This systematic review synthesized published literature (2000 - 2023) to identify HIV interventions specifically designed for transgender persons in the United States (PROSPERO registration number: CRD42021256460). The review also summarized strategies for improving outcomes related to the four pillars of the Ending the HIV Epidemic (EHE) initiative in the United States: Diagnose, Treat, Prevent, and Respond. A comprehensive search was conducted using the Centers for Disease Control and Prevention's HIV Prevention Research Synthesis Project database, which included over 120,000 citations from routine systematic searches in CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts. Of 23 interventions that met inclusion criteria, 94% focused on transgender women of color and 22% focused on young transgender persons aged 15-29 years old. Most interventions focused on Treat or Prevent, few focused on Diagnosis, and none focused on Respond. Twenty interventions (87%) showed improvement in at least one EHE related outcome and a quarter of these effective interventions were tested with randomized controlled trials. Common strategies observed in effective interventions include the following: engaging the community in intervention development; pilot-testing with the focus population to ensure appropriateness and acceptability; addressing social determinants of health (e.g. stigma, discrimination, violence) through empowerment and gender-affirming approaches; increasing access to care, prevention, and services through co-location and one-stop shop models; and utilizing peer-led counseling, education, support, and navigation. Continuous effort is needed in addressing gaps, including more research for transgender men and rural settings and for how best to adopt and adapt best practices for subgroups of transgender population.

A qualitative systematic review was conducted to evaluate pre-exposure prophylaxis (PrEP) interventions, describe characteristics of best practices for increasing PrEP use and persistence, and explore research gaps based on current PrEP interventions. We searched CDC's Prevention Research Synthesis (PRS) Project's cumulative HIV database (includes CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts) to identify PrEP intervention studies conducted in the U.S., published between 2000 and 2022 (last searched January 2023). Eligibility criteria include studies that evaluated PrEP interventions for persons testing negative for HIV infection, or for healthcare providers who prescribed PrEP; included comparisons between groups or pre/post; and reported at least one relevant PrEP outcome. Each eligible intervention was evaluated on the quality of study design, implementation, analysis, and strength of evidence (PROSPERO registration number: CRD42021256460). Of the 26 eligible interventions, the majority were focused on men who have sex with men (n = 18) and reported PrEP adherence outcomes (n = 12). Nine interventions met the criteria for Best Practices (i.e., evidence-based interventions, evidence-informed interventions). Five were digital health interventions while two implemented individual counseling, one offered motivational interviewing, and one provided integrated medical care with a PrEP peer navigator. Longer intervention periods may provide more time for intervention exposure to facilitate behavioral change, and engaging the community when developing, designing and implementing interventions may be key for effectiveness. For digital health interventions, two-way messaging may help participants feel supported. Research gaps included a lack of Best Practices for several populations (e.g., Black persons, Hispanic/Latino persons, persons who inject drugs, and women of color) and evidence for various intervention strategies (e.g., interventions for promoting provider's PrEP prescription behavior, peer support). These findings call for more collaborative work with communities to develop interventions that work and implement and disseminate Best Practices for increasing PrEP use and persistence in communities.

INTRODUCTION: HIV preexposure prophylaxis (PrEP) is highly effective when taken as prescribed. Digital health adherence interventions have been identified as effective for improving antiretroviral therapy adherence among people with HIV, but limited evidence exists for PrEP adherence interventions among people without HIV. The purpose of this Community Guide systematic review was to present the characteristics and effectiveness of digital PrEP adherence interventions. METHODS: The author searched the CDC HIV Prevention Research Synthesis cumulative database for digital health interventions with PrEP adherence outcomes published in peer-reviewed journals from 2000-2022. Studies with comparison arms or pre-post data evaluating interventions in high-income countries were included. Two reviewers independently screened citations, extracted data, conducted risk of bias assessment, and resolved discrepancies through discussion. Summary effect estimates were calculated using median and interquartile interval. RESULTS: Nine studies were included and all focused on gay, bisexual, and other men who have sex with men. Eight studies were U.S.-based while the other was conducted in the Netherlands. Five were randomized control trials and four were pre-/post studies. All studies showed improved adherence in the intervention arms compared with comparison groups or pre-intervention data. One study also reported improvement in PrEP care retention. DISCUSSION: Digital health adherence interventions with different strategies to improve PrEP and HIV-related outcomes were identified. The small number of studies identified is a limitation. Findings from this review served as the basis for the Community Preventive Services Task Force recommendation to use these interventions to increase PrEP adherence to prevent HIV infection.

In 2016, CDC identified a multidrug-resistant (MDR) strain of Salmonella enterica serotype Newport that is now monitored as a persisting strain (REPJJP01). Isolates have been obtained from U.S. residents in all 50 states and the District of Columbia, linked to travel to Mexico, consumption of beef products obtained in the United States, or cheese obtained in Mexico. In 2021, the number of isolates of this strain approximately doubled compared with the 2018-2020 baseline and remained high in 2022. During January 1, 2021- December 31, 2022, a total of 1,308 isolates were obtained from patients, cattle, and sheep; 86% were MDR, most with decreased susceptibility to azithromycin. Approximately one half of patients were Hispanic or Latino; nearly one half reported travel to Mexico during the month preceding illness, and one third were hospitalized. Two multistate outbreak investigations implicated beef products obtained in the United States. This highly resistant strain might spread through travelers, animals, imported foods, domestic foods, or other sources. Isolates from domestic and imported cattle slaughtered in the United States suggests a possible source of contamination. Safe food and drink consumption practices while traveling and interventions across the food production chain to ensure beef safety are necessary in preventing illness.

Salmonella infection causes epidemic death in wild songbirds, with potential to spread to humans. In February 2021, public health officials in Oregon and Washington, USA, isolated a strain of Salmonella enterica serovar Typhimurium from humans and a wild songbird. Investigation by public health partners ultimately identified 30 illnesses in 12 states linked to an epidemic of Salmonella Typhimurium in songbirds. We report a multistate outbreak of human salmonellosis associated with songbirds, resulting from direct handling of sick and dead birds or indirect contact with contaminated birdfeeders. Companion animals might have contributed to the spread of Salmonella between songbirds and patients; the outbreak strain was detected in 1 ill dog, and a cat became ill after contact with a wild bird. This outbreak highlights a One Health issue where actions like regular cleaning of birdfeeders might reduce the health risk to wildlife, companion animals, and humans.

This systematic review synthesized published literature (January 2008-October 2021) about the association between social determinants of health (SDOH) and HIV testing among Hispanic/Latino gay, bisexual, and other men who have sex with men (HLMSM), a group disproportionally affected by HIV. Having higher education than a high school diploma, health insurance and access to health care services, and visiting a health care provider in the past 12 months were some of the determinants associated with HIV testing, while limited English proficiency was associated with reduced odds of HIV-testing among HLMSM. More research is needed to understand the relationship of SDOH (especially neighborhood) and HIV testing, how SDOH may affect HIV testing among different HLMSM groups, and how to increase self-testing and use of e-health in this priority population. Additionally, culturally and linguistically appropriate multilevel interventions and health services for HLMSM are urgently needed to diagnose HIV as early as possible after infection.

Up to 50% of those diagnosed with HIV in the U.S. are not retained in medical care. Care retention provides opportunity to monitor benefits of HIV therapy and enable viral suppression. To increase retention, there is a need to prioritize best practices appropriate for translation and dissemination for real-world implementation. Eighteen interventions from CDC's Compendium of Evidence-Based Interventions were scored using the RE-AIM framework to determine those most suitable for dissemination. A CDC Division of HIV Prevention workgroup developed a RE-AIM scale with emphasis on the Implementation and Maintenance dimensions and less emphasis on the Efficacy dimension since all 18 interventions were already identified as evidence-based or evidence-informed. Raters referenced primary efficacy publications and scores were averaged for a ranked RE-AIM score for interventions. Of 18 interventions, four included care linkage and 7 included viral suppression outcomes. Interventions received between 20.6 and 35.3 points (45 maximum). Scores were converted into a percentage of the total possible with ranges between 45.8 and 78.4%. Top four interventions were ARTAS (78.4%); Routine Screening for HIV (RUSH) (73.2%); Optn4Life (67.4%) and Virology Fast Track (65.9%). All four scored high on Implementation and Maintenance dimensions. Select items within the scale were applicable to health equity, covering topics such as reaching under-served focus populations and acceptability to that population. Navigation-enhanced Case Management (NAV) scored highest on the health equity subscale. RE-AIM prioritization scores will inform dissemination and translation efforts, help clinical staff select feasible interventions for implementation, and support sustainability for those interventions.

Pre-exposure prophylaxis (PrEP), an antiretroviral medication to prevent HIV, is becoming more widely available in the United States since the Federal Drug Administration approved it in 2012. However, PrEP use among men who have sex with men (MSM) is still limited and many MSM who are willing to take PrEP are not on PrEP. We performed a systematic review to identify factors associated with willingness to use PrEP among MSM who are not on PrEP. The majority of the 23 relevant studies had low risk of bias and used a cross-sectional design. Willingness was associated with being Hispanic/Latino (odds ratio [OR] = 1.68, 95% confidence interval [CI] [1.01-2.78]), Black (OR = 1.41, 95% CI [1.02-1.95]), younger (OR = 1.08, 95% CI [1.02-1.15]), having no college degree (OR = 1.37, 95% CI [1.12-1.59]), or low income (OR = 1.21, 95% CI [1.12-1.32]). A higher proportion of MSM who had recent condomless anal sex (OR = 1.85, 95% CI [1.49-2.29]) were diagnosed with sexually transmitted infection (OR = 1.60, 95% CI [1.27-2.01]), or MSM who had multiple sex partners (OR = 1.58, 95% CI [1.07-2.32]) were more willing to use PrEP compared with their respective counterparts. Findings suggest that MSM with racial/ethnic minority status, low-socioeconomic status, younger age, and engagement in HIV risk behaviors are willing to take PrEP but may lack access. Study limitations include the inability to conduct meta-analyses on certain predictor variables due to a small number of studies. This review identified MSM subpopulations who may benefit from interventions increasing PrEP access.

From 2016-2019, dry bulb onions were the suspected cause of three multistate outbreaks in the United States. We investigated a large multistate outbreak of Salmonella Newport infections that caused illnesses in both the United States and Canada in 2020. Epidemiologic, laboratory and traceback investigations were conducted to determine the source of the infections, and data were shared among U.S. and Canadian public health officials. We identified 1127 U.S. illnesses from 48 states with illness onset dates ranging from 19 June to 11 September 2020. Sixty-six per cent of ill people reported consuming red onions in the week before illness onset. Thirty-five illness sub-clusters were identified during the investigation and seventy-four per cent of sub-clusters served red onions to customers during the exposure period. Traceback for the source of onions in illness sub-clusters identified a common onion grower in Bakersfield, CA as the source of red onions, and onions were recalled at this time. Although other strains of Salmonella Newport were identified in environmental samples collected at the Bakersfield, CA grower, extensive environmental and product testing did not yield the outbreak strain. This was the third largest U.S. foodborne Salmonella outbreak in the last 30 years. It is the first U.S. multistate outbreak with a confirmed link to dry bulb onions, and it was nearly 10-fold larger than prior outbreaks with a suspected link to onions. This outbreak is notable for its size and scope, as well as the international data sharing that led to implication of red onions as the primary cause of the outbreak. Although an environmental assessment at the grower identified several factors that likely contributed to the outbreak, no main reason was identified. The expedient identification of the outbreak vehicle and response of multiple public health agencies allowed for recall and removal of product from the marketplace, and rapid messaging to both the public and industry on actions to protect consumers; these features contributed to a decrease in cases and expeditious conclusion of the outbreak.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of five intervention strategies: patient navigation, appointment help/alerts, psychosocial support, transportation/appointment accompaniment, and data-to-care on HIV care outcomes among persons with HIV (PWH) who are out of care (OOC). DESIGN: A systematic review with meta-analysis. METHODS: We searched CDC's Prevention Research Synthesis (PRS) Project's cumulative HIV database to identify intervention studies conducted in the U.S., published between 2000 and 2020 that included comparisons between groups or prepost, and reported at least one relevant outcome (i.e., re-engagement and retention in HIV care, and viral suppression). Effect sizes were meta-analyzed using random-effect models to assess intervention effectiveness. RESULTS: Thirty-nine studies reporting on 42 unique interventions met the inclusion criteria. Overall, intervention strategies are effective in improving re-engagement in care [odds ratio (OR) = 1.79; 95% confidence interval (95% CI): 1.36-2.36, k = 14], retention in care (OR = 2.01; 95% CI: 1.64-2.64, k = 22), and viral suppression (OR = 2.50; 95% CI: 1.87-3.34, k = 27). Patient navigation, appointment help/alerts, psychosocial support, and transportation/appointment accompaniment improved all three HIV care outcomes. Data-to-care improved re-engagement and retention but had insufficient evidence for viral suppression. CONCLUSION: Several strategies are effective for improving HIV care outcomes among PWH who are OOC. More work is still needed for consistent definitions of OCC and HIV care outcomes, better reporting of intervention and cost data, and identifying how best to implement and scale-up effective strategies to engage and retain OOC PWH in care and reach the ending the HIV epidemic goals.

OBJECTIVES: HIV prevalence is an estimated 14% among transgender women (TW) and 3% among transgender men (TM). HIV care is vital for viral suppression but is hindered by transphobia and HIV stigma. We assessed HIV care outcomes among transgender persons (TG) with HIV in the United States. DESIGN: Systematic review and meta-analysis of peer-reviewed journal articles. METHODS: We searched multiple electronic databases and CDC's HIV Prevention Research Synthesis database for 2006-September 2018. Eligible reports were US-based studies that included TG and reported HIV care outcomes. Random-effects models were used to calculate HIV care outcome rates. The protocol is registered with PROSPERO (CRD42018079564). RESULTS: Few studies reported outcomes for TM; therefore, only TW meta-analysis results are reported. Twenty-one studies were identified having low-to-medium risk-of-bias scores. Among TW with HIV, 82% had ever received HIV care; 72% were receiving care, and 83% of those were retained in HIV care. Sixty-two percent were currently virally suppressed. Among those receiving HIV care or antiretroviral therapy (ART), 67% were virally suppressed at last test. Sixty-five percent were linked to HIV care ≤3 months after diagnosis. Seventy-one percent had ever been prescribed ART. Approximately 66% were taking ART, and 66% were ART-adherent. Only 56% were currently adherent the previous year. CONCLUSIONS: HIV care outcomes for TW were not ideal, and research gaps exists for TM. High heterogeneity was observed; therefore, caution should be taken interpreting the findings. Integrating transgender-specific health needs are needed to improve outcomes of transgender persons across the HIV care continuum.

In the United States, Hispanic/Latino men who have sex with men (HLMSM) are disproportionally affected by HIV. We conducted a rapid review of national surveillance data to examine disparities in HIV prevention and care outcomes among HLMSM. Thirteen reports provided relevant data from 2011 to 2018. Compared to White MSM, a higher percentage of HIV-negative HLMSM reported not taking PrEP and engaging in condomless sex; a lower percentage of HIV-negative HLMSM at risk for HIV reported PrEP awareness and use; and a lower percentage of HIV-positive HLMSM were aware of their status, linked to HIV care, and virally suppressed. Viral suppression rates in HLMSM were better among Ryan White clients than the national rates, suggesting that access to comprehensive care/services reduces disparities. Findings also call for identifying individual, social, and structural factors contributing to condomless sex without PrEP use and HIV status unawareness and identifying best approaches for scaling up comprehensive care/services.

In July 2020, PulseNet, the national molecular subtyping network for enteric disease surveillance, detected a cluster of 17 Salmonella Typhimurium infections. The isolates were closely related genetically to each other (four allele differences) by whole genome sequencing (WGS) analysis and related to isolates from two previous outbreaks of S. Typhimurium infections linked to pet hedgehogs (1,2). An investigation was initiated to characterize illnesses and identify the outbreak source. | | A case was defined as the isolation of S. Typhimurium closely related by WGS to the outbreak strain in a specimen from a patient with illness onset during April–November 2020. State and local officials interviewed patients about hedgehog exposures and purchase information. Animal and environmental sampling of hedgehog enclosures was conducted at some patient residences. Hedgehog purchase locations were contacted in an attempt to identify a possible common source or supplier of hedgehogs. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.*

Stigma may contribute to HIV disparities for men who have sex with men (MSM). This systematic review quantified the effects of HIV stigma interventions for MSM on stigma and sex risk. We conducted a systematic search to identify US-based studies published between 2000 and June 2019 focused on HIV and MSM, and either measured stigma pre-post or included a stigma intervention component. Twenty-nine articles, representing 26 unique studies met inclusion criteria. Random effect models showed no intervention effect for reducing stigma and a non-significant increase in HIV testing. Significant decreases in condomless sex with males, condomless sex with females, and substance-influenced sex were found. Few intervention studies measured stigma pre-post. Findings suggest that including a stigma reduction component in interventions can improve HIV testing and reduce sex risk for MSM. Developing interventions to address stigma may be important in decreasing HIV infection among MSM and ending the HIV epidemic.

On September 16, 2019, PulseNet, the national molecular subtyping network for foodborne disease surveillance, reported a multistate cluster of seven Escherichia coli O157:H7 infections from California (five), Oregon (one), and Pennsylvania (one). Isolates from cases of human illness were sequenced and then analyzed using core-genome multilocus sequence typing (cgMLST); the isolates were closely related within three allele differences (1). Federal, state, and local officials initiated a multistate outbreak investigation to identify the source and prevent additional illnesses.

Patient navigation is a promising strategy for improving health among persons with multiple barriers to HIV care, yet little is known about navigation's core components. From 24 systematically identified navigation studies, we abstracted navigators' activities, grouped activities into 20 thematic activity categories, and ordered them by frequency. Subsequently, Principal Components Analysis of activity categories was used identify independent clusters. Accompaniment characterized 71% of navigation programs; ≥ half included health education (58%), collaboration/coordination (58%), linkage-to-care (54%), transportation support (54%), service referrals (50%) and instrumental support (50%). Five unique components (comprising 13 activity categories) were identified: (1) services beyond office, (2) health education and relationship building, (3) accompaniment and instrumental support, (4) locating patients and tracking information, and (5) beyond HIV care. Navigators who located patients or tracked information were less likely to provide accompaniment or instrumental support (r = - 0.60, p = 0.002). Findings can enhance precision in developing, describing, evaluating and improving navigation programs.

OBJECTIVE: Research synthesis, through qualitative or quantitative systematic reviews, allows for integrating results of primary research to improve public health. We examined more than 2 decades of work in HIV prevention by the Centers for Disease Control and Prevention's (CDC's) HIV/AIDS Prevention Research Synthesis (PRS) Project. We describe the context and contributions of research synthesis, including systematic reviews and meta-analyses, through the experience of the PRS Project. METHODS: We reviewed PRS Project publications and products and summarized PRS contributions from 1996 to July 2020 in 4 areas: synthesis of interventions and epidemiologic studies, synthesis methods, prevention programs, and prevention policy. RESULTS: PRS Project publications summarized risk behaviors and effects of prevention interventions (eg, changing one's perception of risk, teaching condom negotiation skills) across populations at risk for HIV infection and intervention approaches (eg, one-on-one or group meetings) as the HIV/AIDS epidemic and science evolved. We used the PRS Project cumulative database and intervention efficacy reviews to contribute to prevention programs and policies through identification of evidence-based interventions and development of program guidance. Subject matter experts and scientific evidence informed PRS Project products and contributions, which were implemented through strategic programmatic partnerships. CONCLUSIONS: The contributions of the PRS Project to HIV prevention and public health efforts in the United States can be credited to CDC's long-standing support of the project and its context within a federal prevention agency, where HIV programs and policies were developed and implemented. The effect of the PRS Project was likely facilitated by opportunities to directly influence program and policy because of connections with other research translation activities and program and policy decision making within CDC.

Patient navigation is increasingly used to link and (re)engage persons with human immunodeficiency virus (HIV) to care. A more holistic understanding of patient navigation can be achieved by exploring the experiences of navigators, the persons who comprise half of the navigation process. We conducted a meta-synthesis of navigator experiences with HIV patient navigation using a phenomenological approach. We identified nine relevant studies. Data were analyzed using thematic synthesis. Analysis identified two overarching themes relating to (1) the breadth and depth of bidirectional relationships and functional activities that navigators undertake to connect their clients to care and (2) the inherently personal experience of delivering navigation services. From these thematic findings, we recommend that HIV patient navigators exhibit capacity and expertise in developing and maintaining interpersonal relationships with clients and health care systems/providers and develop self-care practices and emotional boundaries with clients. Our review seeks to advance public health research and practice by articulating key experiences and perspectives of HIV patient navigators, drawing findings and recommendations applicable to the development, implementation, and evaluation of HIV patient navigation.

Shiga toxin-producing Escherichia coli (STEC) cause substantial and costly illnesses. Leafy greens are the second most common source of foodborne STEC O157 outbreaks. We examined STEC outbreaks linked to leafy greens during 2009-2018 in the United States and Canada. We identified 40 outbreaks, 1,212 illnesses, 77 cases of hemolytic uremic syndrome, and 8 deaths. More outbreaks were linked to romaine lettuce (54%) than to any other type of leafy green. More outbreaks occurred in the fall (45%) and spring (28%) than in other seasons. Barriers in epidemiologic and traceback investigations complicated identification of the ultimate outbreak source. Research on the seasonality of leafy green outbreaks and vulnerability to STEC contamination and bacterial survival dynamics by leafy green type are warranted. Improvements in traceability of leafy greens are also needed. Federal and state health partners, researchers, the leafy green industry, and retailers can work together on interventions to reduce STEC contamination.

Increasing care engagement is essential to meet HIV prevention goals and achieve viral suppression. It is difficult, however, for agencies to establish the systems and practice improvements required to ensure coordinated care, especially for clients with complex health needs. We describe the theory-driven, field-informed transfer process used to translate key components of the evidence-informed Ryan White Part A New York City Care Coordination Program into an online practice improvement toolkit, STEPS to Care (StC), with the potential to support broader dissemination. Informed by analyses of qualitative and quantitative data collected from eight agencies, we describe our four phases: (1) review of StC strategies and key elements, (2) translation into a three-part toolkit: Care Team Coordination, Patient Navigation, and HIV Self-Management, (3) pilot testing, and (4) toolkit refinement for national dissemination. Lessons learned can guide the translation of evidence-informed strategies to online environments, a needed step to achieve wide-scale implemention.

BACKGROUND: This article summarizes the results from systematic reviews of human immunodeficiency virus (HIV) prevention interventions for people who use drugs (PWUD). We performed an overview of reviews, meta-analysis, meta-epidemiology, and PROSPERO Registration CRD42017070117. METHODS: We conducted a comprehensive systematic literature search using the Centers for Disease Control and Prevention HIV/AIDS Prevention Research Synthesis Project database to identify quantitative systematic reviews of HIV public heath interventions with PWUD published during 2002-2017. We recombined results of US studies across reviews to quantify effects on HIV infections, continuum of HIV care, sexual risk, and 5 drug-related outcomes (sharing injection equipment, injection frequency, opioid use, general drug use, and participation in drug treatment). We conducted summary meta-analyses separately for reviews of randomized controlled trials (RCTs) and quasi-experiments. We stratified effects by 5 intervention types: behavioral-psychosocial (BPS), syringe service programs (SSP), opioid agonist therapy (OAT), financial and scheduling incentives (FSI), and case management (CM). RESULTS: We identified 16 eligible reviews including >140 US studies with >55 000 participants. Summary effects among US studies were significant and favorable for 4 of 5 outcomes measured under RCT (eg, reduced opioid use; odds ratio [OR] = 0.70, confidence interval [CI] = 0.56-0.89) and all 6 outcomes under quasi-experiments (eg, reduced HIV infection [OR = 0.42, CI = 0.27-0.63]; favorable continuum of HIV care [OR = 0.68, CI = 0.53-0.88]). Each intervention type showed effectiveness on 1-6 outcomes. Heterogeneity was moderate to none for RCT but moderate to high for quasi-experiments. CONCLUSIONS: Behavioral-psychosocial, SSP, OAT, FSI, and CM interventions are effective in reducing risk of HIV and sequelae of injection and other drug use, and they have a continuing role in addressing the opioid crisis and Ending the HIV Epidemic.

The Camp Fire, California's deadliest wildfire, began November 8, 2018, and was extinguished November 25 (1). Approximately 1,100 evacuees from the fire sought emergency shelter. On November 10, acute gastroenteritis (AGE) was reported in two evacuation shelters; norovirus illness was suspected, because it is commonly detected in shelter-associated AGE outbreaks. Norovirus is highly contagious and resistant to several disinfectants. Butte County Public Health Department (BCPHD), assisted by the California Department of Public Health (CDPH), initiated active surveillance to identify cases, confirm the etiology, and assess shelter infection prevention and control (IPC) practices to guide recommendations. During November 8-30, a total of 292 patients with AGE were identified among nine evacuation shelters; norovirus was detected in 16 of 17 unique patient stool specimens. Shelter IPC assessments revealed gaps in illness surveillance, isolation practices, cleaning, disinfection, and handwashing. CDPH and BCPHD collaborated with partner agencies to implement AGE screening, institute isolation protocols and 24-hour cleaning services, and promote proper hand hygiene. During disasters with limited resources, damaged infrastructure, and involvement of multiple organizations, establishing shelter disease surveillance and IPC is difficult. However, prioritizing effective surveillance and IPC at shelter activation is necessary to prevent, identify, and contain outbreaks.

In the United States, men who have sex with men (MSM) are disproportionately affected by HIV. To identify research gaps and inform HIV prevention for MSM, we conducted a scoping review of systematic reviews using CDC's Prevention Research Synthesis database. Eligibility criteria comprised English-language systematic reviews focused on HIV prevention for MSM, published during 1988-2017, and included at least one U.S. primary study. We coded data type, subpopulations, topics, and key findings. To assess study quality, we used the Assessment of Multiple Systematic Reviews (AMSTAR). Among 129 relevant systematic reviews, study quality was high or moderate for 63%. Most common topics were sexual behavior and disease vulnerability. The most frequently mentioned MSM subgroups were HIV-positive, Black or African American, and young. Research gaps include Hispanic/Latino MSM, pre-exposure prophylaxis (PrEP), treatment as prevention, social determinants of health, health disparities, syndemics, and protective factors for sexual health.

Since WHO released the first PrEP guidance in 2012, the PrEP research literature has rapidly increased, but PrEP uptake is still low. To identify research gaps, this scoping review describes study characteristics, identifies populations, and maps study topics in PrEP publications. We identified 561 PrEP primary studies published in English between 2006 and 2018. The most commonly used study design was cross-sectional. Almost half of studies were conducted in non-U.S. countries and focused on men who have sex with men. We mapped study topics using five categories. The most studied category was Potential PrEP user/prescriber (41.3%) followed by Considerations while on PrEP (28.2%), PrEP efficacy and safety (20.9%), Cost-effectiveness or economic evaluation (5.2%), and Methods of and experiences with PrEP clinical trials (4.2%). Although the PrEP literature has dramatically increased, some research areas (e.g., PrEP awareness in non-U.S. countries, intervention studies to promote PrEP use) and populations (e.g., Black women) are still understudied.

BACKGROUND: Produce-associated outbreaks of Shiga toxin-producing Escherichia coli (STEC) were first identified in 1991. In April 2018, New Jersey and Pennsylvania officials reported a cluster of STEC O157 infections associated with multiple locations of a restaurant chain. CDC queried PulseNet, the national laboratory network for foodborne disease surveillance, for additional cases and began a national investigation. METHODS: A case was defined as an infection between March 13 and August 22, 2018 with one of the 22 identified outbreak-associated E. coli O157:H7 or E. coli O61 pulsed-field gel electrophoresis pattern combinations, or with a strain STEC O157 that was closely related to the main outbreak strain by whole genome sequencing. We conducted epidemiologic and traceback investigations to identify illness sub-clusters and common sources. An FDA-led environmental assessment, which tested water, soil, manure, compost, and scat samples, was conducted to evaluate potential sources of STEC contamination. RESULTS: We identified 240 case-patients from 37 states; 104 were hospitalized, 28 developed hemolytic uremic syndrome, and five died. Of 179 people who were interviewed, 152 (85%) reported consuming romaine lettuce in the week before illness onset. Twenty sub-clusters were identified. Product traceback from sub-cluster restaurants identified numerous romaine lettuce distributors and growers; all lettuce originated from the Yuma growing region. Water samples collected from an irrigation canal in the region yielded the outbreak strain of STEC O157. CONCLUSION: We report on the largest multistate leafy green-linked STEC O157 outbreak in several decades. The investigation highlights the complexities associated with investigating outbreaks involving widespread environmental contamination.

This overview of reviews summarizes the evidence from systematic reviews (SR) on the effectiveness of antiretroviral therapy (ART) adherence interventions for people with HIV (PWH) and descriptively compares adherence interventions among key populations. Relevant articles published during 1996-2017 were identified by comprehensive searches of CDC's HIV/acquired immunodeficiency syndrome (AIDS) Prevention Research Synthesis Database and manual searches. Included SRs examined primary interventions intended to improve ART adherence, focused on PWH, and assessed medication adherence or biologic outcomes (e.g., viral load). We synthesized the qualitative data and used the Assessment of Multiple Systematic Reviews (AMSTAR) for quality assessment. Forty-one SRs met inclusion criteria. Average quality was high. SRs that evaluated text-messaging interventions (n = 9) consistently reported statistically significant improvements in adherence and biologic outcomes. Other ART adherence strategies (e.g., behavioral, directly administered antiretroviral therapy [DAART]) reported improvements, but did not report significant effects for both outcomes, or intervention effects that did not persist postintervention. In the review focused on people who inject drugs (n = 1), DAART alone or in combination with medication-assisted therapy improved both outcomes. In SRs focused on children or adolescents aged <18 years (n = 5), regimen-related and hospital-based DAART improved biologic outcomes. ART adherence interventions (e.g., text-messaging) improved adherence and biologic outcomes; however, results differed for other intervention strategies, populations, and outcomes. Because few SRs reported evidence for populations at high risk (e.g., men who have sex with men), the results are not generalizable to all PWH. Future implementation studies are needed to examine medication adherence interventions in specific populations and address the identified gaps.

Patient navigation is increasingly utilized to link and (re)engage persons with HIV to care. Understanding client experiences with HIV patient navigation can facilitate intervention design and translation of evidence to practice. We conducted a qualitative meta-synthesis of client experiences with HIV patient navigation. Data were analyzed using thematic synthesis. We identified seven relevant studies; all collected data via in-depth interviews with persons with HIV who participated in HIV patient navigation. Four interrelated themes emerged from analysis that pertain to (1) the complexity of the health and social service environment and the holistic approaches taken by the navigator, (2) the profound significance of the client-navigator relationship, (3) client reluctance to end the navigation program, and (4) client self-efficacy and feelings of hope and psychological change as a result of their navigation experience. The unifying theme across all studies was the value and impact of the client-navigator relationship on client experience and quality of life. Programs should consider hiring navigators who possess strong relational skills and are peers of the clients, and clearly delineating the role of the navigator. Research should examine the impact of the client-navigator relationship on client outcomes and further investigate how participating in patient navigation affects client self-efficacy, client resiliency, and the role of posttraumatic growth to achieve improved HIV outcomes. This review underscores the significance of the relationship within intensive, multilevel interventions for individuals and communities marginalized and isolated from health and social service systems.

We investigated a large multistate outbreak that occurred in the United States in 2015-2016. Epidemiologic, laboratory, and traceback studies were conducted to determine the source of the infections. We identified 907 case-patients from 40 states with illness onset dates ranging from July 3, 2015 to March 2, 2016. Sixty-three percent of case-patients reported consuming cucumbers in the week before illness onset. Ten illness sub-clusters linked to events or purchase locations were identified. All sub-clusters investigated received cucumbers from a single distributor which were sourced from a single grower in Mexico. Seventy-five cucumber samples were collected, 19 of which yielded the outbreak strain. Whole genome sequencing performed on 154 clinical isolates and 19 cucumber samples indicated that the sequenced isolates were closely related genetically to one another. This was the largest US foodborne disease outbreak in the last ten years and the third largest in the past 20 years. This was at least the fifth multistate outbreak caused by contaminated cucumbers since 2010. The outbreak is noteworthy because a recall was issued only 17 days after the outbreak was identified, which allowed for the removal of the contaminated cucumbers still available in commerce, unlike previous cucumber associated outbreaks. The rapid identification and response of multiple public health agencies resulted in preventing this from becoming an even larger outbreak.

INTRODUCTION: The research literature addressing pre-exposure prophylaxis (PrEP) has increased considerably over the last decade. To better understand the research areas and explore research gaps, we will conduct a scoping review to map study topics and describe study characteristics and populations in publications focused on PrEP. The purpose of this protocol is to describe planned methods for the scoping review. METHODS AND ANALYSIS: We will implement a comprehensive systematic literature search to identify PrEP citations in the United States Centres for Disease Control and Prevention HIV/AIDS Prevention Research Synthesis Project database that is unique and extensively focuses on HIV/sexually transmitted infections/hepatitis. We will screen and include studies that are (1) focused on HIV PrEP, (2) primary research with human participants and (3) published in English. Two reviewers will independently abstract data on authors' names, study years, countries, population characteristics and design. To describe and summarise study topics, we will use 19 codes and five categories that were developed from a preliminary study. The five categories are category 1: potential PrEP user/prescriber (behaviours/issues for potential PrEP takers/healthcare professionals), category 2: considerations while on PrEP (experiences of and problems related to staying on or prescribing PrEP), category 3: PrEP efficacy and safety (biomedical aspects and medication efficacy), category 4: methods of and experiences with PrEP clinical trials (possesses/experiences of clinical trials) and category 5: cost-effectiveness or economic evaluation (cost studies). Data will be analysed with descriptive statistics. ETHICS AND DISSEMINATION: The findings will be presented at HIV-related conferences and published in peer-review journals.