parent-reported health needs and conditions, as well as missed days from school. It is particularly important for parents to seek care when they suspect their child has experienced a TBI to receive a diagnosis and monitor the impacts of the TBI. © 2024

OBJECTIVE: The effects of sanitation and hygiene interventions on the gut microbiome and enteric pathogen burden are not well understood. We measured the association between free chlorine residue (FCR) levels in drinking water, microbiome composition, and stool enteric pathogens in infants and young children in Haiti. METHODS: FCR levels were measured in household drinking water and enteric pathogen burden was evaluated using multiplex RT-PCR of stool among 131 children from one month to five years of age living in Mirebalais, Haiti. Microbiome profiling was performed using metagenomic sequencing. RESULTS: Most individuals lived in households with undetectable FCR measured in the drinking water (112/131, 86%). Detection of enteric pathogen DNA in stool was common and did not correlate with household water FCR. The infant microbiome in households with detectable FCR demonstrated reduced richness (fewer total number of species, P=0.04 Kruskall-Wallis test) and less diversity by Inverse Simpson measures (P=0.05) than households with undetectable FCR. Infants in households with a detectable FCR were more likely to have abundant Bifidobacterium. Using in vitro susceptibility testing, we found that some Bifidobacterium species were resistant to chlorine. CONCLUSIONS: FCR in household drinking water did not correlate with enteric pathogen burden in our study.

Reducing foodborne disease incidence is a public health priority. This report summarizes preliminary 2023 Foodborne Diseases Active Surveillance Network (FoodNet) data and highlights efforts to increase the representativeness of FoodNet. During 2023, incidences of domestically acquired campylobacteriosis, Shiga toxin-producing Escherichia coli infection, yersiniosis, vibriosis, and cyclosporiasis increased, whereas those of listeriosis, salmonellosis, and shigellosis remained stable compared with incidences during 2016-2018, the baseline used for tracking progress towards federal disease reduction goals. During 2023, the incidence and percentage of infections diagnosed by culture-independent diagnostic tests (CIDTs) reported to FoodNet continued to increase, and the percentage of cases that yielded an isolate decreased, affecting observed trends in incidence. Because CIDTs allow for diagnosis of infections that previously would have gone undetected, lack of progress toward disease reduction goals might reflect changing diagnostic practices rather than an actual increase in incidence. Continued surveillance is needed to monitor the impact of changing diagnostic practices on disease trends, and targeted prevention efforts are needed to meet disease reduction goals. During 2023, FoodNet expanded its catchment area for the first time since 2004. This expansion improved the representativeness of the FoodNet catchment area, the ability of FoodNet to monitor trends in disease incidence, and the generalizability of FoodNet data.

BACKGROUND: Uganda has a sentinel surveillance system in seven high-risk sites to monitor yellow fever (YF) patterns and detect outbreaks. We evaluated the performance of this system from 2017 to 2022. METHODS: We evaluated selected attributes, including timeliness (lags between different critical time points), external completeness (proportion of expected sentinel sites reporting ≥ 1 suspect case in the system annually), and internal completeness (proportion of reports with the minimum required data elements filled), using secondary data in the YF surveillance database from January 2017-July 2022. We conducted key informant interviews with stakeholders at health facility and national level to assess usefulness, flexibility, simplicity, and acceptability of the surveillance system. RESULTS: In total, 3,073 suspected and 15 confirmed YF cases were reported. The median time lag from sample collection to laboratory shipment was 37 days (IQR:21-54). External completeness was 76%; internal completeness was 65%. Stakeholders felt that the surveillance system was simple and acceptable, but were uncertain about flexibility. Most (71%) YF cases in previous outbreaks were detected through the sentinel surveillance system; data were used to inform interventions such as intensified YF vaccination. CONCLUSION: The YF sentinel surveillance system was useful in detecting outbreaks and informing public health action. Delays in case confirmation and incomplete data compromised its overall effectiveness and efficiency.

OBJECTIVES: Higher prevalence of several chronic diseases occurs in men in the United States, including diabetes and prediabetes. Of the 34 million adults with diabetes and 88 million with prediabetes there is a higher prevalence of both conditions in men compared to women. Black, Hispanic, and American Indian men have some of the highest rates of diabetes and diabetes complications. Adopting a healthy lifestyle including healthy eating and physical activity, is important in preventing type 2 diabetes and diabetes complications. DESIGN: This study included six focus groups that explored facilitators and barriers to adopting a healthy lifestyle in Black, Hispanic, and American Indian men with diabetes or at risk for type 2 diabetes. Thematic analysis was used to identify facilitators and barriers to adopting a healthy lifestyle. RESULTS: Participants included males 18 years of age and older identifying as Black, Hispanic, or American Indian and diagnosed with prediabetes, diabetes, hypertension, or otherwise at risk for type 2 diabetes. Thirty-seven men participated, 19 diagnosed with diabetes and 18 at risk for type 2 diabetes. Fourteen Black, 14 Hispanic, and 9 American Indian men participated. The themes of facilitators to a healthy lifestyle included: family and the social network; psychosocial factors; health status, health priorities and beliefs about aging; knowledge about health and healthy behavior; and healthy community resources. Themes of barriers to a healthy lifestyle also included: mistrust of the health care system, cost, and low socioeconomic status. CONCLUSIONS: This study underscores the complexity of factors involved in adopting a healthy lifestyle for some racial and ethnic minority men with diabetes or at risk for type 2 diabetes.

BACKGROUND: In 2022, an Ebola disease outbreak caused by Sudan virus (SUDV) occurred in Uganda, primarily affecting Mubende and Kassanda districts. We determined risk factors for SUDV infection among household members (HHM) of cases. METHODS: We conducted a case-control and retrospective cohort study in January 2023. Cases were RT-PCR-confirmed SUDV infection in residents of Mubende or Kassanda districts during the outbreak. Case-households housed a symptomatic, primary case-patient for ≥ 24 h and had ≥ 1 secondary case-patient with onset < 2 weeks after their last exposure to the primary case-patient. Control households housed a case-patient and other HHM but no secondary cases. A risk factor questionnaire was administered to the primary case-patient or another adult who lived at home while the primary case-patient was ill. We conducted a retrospective cohort study among case-household members and categorized their interactions with primary case-patients during their illnesses as none, minimal, indirect, and direct contact. We conducted logistic regression to explore associations between exposures and case-household status, and Poisson regression to identify risk factors for SUDV infection among HHM. RESULTS: Case- and control-households had similar median sizes. Among 19 case-households and 51 control households, primary case-patient death (adjusted odds ratio [OR(adj)] = 7.6, 95% CI 1.4-41) and ≥ 2 household bedrooms (OR(adj)=0.19, 95% CI 0.056-0.71) were associated with case-household status. In the cohort of 76 case-HHM, 44 (58%) were tested for SUDV < 2 weeks from their last contact with the primary case-patient; 29 (38%) were positive. Being aged ≥ 18 years (adjusted risk ratio [aRR(adj)] = 1.9, 95%CI: 1.01-3.7) and having direct or indirect contact with the primary case-patient (aRR(adj)=3.2, 95%CI: 1.1-9.7) compared to minimal or no contact increased risk of Sudan virus disease (SVD). Access to a handwashing facility decreased risk (aRR(adj)=0.52, 95%CI: 0.31-0.88). CONCLUSION: Direct contact, particularly providing nursing care for and sharing sleeping space with SVD patients, increased infection risk among HHM. Risk assessments during contact tracing may provide evidence to justify closer monitoring of some HHM. Health messaging should highlight the risk of sharing sleeping spaces and providing nursing care for persons with Ebola disease symptoms and emphasize hand hygiene to aid early case identification and reduce transmission.

BACKGROUND: On 20 September 2022, Uganda declared its fifth Sudan virus disease (SVD) outbreak, culminating in 142 confirmed and 22 probable cases. The reproductive rate (R) of this outbreak was 1.25. We described persons who were exposed to the virus, became infected, and they led to the infection of an unusually high number of cases during the outbreak. METHODS: In this descriptive cross-sectional study, we defined a super-spreader person (SSP) as any person with real-time polymerase chain reaction (RT-PCR) confirmed SVD linked to the infection of ≥ 13 other persons (10-fold the outbreak R). We reviewed illness narratives for SSPs collected through interviews. Whole-genome sequencing was used to support epidemiologic linkages between cases. RESULTS: Two SSPs (Patient A, a 33-year-old male, and Patient B, a 26-year-old male) were identified, and linked to the infection of one probable and 50 confirmed secondary cases. Both SSPs lived in the same parish and were likely infected by a single ill healthcare worker in early October while receiving healthcare. Both sought treatment at multiple health facilities, but neither was ever isolated at an Ebola Treatment Unit (ETU). In total, 18 secondary cases (17 confirmed, one probable), including three deaths (17%), were linked to Patient A; 33 secondary cases (all confirmed), including 14 (42%) deaths, were linked to Patient B. Secondary cases linked to Patient A included family members, neighbours, and contacts at health facilities, including healthcare workers. Those linked to Patient B included healthcare workers, friends, and family members who interacted with him throughout his illness, prayed over him while he was nearing death, or exhumed his body. Intensive community engagement and awareness-building were initiated based on narratives collected about patients A and B; 49 (96%) of the secondary cases were isolated in an ETU, a median of three days after onset. Only nine tertiary cases were linked to the 51 secondary cases. Sequencing suggested plausible direct transmission from the SSPs to 37 of 39 secondary cases with sequence data. CONCLUSION: Extended time in the community while ill, social interactions, cross-district travel for treatment, and religious practices contributed to SVD super-spreading. Intensive community engagement and awareness may have reduced the number of tertiary infections. Intensive follow-up of contacts of case-patients may help reduce the impact of super-spreading events.

BACKGROUND: Individuals living in communities with poor access to healthcare may be unaware of their high blood pressure (BP). While the use of community health workers (CHWs) can address gaps in human resources for health, CHWs in Uganda have not been used previously for BP screening and management. We report the results of an initiative to train CHWs to evaluate BP and to administer group-based education in Kalangala and Buvuma Island Districts of Lake Victoria, Uganda. METHODS: We randomly selected 42 of 212 villages. We trained CHWs based in island districts on measuring BP. CHWs visited all households in the selected villages and invited all adults ≥ 18 years to be screened for high BP. We used the World Health Organization's STEPwise tool to collect data on demographic and behavioral characteristics and BP measurements. High blood pressure was defined as systolic BP (SBP) ≥ 140 mm Hg and/or diastolic BP (DBP) ≥ 90 mm Hg over three readings. CHWs created and led fortnight support groups for individuals identified with high blood pressure at baseline. At each group meeting, CHWs re-measured BP and administered an intervention package, which included self-management and lifestyle education to participants. The paired t-test was used to compare mean values of systolic blood pressure (SBP) and diastolic blood pressure (DBP) before and after the intervention. Generalized estimating equations (GEE) were used to model longitudinal changes in BP. RESULTS: We trained 84 CHWs to measure BP and deliver the intervention package. Among 2,016 community members, 570 (28.3%) had high blood pressure; of these, 63 (11.1%) had a previous diagnosis of hypertension. The comparison of SBP and DBP before and after the intervention revealed significant reductions in mean SBP from 158mmHg (SD = 29.8) to 149 mmHg (SD = 29.8) (p < 0.001) and mean DBP from 97mmHg (SD = 14.3) to 92mmHg (p < 0.001). GEE showed decreases of -1.133 (SBP) and - 0.543 mmHg (DBP)/fortnight. CONCLUSION: High BP was common but previously undiagnosed. The CHW-led group-based self-management and education for controlling high BP was effective in the island districts in Uganda. Scaling up the intervention in other hard-to-reach districts could improve control of high BP on a large scale.

BACKGROUND: Hospital-onset bacteraemia and fungaemia (HOB) is being explored as a surveillance and quality metric. The objectives of the current study were to determine sources and preventability of HOB in hospitalised patients in the USA and to identify factors associated with perceived preventability. METHODS: We conducted a cross-sectional study of HOB events at 10 academic and three community hospitals using structured chart review. HOB was defined as a blood culture on or after hospital day 4 with growth of one or more bacterial or fungal organisms. HOB events were stratified by commensal and non-commensal organisms. Medical resident physicians, infectious disease fellows or infection preventionists reviewed charts to determine HOB source, and infectious disease physicians with training in infection prevention/hospital epidemiology rated preventability from 1 to 6 (1=definitely preventable to 6=definitely not preventable) using a structured guide. Ratings of 1-3 were collectively considered 'potentially preventable' and 4-6 'potentially not preventable'. RESULTS: Among 1789 HOB events with non-commensal organisms, gastrointestinal (including neutropenic translocation) (35%) and endovascular (32%) were the most common sources. Overall, 636/1789 (36%) non-commensal and 238/320 (74%) commensal HOB events were rated potentially preventable. In logistic regression analysis among non-commensal HOB events, events attributed to intravascular catheter-related infection, indwelling urinary catheter-related infection and surgical site infection had higher odds of being rated preventable while events with neutropenia, immunosuppression, gastrointestinal sources, polymicrobial cultures and previous positive blood culture in the same admission had lower odds of being rated preventable, compared with events without those attributes. Of 636 potentially preventable non-commensal HOB events, 47% were endovascular in origin, followed by gastrointestinal, respiratory and urinary sources; approximately 40% of those events would not be captured through existing healthcare-associated infection surveillance. DISCUSSION: Factors identified as associated with higher or lower preventability should be used to guide inclusion, exclusion and risk adjustment for an HOB-related quality metric.