INTRODUCTION: A drowning definition is available for use with National Syndromic Surveillance Program (NSSP) data. However, its accuracy in capturing drowning emergency department and urgent care visits at the regional level is unknown. We tested the ability of the syndromic surveillance (SS) definition in capturing unintentional and undetermined intent drowning (UUID) and describe UUID SS visit trends in a large metropolitan area. METHODS: We applied the drowning definition to NSSP data from 2016 to 2022 for the 8-county metropolitan Houston region. We queried the dataset for UUID ICD-10-CM codes and manually reviewed the chief complaint (CC) and discharge diagnosis (DD) for SS visits. True-positives were calculated by dividing the number of UUID cases identified by UUID ICD-10-CM codes and CC/DD review by the total visits captured by the SS definition. Demographics and trends of UUID visits were calculated from 2018 to 2022 due to limited data from 2016 to 2017 in NSSP. RESULTS: 2,759 visits were captured by the SS definition. After case review, 2,019 (73.2%) had ICD-10-CM drowning codes of any intent; and 2,015 of those (99.8%) were classified as UUID. Of the remaining 740 cases with no ICD-10-CM codes that were pulled by the SS definition, 690 (93.2%) had a CC/DD diagnosis of drowning/submersion/underwater related to aquatic exposure. Taken together, 2,705 (98.0%) were true-positive UUID visits based on the SS drowning definition.. Children (aged < 18 years) constituted 79% of UUID visits. Black, White and Asian/Pacific Islander persons comprised 17%, 60% and 4% of UUID visits respectively. Rates of UUID visits were lowest in 2020. CONCLUSION: Syndromic surveillance is a novel and accurate method to conduct real-time drowning surveillance in a large metropolitan region.

We report a single case of invasive pneumococcal disease (IPD) by serotype 4, multilocus sequence type 10172 (serotype 4/ST10172) isolate with vanG-type resistance genes and reduced vancomycin susceptibility. The isolate was recovered during 2022 from a 66-year-old resident with bacteremic pneumococcal pneumonia within a CDC Active Bacterial Core surveillance (ABCs) site hospital. The patient had received 23-valent pneumococcal polysaccharide vaccine and there was no evidence of concurrent or prior receipt of vancomycin in the previous year. Serotype 4/ST10172 IPD has shown increases within western ABCs sites and the recent acquisition of a vanG element warrants close monitoring of this lineage.

To determine if decreasing lifetime use of methamphetamines, cocaine, ecstasy, and inhalants among high school students occurring from 2009 to 2019 in the U.S. also occurred in five southeastern states, Youth Risk Behavior Survey data representative of high school students in grades 9-12 in 2009 and 2019 were analyzed. In a classroom setting, lifetime use of methamphetamines, cocaine, ecstasy, and inhalants were self-reported. Students nationwide (n = 30,087) were compared to students in Alabama, Georgia, Louisiana, Mississippi, and South Carolina (n = 18,237). Lifetime methamphetamine use significantly increased from 4.8% in 2009 to 6.2% in 2019 in the southeast but decreased from 4.1 to 2.2% nationwide. Use of cocaine, ecstasy, and inhalants remained stable in the southeast while decreasing significantly nationwide from 2009 to 2019. During a period when use of methamphetamines, cocaine, ecstasy, and inhalants among high school students in the U.S. decreased, use in southeastern states did not change. Culturally specific programs and interventions may be needed to prevent illicit drug use in communities of southeastern states where youth remain at risk.

BACKGROUND: Understanding the immune response kinetics to SARS-CoV-2 infection and COVID-19 vaccination is important in nursing home (NH) residents, a high-risk population. METHODS: An observational longitudinal evaluation of 37 consenting vaccinated NH residents with/without SARS-CoV-2 infection from October 2020 to July 2022 was conducted to characterize the immune response to spike protein due to infection and/or mRNA COVID-19 vaccine. Antibodies (IgG) to SARS-CoV-2 full-length spike, nucleocapsid, and receptor binding domain protein antigens were measured, and surrogate virus neutralization capacity was assessed using Meso Scale Discovery immunoassays. The participant's spike exposure status varied depending on the acquisition of infection or receipt of a vaccine dose. Longitudinal linear mixed effects modeling was used to describe trajectories based on the participant's last infection or vaccination; the primary series mRNA COVID-19 vaccine was considered two spike exposures. Mean antibody titer values from participants who developed an infection post receipt of mRNA COVID-19 vaccine were compared with those who did not. In a subset of participants (n = 15), memory B cell (MBC) S-specific IgG (%S IgG) responses were assessed using an ELISPOT assay. RESULTS: The median age of the 37 participants at enrollment was 70.5 years; 30 (81%) had prior SARS-CoV-2 infection, and 76% received Pfizer-BioNTech and 24% Moderna homologous vaccines. After an observed augmented effect with each spike exposure, a decline in the immune response, including %S IgG MBCs, was observed over time; the percent decline decreased with increasing spike exposures. Participants who developed an infection at least two weeks post-receipt of a vaccine were observed to have lower humoral antibody levels than those who did not develop an infection post-receipt. CONCLUSIONS: These findings suggest that understanding the durability of immune responses in this vulnerable NH population can help inform public health policy regarding the timing of booster vaccinations as new variants display immune escape.

Wastewater surveillance (WWS), the systematic detection of infectious agents in wastewater, provided a valuable tool for monitoring SARS-CoV-2 circulation during the COVID-19 pandemic; surveillance has expanded from 20 to 53 jurisdictions across the United States, with increasing capacity to test for more respiratory pathogens (1,2). This report highlights the use of wastewater data by the four National Wastewater Surveillance System’s (NWSS) Centers of Excellence (California; Colorado; Houston, Texas; and Wisconsin) to guide public health action during the 2022–23 respiratory disease season. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.*

BACKGROUND: Regulatory organizations recommend assessing hospital-acquired (HA) venous thromboembolism (VTE) risk for medical inpatients. OBJECTIVES: To develop and validate a risk assessment model (RAM) for HA-VTE in medical inpatients using objective and assessable risk factors knowable at admission. PATIENTS/METHODS: The development cohort included people admitted to medical services at the University of Vermont Medical Center (Burlington, VT, USA) between 2010-19 and the validation cohorts people admitted to Hennepin County Medical Center (Minneapolis, MN, USA), University of Michigan Medical Center (Ann Arbor, MI, USA), and Harris Health Systems (Houston, TX, USA). Individuals with VTE at admission, <18-years old, and admitted for <1 midnight were excluded. We used a Bayesian penalized regression technique to selected candidate HA-VTE risk factors for final inclusion in the RAM. RESULTS: The development cohort included 60,633 admissions and 227 HA-VTE and the validation cohorts 111,269 admissions and 651 HA-VTE. Seven HA-VTE risk factors with t-statistics ≥1.5 were included in the RAM: prior history of VTE, low hemoglobin, elevated creatinine, active cancer, hyponatremia, elevated red cell distribution width, and malnutrition. The AUC and calibration slope were 0.72 and 1.10. The AUC and calibration slopes were 0.70 and 0.93 at Hennepin County Medical Center, 0.70 and 0.87 at the University of Michigan Medical Center, and 0.71 and 1.00 at Harris Health Systems. The RAM performed well stratified by age, sex, and race. CONCLUSIONS: We developed and validated a RAM for HA-VTE in medical inpatients. By quantifying risk, clinicians can determine the potential benefits of measures to reduce HA-VTE.

Mycobacterium abscessus, a nontuberculous mycobacterium found in water and soil, is an opportunistic pathogen responsible for waterborne illness outbreaks in health care settings (1). On September 29, 2022, the Pennsylvania Department of Health (PADOH) received notification of M. abscessus–positive respiratory isolates from ventilator-dependent residents of a 34-bed pediatric facility. The facility is licensed for residential services, but not as a health care facility. A case was defined as the first M. abscessus–positive culture identified from a resident of this facility during March–August 2022. Three cases were identified: two colonizations and one clinical infection. PADOH investigated this outbreak to identify risk factors and recommend infection prevention and control (IPC) measures.

Fungal respiratory illnesses caused by endemic mycoses can be nonspecific and are often mistaken for viral or bacterial infections. We performed fungal testing on serum specimens from patients hospitalized with acute respiratory illness (ARI) to assess the possible role of endemic fungi as etiologic agents. Patients hospitalized with ARI at a Veterans Affairs hospital in Houston, Texas, during November 2016-August 2017 were enrolled. Epidemiologic and clinical data, nasopharyngeal and oropharyngeal samples for viral testing (PCR), and serum specimens were collected at admission. We retrospectively tested remnant sera from a subset of patients with negative initial viral testing using immunoassays for the detection of Coccidioides and Histoplasma antibodies (Ab) and Cryptococcus, Aspergillus, and Histoplasma antigens (Ag). Of 224 patient serum specimens tested, 49 (22%) had positive results for fungal pathogens, including 30 (13%) by Coccidioides immunodiagnostic assays, 19 (8%) by Histoplasma immunodiagnostic assays, 2 (1%) by Aspergillus Ag, and none by Cryptococcus Ag testing. A high proportion of veterans hospitalized with ARI had positive serological results for fungal pathogens, primarily endemic mycoses, which cause fungal pneumonia. The high proportion of Coccidioides positivity is unexpected as this fungus is not thought to be common in southeastern Texas or metropolitan Houston, though is known to be endemic in southwestern Texas. Although serological testing suffers from low specificity, these results suggest that these fungi may be more common causes of ARI in southeast Texas than commonly appreciated and more increased clinical evaluation may be warranted.

OBJECTIVE: Indoor mold after flooding poses health risks including rare but serious invasive mold infections. The purpose of this study was to evaluate use of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes for mold infection and mold exposure in Houston, Texas during the year before and the year after Hurricane Harvey. METHODS: This study used data from MarketScan, a large health insurance claims database. RESULTS: The incidence of invasive mold infections remained unchanged in the year after Hurricane Harvey; however, the incidence of diagnosis codes for mold exposure nearly doubled compared with the year before the hurricane (6.3 vs. 11.0 per 100,000 enrollees, rate ratio: 1.7, 95% confidence interval 1.0-3.1). CONCLUSIONS: Diagnosis codes alone may not be sufficiently sensitive to detect changes in invasive mold infection rates within this population and timeframe, demonstrating the need for more comprehensive studies.

BACKGROUND: Characterizing invasive mold infection (IMI) epidemiology in the context of large flooding events is important for public health planning and clinical decision making. METHODS: We assessed IMI incidence (per 10 000 healthcare encounters) 1 year before and after Hurricane Harvey at 4 hospitals in Houston, Texas. Potential IMI cases were assigned as proven or probable cases using established definitions, and surveillance cases using a novel definition. We used rate ratios to describe IMI incidence and multivariable logistic regression to examine patient characteristics associated with IMI case status. RESULTS: IMI incidence was significantly higher posthurricane (3.69 cases) than prehurricane (2.50 cases) (rate ratio, 1.48 [95% confidence interval, 1.10-2.00]), largely driven by surveillance IMI cases. Aspergillus was the most common species cultured (33.5% prehurricane and 39.9% posthurricane). About one-quarter (25.8%) of IMI patients lacked classical IMI risk factors such as hematologic malignancy and transplantations. Overall, 45.1% of IMI patients received intensive care, and in-hospital all-cause mortality was 24.2%. CONCLUSIONS: IMI incidence likely increased following Hurricane Harvey and outcomes for IMI patients were severe. Patient and clinician education on IMI prevention and identification is warranted, particularly as the frequency of extreme weather events increases due to climate change.

INTRODUCTION: The COVID-19 pandemic has had unprecedented socioeconomic and health impacts in the U.S. This study examined racial/ethnic and school poverty status differences in the relationship between parent job loss, experiences with hunger, and indicators of mental health problems among public high-school students nationwide during the COVID-19 pandemic. METHODS: The study analyzed data from the Adolescent Behaviors and Experiences Survey, conducted in January-June 2021. The Adolescent Behaviors and Experiences Survey was a 1-time, cross-sectional, online survey that used a stratified, 3-stage cluster sample to obtain a nationally representative sample of high-school students in the U.S. This study was limited to public-school students (n=7,379). RESULTS: Among public high-school students nationwide, 36.9% experienced poor mental health during the pandemic, and during the past year, 43.9% experienced persistent feelings of sadness or hopelessness, 19.8% seriously considered attempting suicide, and 9.1% attempted suicide. Parent job loss and having gone hungry were associated with indicators of mental health problems overall and across racial/ethnic groups and school poverty status levels. CONCLUSIONS: Students who experience parent job loss and hunger are likely to also experience poor mental health and may be at higher risk for suicide.

Among disease vectors, Aedes aegypti (L.) (Diptera: Culicidae) is one of the most insidious species in the world. The disease burden created by this species has dramatically increased in the past 50 years, and during this time countries have relied on pesticides for control and prevention of viruses borne by Ae. aegypti. The small number of available insecticides with different modes of action had led to increases in insecticide resistance, thus, strategies, like the "Incompatible Insect Technique" using Wolbachia's cytoplasmic incompatibility are desirable. We evaluated the effect of releases of Wolbachia infected Ae. aegypti males on populations of wild Ae. aegypti in the metropolitan area of Houston, TX. Releases were conducted by the company MosquitoMate, Inc. To estimate mosquito population reduction, we used a mosquito abundance Bayesian hierarchical estimator that accounted for inefficient trapping. MosquitoMate previously reported a reduction of 78% for an intervention conducted in Miami, FL. In this experiment we found a reduction of 93% with 95% credibility intervals of 86% and 96% after six weeks of continual releases. A similar result was reported by Verily Life Sciences, 96% [94%, 97%], in releases made in Fresno, CA.

Background: Promoting safe driver behaviors is an important aspect of road safety. To better understand road safety behaviors, there is a role for practical instruments that can validly measure typical road safety behaviors among occupational drivers. The Occupational Driver Behavior Questionnaire (ODBQ) was developed to assess road safety behaviors among home health nurses in Australia. Methods: We administered a cross-sectional survey to a sample of taxi drivers in two U.S. metropolitan areas. The survey included Newnam's ODBQ-12 and a study-specific 15-item version (ODBQ-15) assessing 4 different road safety behaviors with 3 more items added and motor-vehicle crashes in the past year. Logistic regression analyses examined the association of the road safety behaviors with motor vehicle crashes. A series of confirmatory factor analysis (CFA) models assessed the construct validity of the ODBQ-12 and ODBQ-15. Results: We pooled survey data from 497 Houston drivers and 500 Los Angeles drivers to assess study aims. CFA models examining the 12-item and the 15-item ODBQ versions had good model fit (Comparative Fit Index > 0.95, Tucker Lewis Index 0.95, root mean square error of approximation < 0.06, standardized root mean square residual 0.05). The ODBQ's road safety behaviors were significantly associated (p < 0.001) with crashes while working (ORs 0.510.75) and not working (ORs 0.570.84). Conclusions: The ODBQ-12 and ODBQ-15 were both significantly associated with motor vehicle crashes among taxicab drivers in two large U.S. metropolitan areas. Researchers studying occupational drivers who transport passengers may want to consider using the ODBQ-15. The 3 additional items are meaningful to this workforce and are priority areas for international road safety efforts. 2022

TO THE EDITORWe read with concern the report by Darkoh and colleagues describing vancomycin resistance in Clostridioides difficile isolates recovered from patients in Houston, Texas, and Nairobi, Kenya [1]. The authors suggested that vancomycin resistance, which they found to be common, may lead to therapeutic failure for patients infected with C. difficile and that routine antimicrobial susceptibility testing (AST) should be expanded. The authors report that 26% of C. difficile toxin gene-positive patients in Houston and 67% of sequential hospitalized patients in Nairobi with acute diarrhea had growth on primary screening media containing 4g/mL vancomycin. This alarmingly high proportion of a vancomycin resistant phenotype exceeds initial treatment failure rates reported in the literature [2], calling into question the reliability of these findings.

BACKGROUND: Among people affected by Hurricane Harvey, we assessed experiences and perceptions (e.g., knowledge, attitudes, and practices) regarding mold and its impact on health and elicited participants' opinions about how to improve public health messaging about indoor mold after a large flooding event. METHODS: Houston Health Department conducted four focus groups with 31 Houston metropolitan area residents during January to March 2020, using a semi-structured discussion guide and federal communication materials about indoor mold. Drawing from a theoretical framework analysis, transcripts were grouped into relevant themes using inductive and deductive coding. RESULTS: Hurricane Harvey had a large impact on participants' living standards, and widespread financial barriers to remediation led to long-term mold exposure for many participants. Knowledge about mold's impact on health and proper mold clean-up practices varied, and clean-up behaviors did not commonly align with federal guidance. Participants generally preferred traditional forms of outreach, such as in-person, radio, and television announcements, to communicate public health messaging. CONCLUSIONS: More strategic dissemination of expanded public health educational materials about proper mold clean-up practices and the health risks of mold exposure following flooding events is needed.

The national "Ending the HIV Epidemic: A Plan for America" supports expanded testing in jurisdictions and groups with disproportionate HIV burden. Public health planners benefit from learning HIV testing service (HTS) strengths, challenges, and innovations. We conducted semistructured interviews with 120 HTS staff from local health departments, community-based organizations, and community members in Houston, Texas; Miami, Florida; New Orleans, Louisiana; and Washington, DC. We coded interview transcripts using qualitative methods to identify themes. Program strengths include HIV testing integration with other client services; prioritized testing and tailored incentives; multiple advertising methods; and partnerships among HTS providers. Challenges include stigma, fear, and disparities; funding requirements that create competition between providers; and service accessibility, unnecessary repeat testing, and insufficient innovation. The four jurisdictions addressed some, but not all, of these challenges. Cross-jurisdictional collaboration, together with state and federal partners plus program data may help identify additional strategies for strengthening HTS.

OBJECTIVES: Extensive floodwater damage following hurricane Harvey raised concerns of increase in invasive mould infections (IMIs), especially in immunocompromised patients. To more comprehensively characterize the IMI landscape pre- and post- Harvey, we used a modified, less restrictive clinical IMI (mcIMI) definition by incorporating therapeutic-intent antifungal drug prescriptions combined with an expanded list of host and clinical features. METHODS: We reviewed 103 patients at MD Anderson Cancer Center (Houston, Texas), who lived in Harvey-affected counties and had mould-positive cultures within 12 months pre-/post-Harvey (36 and 67 patients, respectively). Cases were classified as proven or probable IMI (EORTC/MSG criteria), mcIMI, or colonization/ contamination. We also compared in-hospital mortality and 42- day survival outcomes of patients with mcIMI pre-/ post- Harvey. RESULTS: The number of patients with mould- positive cultures from Harvey- affected counties almost doubled from 36 pre- Harvey to 67 post- Harvey (p < 0.01). In contrast, no significant changes in (mc) IMI incidence post- Harvey nor changes in the etiological mould genera were noted. However, patients with mcIMIs from flood affected areas had significantly higher in- hospital mortality (p = 0.01). CONCLUSIONS: We observed increased colonization but no excess cases of (mc)IMIs in immunosuppressed cancer patients from affected areas following a large flooding event such as hurricane Harvey.

Results from sampling healthcare surfaces for pathogens are difficult to interpret without understanding the factors that influence pathogen detection. We investigated the recovery of four healthcare-associated pathogens from three common surface materials, and how a body fluid simulant (artificial test soil, ATS), deposition method, and contamination levels influence the percent of organisms recovered (%R). Known quantities of carbapenemase-producing KPC+ Klebsiella pneumoniae (KPC), Acinetobacter baumannii, vancomycin-resistant Enterococcus faecalis, and Clostridioides difficile spores (CD) were suspended in Butterfield's buffer or ATS, deposited on 323cm2 steel, plastic, and laminate surfaces, allowed to dry 1h, then sampled with a cellulose sponge wipe. Bacteria were eluted, cultured, CFU counted and %R determined relative to the inoculum. The %R varied by organism, from <1% (KPC) to almost 60% (CD) and was more dependent upon the organism's characteristics and presence of ATS than on surface type. KPC persistence as determined by culture also declined by >1 log10 within the 60 min drying time. For all organisms, the %R was significantly greater if suspended in ATS than if suspended in Butterfield's buffer (p<0.05), and for most organisms the %R was not significantly different when sampled from any of the three surfaces. Organisms deposited in multiple droplets were recovered at equal or higher %R than if spread evenly on the surface. This work assists in interpreting data collected while investigating a healthcare infection outbreak or while conducting infection intervention studies.

BACKGROUND: Despite vaccine-induced decreases in US rotavirus (RV) disease, acute gastroenteritis (AGE) remains relatively common. We evaluated AGE pathogen distribution in hospitalized US children in the post-RV vaccine era. METHODS: From December 2011 to June 2016, the New Vaccine Surveillance Network (NVSN) conducted prospective, active, population-based surveillance in hospitalized children with AGE. We tested stools from 2 NVSN sites (Kansas City, Houston) with Luminex x-TAG Gastrointestinal Pathogen Panels (Luminex GPP) and analyzed selected signs and symptoms. RESULTS: For 660 pediatric AGE inpatients and 624 age-matched healthy controls (HCs), overall organism detection was 51.2% and 20.6%, respectively (P < .001). Among AGE subjects, GPP polymerase chain reaction detected >1 virus in 39% and >1 bacterium in 14% of specimens. Detection frequencies for AGE subjects vs HCs were norovirus (NoV) 18.5% vs 6.6%, RV 16.1% vs 9.8%, adenovirus 7.7% vs 1.4%, Shigella 4.8% vs 1.0%, Salmonella 3.1% vs 0.1%, and Clostridioides difficile in ≥2-year-olds 4.4% vs 2.4%. More co-detections occurred among AGE patients (37/660, 5.6%) than HCs (14/624, 2.2%; P = .0024). Per logistic regression analysis, ill contacts increased risk for NoV, RV, and Shigella (P < .001). More vomiting episodes occurred with NoV and RV, and more diarrheal episodes with Shigella and Salmonella. Modified Vesikari scores were highest for Shigella and lowest for C. difficile. CONCLUSIONS: NoV detection was most frequent; however, RV remained important in hospitalized AGE in the post-RV vaccine era. Continued active surveillance is important to document ongoing vaccine effects, pathogen emergence, and baseline disease burden for new vaccines.

In August 2017, after Hurricane Harvey made landfall, almost 52 inches of rain fell during a three-day period along the Gulf Coast Region of Texas, including Harris County, where Houston is located. Harris County was heavily impacted with over 177,000 homes and buildings (approximately 12 percent of all buildings in the county) experiencing flooding. The objective of this study was to measure 13 heavy metals in soil in residential areas and to assess cancer and non-cancer risk for children and adults after floodwaters receded. Between September and November 2017, we collected 174 surface soil samples in 10 communities, which were classified as "High Environmental Impact" or "Low Environmental Impact" communities, based on a composite metric of six environmental parameters. A second campaign was conducted between May 2019 and July 2019 when additional 204 soil samples were collected. Concentrations of metals at both sampling campaigns were higher in High Environmental Impact communities than in Low Environmental Impact communities and there was little change in metal levels between the two sampling periods. The Pollution Indices of lead (Pb), zinc, copper, nickel, and manganese in High Environmental Impact communities were significantly higher than those in Low Environmental Impact communities. Further, cancer risk estimates in three communities for arsenic through soil ingestion were greater than 1 in 1,000,000. Although average soil Pb was lower than the benchmark of the United States Environmental Protection Agency, the hazard indices for non-cancer outcomes in three communities, mostly attributed to Pb, were greater than 1. Health risk estimates for children living in these communities were greater than those for adults.

IMPORTANCE: The number of clinics marketing stem cell products for joint diseases, chronic pain, and most recently, COVID-19, has increased despite warnings from the US Food and Drug Administration that stem cell products for these and other indications have not been proven safe or effective. OBJECTIVE: To examine bacterial infections in 20 patients who received umbilical cord blood-derived products marketed as stem cell treatment. DESIGN, SETTING, AND PARTICIPANTS: This case series is a national public health investigation including case-finding, medical record review and abstraction, and laboratory investigation, including sterility testing of products and whole-genome sequencing of patient and product isolates. Participants included patients who developed bacterial infections following administration of umbilical cord blood-derived products marketed as stem cell treatment during August 2017 to September 2018. Data analysis was performed from March 2019 to September 2021. EXPOSURES: Umbilical cord blood-derived products marketed as stem cell treatment. MAIN OUTCOMES AND MEASURES: Data were collected on patient infections and exposures. The Centers for Disease Control and Prevention performed sterility testing on undistributed and distributed vials of product marketed as stem cell treatment and performed whole-genome sequencing to compare patient and product bacterial isolates. RESULTS: Culture-confirmed bacterial infections were identified in 20 patients (median [range] age, 63 [2-89] years; 13 male patients [65%]) from 8 US states who sought stem cell treatment for conditions including pain, osteoarthritis, rheumatoid arthritis, and injury; all but 1 required hospitalization. The most frequently isolated bacteria from patients with infections were common enteric species, including Escherichia coli (14 patients) and Enterobacter cloacae (7 patients). Of unopened, undistributed products sampled for testing, 65% (22 of 34 vials) were contaminated with at least 1 of 16 bacterial species, mostly enteric. A patient isolate from Arizona matched isolates obtained from products administered to patients in Florida, and patient isolates from Texas matched undistributed product sent from the company in California. CONCLUSIONS AND RELEVANCE: Unapproved stem cell products can expose patients to serious risks without proven benefit. Sequencing results suggest a common source of extensive contamination, likely occurring during the processing of cord blood into product. Patients and health care practitioners who are considering the use of unapproved products marketed as stem cell treatment should be aware of their unproven benefits and potential risks, including serious infections.

Unprecedented inland precipitation and catastrophic flooding associated with Hurricane Harvey potentially redistributed contaminants from industrial sites and transportation infrastructure to recreational areas that make up networks of green infrastructure, creeks, and waterways used for flood control throughout the Greater Houston Area. Sediment samples were collected in parks located near the Buffalo Bayou watershed 1 week after Hurricane Harvey made landfall and again 7 weeks later. Total concentrations of the U.S. Environmental Protection Agency's (EPA's) 16 priority polycyclic aromatic hydrocarbons (PAHs) were measured in each sample at both time points. Diagnostic ratios were calculated to improve understanding of potential sources of PAHs after flooding. Diagnostic ratios suggest vehicular traffic to be a potential source for PAHs in parks. Although the concentrations of PAHs in all samples were below EPA actionable levels, given that no background values were available for comparison, it is difficult to quantify the impact flooding from Hurricane Harvey had on PAH concentrations in Houston parks. However, given the high frequency of flooding in Houston, and the concentration of industrial facilities and transportation infrastructure adjacent to recreation areas, these data demonstrate that PAHs were still present after unprecedented flooding. This study may also serve as a baseline for future efforts to understand the environmental health impacts of disasters.

To investigate possible cardiac manifestations of Chagas disease, we tested 97 Latinx patients with nonischemic cardiomyopathy in Houston, Texas, USA, for Trypanosoma cruzi infection. We noted a high prevalence of underdiagnosed infection and discrepant results in clinical diagnostic assays. Latinx cardiac patients in the United States would benefit from laboratory screening for T. cruzi infection.

OBJECTIVES: When Hurricane Harvey struck the coastline of Texas in 2017, it caused 88 fatalities and over US $125 billion in damage, along with increased emergency department visits in Houston and in cities receiving hurricane evacuees, such as the Dallas-Fort Worth metroplex (DFW).This study explored demographic indicators of vulnerability for patients from the Hurricane Harvey impact area who sought medical care in Houston and in DFW. The objectives were to characterize the vulnerability of affected populations presenting locally, as well as those presenting away from home, and to determine whether more vulnerable communities were more likely to seek medical care locally or elsewhere. METHODS: We used syndromic surveillance data alongside the Centers for Disease Control and Prevention Social Vulnerability Index to calculate the percentage of patients seeking care locally by zip code tabulation area. We used this variable to fit a spatial lag regression model, controlling for population density and flood extent. RESULTS: Communities with more patients presenting for medical care locally were significantly clustered and tended to have greater socioeconomic vulnerability, lower household composition vulnerability, and more extensive flooding. CONCLUSIONS: These findings suggest that populations remaining in place during a natural disaster event may have needs related to income, education, and employment, while evacuees may have more needs related to age, disability, and single-parent household status.

BACKGROUND: To estimate the infectious period of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in older adults with underlying conditions, we assessed duration of coronavirus disease 2019 (COVID-19) symptoms, reverse-transcription polymerase chain reaction (RT-PCR) positivity, and culture positivity among nursing home residents. METHODS: We enrolled residents within 15 days of their first positive SARS-CoV-2 test (diagnosis) at an Arkansas facility from July 7 to 15, 2020 and instead them for 42 days. Every 3 days for 21 days and then weekly, we assessed COVID-19 symptoms, collected specimens (oropharyngeal, anterior nares, and saliva), and reviewed medical charts. Blood for serology was collected on days 0, 6, 12, 21, and 42. Infectivity was defined by positive culture. Duration of culture positivity was compared with duration of COVID-19 symptoms and RT-PCR positivity. Data were summarized using measures of central tendency, frequencies, and proportions. RESULTS: We enrolled 17 of 39 (44%) eligible residents. Median participant age was 82 years (range, 58-97 years). All had ≥3 underlying conditions. Median duration of RT-PCR positivity was 22 days (interquartile range [IQR], 8-31 days) from diagnosis; median duration of symptoms was 42 days (IQR, 28-49 days). Of 9 (53%) participants with any culture-positive specimens, 1 (11%) severely immunocompromised participant remained culture-positive 19 days from diagnosis; 8 of 9 (89%) were culture-positive ≤8 days from diagnosis. Seroconversion occurred in 12 of 12 (100%) surviving participants with ≥1 blood specimen; all participants were culture-negative before seroconversion. CONCLUSIONS: Duration of infectivity was considerably shorter than duration of symptoms and RT-PCR positivity. Severe immunocompromise may prolong SARS-CoV-2 infectivity. Seroconversion indicated noninfectivity in this cohort.

BACKGROUND: Ordinances requiring the implementation of robbery prevention measures have been enacted at the city level in many jurisdictions. We evaluated the impact of an ordinance requiring crime prevention measures on subsequent crime rates. METHODS: Crime reports for robbery and aggravated assault from January 2006 through December 2015 were linked to randomly-selected convenience stores and small retail grocers in Houston (n = 293). Store characteristics and compliance with a list of safety measures were collected by surveyors in 2011. Generalized linear mixed models were used to compare rates of crime before and after the implementation of the ordinance. RESULTS: Robberies decreased significantly after the ordinance went into effect (rate ratio = 0.38; 95% confidence interval 0.29-0.51). No individual safety measure was associated with decreased robbery rates. No similar decrease was observed for aggravated assault. CONCLUSIONS: City ordinances mandating crime prevention measures can be effective. We could not parse out the effectiveness of individual elements, suggesting a comprehensive approach may be more effective.

BACKGROUND: COVID-19 has disproportionately affected older adults and certain racial and ethnic groups in the US. Data quantifying the disease burden, as well as describing clinical outcomes during hospitalization among these groups, is needed. OBJECTIVE: We aimed to describe interim COVID-19 hospitalization rates and severe clinical outcomes by age group and race and ethnicity among Veterans in a multi-site surveillance network. METHODS: We implemented a multisite COVID-19 surveillance platform in 5 Veterans Affairs Medical Centers (VAMCs: Atlanta, Bronx, Houston, Palo Alto, and Los Angeles), collectively serving >396,000 patients annually. From February 27- July 17 2020, we actively identified SARS-CoV-2 positive inpatient cases through screening of admitted patients and review of laboratory test results. We manually abstracted medical charts for demographics, underlying medical conditions, and clinical outcomes of COVID-19 hospitalized patients. We calculated hospitalization incidence and incidence rate ratios, and relative risk (RR) for invasive mechanical ventilation, intensive care unit (ICU) admission, and death after adjusting for age, race and ethnicity, and underlying medical conditions. RESULTS: We identified 621 laboratory-confirmed hospitalized COVID-19 cases. Median age was 70 years, 66% were aged ≥65 years, and 94% were male. Most COVID-19 diagnoses were among non-Hispanic Blacks (52%), followed by non-Hispanic Whites (25%) and Hispanic or Latinos (18%). Hospitalization rates were highest among Veterans aged ≥85 years, Hispanic or Latino, and non-Hispanic Black (430, 317 and 298 per 100,000, respectively); Veterans aged ≥85 years had a 14-fold increased rate of hospitalization compared with Veterans aged 18-29 years (95% CI: 5.7-34.6), while Hispanic or Latino and Black Veterans had a 4.6 and 4.2-fold increased rate of hospitalization compared with non-Hispanic White Veterans (95% CI: 3.6-5.9), respectively. Overall, 11.6% of patients required invasive mechanical ventilation, 26.6% were admitted to the intensive care unit (ICU), and 16.9% died in hospital. The adjusted RR for invasive mechanical ventilation and ICU admission did not differ by age group or race/ethnicity, but Veterans aged ≥65 had a 4.5-fold increased risk of death while hospitalized with COVID-19 compared with those aged <65 years (95% CI: 2.4-8.6). CONCLUSIONS: COVID-19 surveillance at 5 VAMCs across the US demonstrated higher hospitalization rates and severe outcomes in older Veterans, and higher hospitalization rates in Hispanic or Latino and non-Hispanic Black Veterans compared to non-Hispanic White Veterans. These data highlight the need for targeted prevention and timely treatment for Veterans, with special attention to increasing age, Hispanic or Latino and non-Hispanic Black Veterans.

BACKGROUND: Men who have sex with men (MSM) using HIV pre-exposure prophylaxis (PrEP) may be at high risk for bacterial sexually transmitted infections (STIs). We examined the prevalence of extragenital gonorrhea and chlamydia by PrEP status among a multisite sample of US MSM. METHODS: MSM aged ≥18 years were recruited through venue-based sampling to participate in the 2017 National HIV Behavioral Surveillance. In 5 cities (San Francisco, Washington DC, New York City, Miami, and Houston), participants completed a questionnaire, HIV testing, and pharyngeal and rectal STI specimen self-collection. We measured prevalence of pharyngeal and rectal gonorrhea and chlamydia among self-reported non-HIV-positive MSM who reported using or not using PrEP in the previous 12 months. RESULTS: Overall, 29.6% (481/1627) of non-HIV-positive MSM reported PrEP use in the past year. MSM who reported PrEP use were more likely to have any STI (ie, extragenital gonorrhea and/or chlamydia) than MSM not on PrEP [14.6% vs. 12.0%, adjusted prevalence ratio (aPR) = 1.5, 95% confidence interval (CI) : 1.1 to 2.0], reflecting differences in rectal chlamydia prevalence (8.7% vs. 6.0%, aPR = 1.6, 95% CI: 1.1 to 2.4). PrEP use was not associated with pharyngeal chlamydia, pharyngeal gonorrhea, or rectal gonorrhea. CONCLUSIONS: The prevalence of extragenital STI was high for both MSM on PrEP and those not on PrEP in the past year. MSM on PrEP were more likely to have rectal chlamydia but not pharyngeal STIs or rectal gonorrhea. Our findings support regular STI testing at exposed anatomic sites as recommended for sexually active MSM, including those on PrEP.

Rapid and profound changes anticipated in the future of work will have significant implications for the education and training of occupational safety and health (OSH) professionals and the workforce. As the nature of the workplace, work, and the workforce change, the OSH field must expand its focus to include existing and new hazards (some yet unknown), consider how to protect the health and well-being of a diverse workforce, and understand and mitigate the safety implications of new work arrangements. Preparing for these changes is critical to developing proactive systems that can protect workers, prevent injury and illness, and promote worker well-being. An in-person workshop held on February 3-4, 2020 at The University of Texas Health Science Center (UTHealth) School of Public Health in Houston, Texas, USA, examined some of the challenges and opportunities OSH education will face in both academic and industry settings. The onslaught of the COVID-19 global pandemic reached the United States one month after this workshop and greatly accelerated the pace of change. This article summarizes presentations from national experts and thought leaders across the spectrum of OSH and professionals in the fields of strategic foresight, systems thinking, and industry, and provides recommendations for the field.

BACKGROUND: Limited data exist in the United States on the prevalence of HIV among women who exchange sex. SETTING: We estimate HIV prevalence of women who exchange sex from a 2016 survey in Chicago, Detroit, Houston, and Seattle and compare it with the prevalence of HIV among women of low socioeconomic status (SES), who did not exchange sex, and women in the general population. METHODS: Women who exchange sex were recruited via respondent-driven sampling among some cities participating in National HIV Behavioral Surveillance, interviewed, and offered HIV testing. We estimate HIV prevalence and, using prevalence ratios, compare it with the prevalence among women of low SES who did not exchange sex in the 2013 National HIV Behavioral Surveillance cycle, and to women in the general population estimated using 2015 National HIV Surveillance data. RESULTS: One thousand four hundred forty women reported exchange sex in 2016. Aggregated HIV prevalence was 4.9% [95% confidence interval (CI): 2.7 to 7.1] among women who exchanged sex, 1.6% (95% CI: 0.3 to 2.8) among women of low SES who did not exchange sex, and 0.6% (95% CI: 0.5% to 0.6%) among women in the general population. HIV prevalence among women who exchanged sex was 3.1 times (95% CI: 1.6 to 5.9) as high as among women of low SES who did not exchange sex, and 8.8 times (95% CI: 7.0 to 11.1) as high as among women in the general population. CONCLUSION: HIV prevalence was significantly higher among women who exchanged sex compared with women in the general population and women of low SES who did not exchange sex.