While many transmission models have been developed for community spread of respiratory pathogens, less attention has been given to modeling the interdependence of disease introduction and spread seen in congregate settings, such as prisons or nursing homes. As demonstrated by the explosive outbreaks of COVID-19 seen in congregate settings, the need for effective outbreak prevention and mitigation strategies for these settings is critical. Here we consider how interventions that decrease the size of the susceptible populations, such as vaccination or depopulation, impact the expected number of infections due to outbreaks. Introduction of disease into the resident population from the community is modeled as a branching process, while spread between residents is modeled via a compartmental model. Control is modeled as a proportional decrease in both the number of susceptible residents and the reproduction number. We find that vaccination or depopulation can have a greater than linear effect on anticipated infections. For example, assuming a reproduction number of 3.0 for density-dependent COVID-19 transmission, we find that reducing the size of the susceptible population by 20% reduced overall disease burden by 47%. We highlight the California state prison system as an example for how these findings provide a quantitative framework for implementing infection control in congregate settings. Additional applications of our modeling framework include optimizing the distribution of residents into independent residential units, and comparison of preemptive versus reactive vaccination strategies.

The explosive outbreaks of COVID-19 seen in congregate settings such as prisons and nursing homes, has highlighted a critical need for effective outbreak prevention and mitigation strategies for these settings. Here we consider how different types of control interventions impact the expected number of symptomatic infections due to outbreaks. Introduction of disease into the resident population from the community is modeled as a stochastic point process coupled to a branching process, while spread between residents is modeled via a deterministic compartmental model that accounts for depletion of susceptible individuals. Control is modeled as a proportional decrease in the number of susceptible residents, the reproduction number, and/or the proportion of symptomatic infections. This permits a range of assumptions about the density dependence of transmission and modes of protection by vaccination, depopulation and other types of control. We find that vaccination or depopulation can have a greater than linear effect on the expected number of cases. For example, assuming a reproduction number of 3.0 with density-dependent transmission, we find that preemptively reducing the size of the susceptible population by 20% reduced overall disease burden by 47%. In some circumstances, it may be possible to reduce the risk and burden of disease outbreaks by optimizing the way a group of residents are apportioned into distinct residential units. The optimal apportionment may be different depending on whether the goal is to reduce the probability of an outbreak occurring, or the expected number of cases from outbreak dynamics. In other circumstances there may be an opportunity to implement reactive disease control measures in which the number of susceptible individuals is rapidly reduced once an outbreak has been detected to occur. Reactive control is most effective when the reproduction number is not too high, and there is minimal delay in implementing control. We highlight the California state prison system as an example for how these findings provide a quantitative framework for understanding disease transmission in congregate settings. Our approach and accompanying interactive website (https://phoebelu.shinyapps.io/DepopulationModels/) provides a quantitative framework to evaluate the potential impact of policy decisions governing infection control in outbreak settings.

Reptile-associated human salmonellosis cases have increased recently in the United States. It is not uncommon to find healthy chelonians shedding Salmonella enterica. The rate and frequency of bacterial shedding are not fully understood, and most studies have focused on captive vs. free-living chelonians and often in relation to an outbreak. Their ecology and significance as sentinels are important to understanding Salmonella transmission. In 2012-2013, Salmonella prevalence was determined for free-living aquatic turtles in man-made ponds in Clarke and Oconee Counties, in northern Georgia (USA) and the correlation between species, basking ecology, demographics (age/sex), season, or landcover with prevalence was assessed. The genetic relatedness between turtle and archived, human isolates, as well as, other archived animal and water isolates reported from this study area was examined. Salmonella was isolated from 45 of 194 turtles (23.2%, range 14-100%) across six species. Prevalence was higher in juveniles (36%) than adults (20%), higher in females (33%) than males (18%), and higher in bottom-dwelling species (31%; common and loggerhead musk turtles, common snapping turtles) than basking species (15%; sliders, painted turtles). Salmonella prevalence decreased as forest cover, canopy cover, and distance from roads increased. Prevalence was also higher in low-density, residential areas that have 20-49% impervious surface. A total of 9 different serovars of two subspecies were isolated including 3 S. enterica subsp. arizonae and 44 S. enterica subsp. enterica (two turtles had two serotypes isolated from each). Among the S. enterica serovars, Montevideo (n = 13) and Rubislaw (n = 11) were predominant. Salmonella serovars Muenchen, Newport, Mississippi, Inverness, Brazil, and Paratyphi B. var L(+) tartrate positive (Java) were also isolated. Importantly, 85% of the turtle isolates matched pulsed-field gel electrophoresis patterns of human isolates, including those reported from Georgia. Collectively, these results suggest that turtles accumulate Salmonella present in water bodies, and they may be effective sentinels of environmental contamination. Ultimately, the Salmonella prevalence rates in wild aquatic turtles, especially those strains shared with humans, highlight a significant public health concern.

BACKGROUND: Nutrition interventions are a common component of worksite wellness programs and have been recognized as an effective strategy to change employee dietary behaviors. However, little is known about worksite food behaviors or the foods that are obtained at workplaces at the national level. OBJECTIVE: The aims were to examine the frequency of and the amount of money spent obtaining foods at work among employed US adults, to determine the foods most commonly obtained at work, and to assess the dietary quality of these foods. DESIGN: This is a cross-sectional analysis of data from the US Department of Agriculture Food Acquisition and Purchasing Survey, a nationally representative household survey conducted from April 2012 through January 2013 on food purchases and acquisitions during a 7-day study period. PARTICIPANTS: The study included 5,222 employed adult Americans. MAIN OUTCOME MEASURES: The study assessed the prevalence of obtaining any foods at work overall and according to sociodemographic subgroups, number of acquisitions and calories obtained, most commonly obtained foods and leading food sources of calories, and 2010 Healthy Eating Index (HEI) scores that represent dietary quality. STATISTICAL ANALYSES PERFORMED: Prevalence estimates of obtaining >/=1 foods at work were compared according to sociodemographic characteristic using chi(2) tests. RESULTS: Nearly a quarter (23.4%) of working adults obtained foods at work during the week, and the foods they obtained averaged 1,292 kcal per person per week. The leading food types obtained included foods typically high in solid fat, added sugars, or sodium, such as pizza, regular soft drinks, cookies or brownies, cakes and pies, and candy. HEI scores suggest that work foods are high in empty calories, sodium, and refined grains and low in whole grains and fruit. CONCLUSIONS: Working adults commonly obtain foods at work, and the foods they obtain have limited dietary quality. Future research should examine the role worksites can play to help ensure access to and promote healthier options.

One contributing factor to the obesity epidemic is the large portion sizes served in restaurants. However, no study has looked at the parents' desire for smaller-portioned meals for their children at restaurants in the U.S. This study examined parents' preference for restaurants to offer smaller, lower-priced child portions for their children and reasons for the preference. Multivariable logistic regression was used to estimate adjusted odds ratios (ORs) for the association between preference for child portions and variables on parental sociodemographic characteristics and weight status. About 70% of parents said they would prefer that restaurants offer smaller, lower-priced child portions of all menu offerings. The adjusted odds of preferring child portions were significantly higher among Hispanic parents (OR, 1.95 vs. non-Hispanic whites) but significantly lower among parents with lower education (</= high school, OR, 0.64; some college, OR, 0.69 vs. college graduate) and parents residing in the Midwest or West (Midwest, OR, 0.61; West, OR, 0.58 vs. South). The most common reason for preferring child portions of all meals was "wanting my child to eat healthier foods that are not offered on the children's menu" (72%). These findings can be used to encourage restaurants and other venues to consider offering child portions of healthier menu items.

PURPOSE: Characteristics of parents who purchased kids' meals, reasons for the purchase, and desire for healthy options were examined. DESIGN: Quantitative, cross-sectional study. SETTING: National. PARTICIPANTS: The SummerStyles survey data of 1147 parents (>/=18 years). MEASURES: Self-reported outcome variables were purchase of kids' meals (yes/no), reasons for the purchase (13 choices), and desire for healthy options (yes/no). ANALYSIS: We used multivariable logistic regression to estimate odds ratios (ORs) for purchasing kids' meals based on parental sociodemographic and behavioral characteristics. RESULTS: Over half (51%) of parents reported purchasing kids' meals in the past month. The adjusted OR of purchasing kids' meals were significantly higher among younger parents (OR = 3.44 vs >/=50 years) and among parents who consumed sugar-sweetened beverages (SSBs) daily (OR = 2.70 vs none). No differences were found for race/ethnicity, income, and education. Parents who purchased kids' meals reported that the top 3 reasons for purchase were (1) because their children asked for kids' meals, (2) habit, and (3) offering of healthier sides such as fruits or fruit cups. Thirty-seven percent of parents who did not purchase kids' meals expressed willingness to purchase kids' meals if healthy options were available; this willingness was highest among younger parents (47%; P < .05). CONCLUSIONS: Kids' meal purchases were somewhat common. Our findings on characteristics of parents who frequently bought kids' meals (ie, younger parents and SSB consumers), common reasons for purchasing kids' meals, and willingness to buy healthier kids' meal can be used to inform intervention efforts to improve quality of kids' meals.

BACKGROUND: Primary HPV testing (without the Pap test) has recently been recommended as a cervical cancer screening option in the United States. U.S. women's awareness and acceptance of primary HPV testing were evaluated. METHODS: Data from a 2015 web-based survey of U.S. adults was examined. Analyses were limited to women who were >/=18years old, had not undergone a hysterectomy, had not been diagnosed with cervical cancer, and would accept cervical cancer screening (N=1309). Logistic regression was used to identify predictors of acceptance of primary HPV testing every 3years. RESULTS: Primary HPV testing every 3years was the least accepted cervical cancer screening option (13.5%), and annual Pap testing was the most accepted (41.2%). Most women (65.2%) reported that they were unsure how the HPV test is administered. HPV-vaccinated women were more likely to accept primary HPV testing every 3years than unvaccinated women (Adj OR=1.80, 95% CI=1.22-2.63, p=0.003). And, women who had participated in HPV testing at any interval were more likely to accept primary HPV testing every 3years than those who did not have regular HPV tests or were unsure how often they had HPV tests (Adj OR=1.74, 95% CI=1.20-2.52, p=0.003). CONCLUSIONS: Acceptance of primary HPV testing among U.S. women was low and associated with variables which may be indicative of general HPV awareness. Widespread adoption of primary HPV testing may require increasing women's familiarity with the HPV test and screening guidelines.

The 2015-2020 Dietary Guidelines for Americans recommend that Americans consume more fruits and vegetables as part of an overall dietary pattern to reduce the risk for diet-related chronic diseases such as cardiovascular disease, type 2 diabetes, some cancers, and obesity (1). Adults should consume 1.5-2.0 cup equivalents of fruits and 2.0-3.0 cups of vegetables per day.* Overall, few adults in each state met intake recommendations according to 2013 Behavioral Risk Factor Surveillance System (BRFSS) data; however, sociodemographic characteristics known to be associated with fruit and vegetable consumption were not examined (2). CDC used data from the 2015 BRFSS to update the 2013 report and to estimate the percentage of each state's population meeting intake recommendations by age, sex, race/ethnicity, and income-to-poverty ratio (IPR) for the 50 states and District of Columbia (DC). Overall, 12.2% of adults met fruit recommendations ranging from 7.3% in West Virginia to 15.5% in DC, and 9.3% met vegetable recommendations, ranging from 5.8% in West Virginia to 12.0% in Alaska. Intake was low across all socioeconomic groups. Overall, the prevalence of meeting the fruit intake recommendation was highest among women (15.1%), adults aged 31-50 years (13.8%), and Hispanics (15.7%); the prevalence of meeting the vegetable intake recommendation was highest among women (10.9%), adults aged ≥51 years (10.9%), and persons in the highest income group (11.4%). Evidence-based strategies that address barriers to fruit and vegetable consumption such as cost or limited availability could improve consumption and help prevent diet-related chronic disease.

Sierra Leone was heavily affected by the Ebola epidemic, with over 14,000 total cases. Given that corpses of people who have died from Ebola are highly infectious and given the extremely high risk of Ebola transmission associated with direct contact with bodies of people who have died of Ebola, community acceptance of safe, dignified medical burials was one of the important components of efforts to stop the Ebola epidemic in Sierra Leone. Information on barriers and facilitators for community acceptance of safe, dignified medical burials is limited. A rapid qualitative assessment using focus group discussions (FGDs) explored community knowledge, attitudes, and practices towards safe and dignified burials in seven chiefdoms in Bo District, Sierra Leone. In total, 63 FGDs were conducted among three groups: women >25 years of age, men >25 years of age, and young adults 19-25 years of age. In addition to concerns about breaking cultural traditions, barriers to safe burial acceptance included concerns by family members about being able to view the burial, perceptions that bodies were improperly handled, and fear that stigma may occur if a family member receives a safe, dignified medical burial. Participants suggested that providing opportunities for community members to participate in safe and dignified burials would improve community acceptance.

PURPOSE: Sugar-sweetened beverage (SSB) consumption is high among U.S. adults and is associated with obesity. Given that more than 100 million Americans consume food or beverages at work daily, the worksite may be a venue for interventions to reduce SSB consumption. However, the level of support for these interventions is unknown. We examined associations between workday SSB intake and employees' support for worksite wellness strategies (WWSs). DESIGN: We conducted a cross-sectional study using data from Web-based annual surveys that gather information on health-related attitudes and behaviors. SETTING: Study setting was the United States. SUBJECTS: A total of 1924 employed adults (≥18 years) selected using probability-based sampling. MEASURES: The self-reported independent variable was workday SSB intake (0, <1 or ≥1 times per day), and dependent variables were employees' support (yes/no) for the following WWSs: (1) accessible free water, (2) affordable healthy food/drink, (3) available healthy options, and (4) less available SSB. ANALYSIS: Multivariable logistic regression was used to control for sociodemographic variables, employee size, and availability of cafeteria/vending machine. RESULTS: About half of employees supported accessible free water (54%), affordable healthy food/drink (49%), and available healthy options (46%), but only 28% supported less available SSB. Compared with non-SSB consumers, daily SSB consumers were significantly less supportive of accessible free water (adjusted odds ratio, .67; p < .05) or less available SSB (odds ratio, .49; p < .05). CONCLUSION: Almost half of employees supported increasing healthy options within worksites, although daily workday SSB consumers were less supportive of certain strategies. Lack of support could be a potential barrier to the successful implementation of certain worksite interventions.

Worldwide, Salmonella spp. is a significant cause of disease for both humans and wildlife, with wild birds adapted to urban environments having different opportunities for pathogen exposure, infection, and transmission compared to their natural conspecifics. Food provisioning by people may influence these factors, especially when high-density mixed species flocks aggregate. White Ibises (Eudocimus albus), an iconic Everglades species in decline in Florida, are becoming increasingly common in urbanized areas of south Florida where most are hand-fed. We examined the prevalence of Salmonella shedding by ibises to determine the role of landscape characteristics where ibis forage and their behavior, on shedding rates. We also compared Salmonella isolated from ibises to human isolates to better understand non-foodborne human salmonellosis. From 2010-2013, 13% (n = 261) adult/subadult ibises and 35% (n = 72) nestlings sampled were shedding Salmonella. The prevalence of Salmonella shedding by ibises significantly decreased as the percent of Palustrine emergent wetlands and herbaceous grasslands increased, and increased as the proportion of open-developed land types (e.g. parks, lawns, golf courses) increased, suggesting that natural ecosystem land cover types supported birds with a lower prevalence of infection. A high diversity of Salmonella serotypes (n = 24) and strain types (43 PFGE types) were shed by ibises, of which 33% of the serotypes ranked in the top 20 of high significance for people in the years of the study. Importantly, 44% of the Salmonella Pulsed-Field Gel Electrophoresis patterns for ibis isolates (n = 43) matched profiles in the CDC PulseNet USA database. Of these, 20% came from Florida in the same three years we sampled ibis. Importantly, there was a negative relationship between the amount of Palustrine emergent wetland and the number of Salmonella isolates from ibises that matched human cases in the PulseNet database (p = 0.056). Together, our results indicate that ibises are good indicators of salmonellae strains circulating in their environment and they have both the potential and opportunity to transmit salmonellae to people. Finally, they may act as salmonellae carriers to natural environments where other more highly-susceptible groups (nestlings) may be detrimentally affected.

PURPOSE: To examine the workplace food and physical activity (PA) environments and wellness culture reported by employed United States adults, overall and by employer size. DESIGN: Cross-sectional study using web-based survey on wellness policies and environmental supports for healthy eating and PA. SETTING: Worksites in the United States. PARTICIPANTS: A total of 2101 adults employed outside the home. MEASURES: Survey items were based on the Centers for Disease Control and Prevention Worksite Health ScoreCard and Checklist of Health Promotion Environments and included the availability and promotion of healthy food items, nutrition education, promotion of breast-feeding, availability of PA amenities and programs, facility discounts, time for PA, stairwell signage, health promotion programs, and health risk assessments. ANALYSIS: Descriptive statistics were used to examine the prevalence of worksite environmental and facility supports by employer size (<100 or ≥100 employees). Chi-square tests were used to examine the differences by employer size. RESULTS: Among employed respondents with workplace food or drink vending machines, approximately 35% indicated the availability of healthy items. Regarding PA, 30.9% of respondents reported that their employer provided opportunities to be physically active and 17.6% reported worksite exercise facilities. Wellness programs were reported by 53.2% working for large employers, compared to 18.1% for smaller employers. CONCLUSION: Employee reports suggested that workplace supports for healthy eating, PA, and wellness were limited and were less common among smaller employers.

BACKGROUND: This paper describes the methods and conceptual framework for Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study data collection. The National Institutes of Health, through the National Institute on Drug Abuse, is partnering with the Food and Drug Administration's (FDA) Center for Tobacco Products to conduct the PATH Study under a contract with Westat. METHODS: The PATH Study is a nationally representative, longitudinal cohort study of 45 971 adults and youth in the USA, aged 12 years and older. Wave 1 was conducted from 12 September 2013 to 15 December 2014 using Audio Computer-Assisted Self-Interviewing to collect information on tobacco-use patterns, risk perceptions and attitudes towards current and newly emerging tobacco products, tobacco initiation, cessation, relapse behaviours and health outcomes. The PATH Study's design allows for the longitudinal assessment of patterns of use of a spectrum of tobacco products, including initiation, cessation, relapse and transitions between products, as well as factors associated with use patterns. Additionally, the PATH Study collects biospecimens from consenting adults aged 18 years and older and measures biomarkers of exposure and potential harm related to tobacco use. CONCLUSIONS: The cumulative, population-based data generated over time by the PATH Study will contribute to the evidence base to inform FDA's regulatory mission under the Family Smoking Prevention and Tobacco Control Act and efforts to reduce the Nation's burden of tobacco-related death and disease.

BACKGROUND: Flight attendants (FAs) may experience circadian disruption due to travel during normal sleep hours and through multiple time zones. This study investigated whether FAs are at higher risk for sleep disturbance compared to teachers, as assessed by questionnaire, diary, and activity monitors. METHODS: Sleep/wake cycles of 45 FAs and 25 teachers were studied. For one menstrual cycle, participants wore an activity monitor and kept a daily diary. Sleep metrics included total sleep in the main sleep period (MSP), sleep efficiency (proportion of MSP spent sleeping), and nocturnal sleep fraction (proportion of sleep between 10 p.m. to 8 a.m. home time). Relationships between sleep metrics and occupation were analyzed with mixed and generalized linear models. RESULTS: Both actigraph and diary data suggest that FAs sleep longer than teachers. However, several actigraph indices of sleep disturbance indicated that FAs incurred significant impairment of sleep compared to teachers. FAs were more likely than teachers to have poor sleep efficiency [adjusted odds ratio (OR) for lowest quartile of sleep efficiency = 1.9, 95% Confidence Interval (CI) 1.2 - 3.0] and to have a smaller proportion of their sleep between 10 p.m. and 8 a.m. home time (adjusted OR for lowest quartile of nocturnal sleep fraction = 3.1, CI 1.1 -9.0). DISCUSSION: Study FAs experienced increased sleep disturbance compared to teachers, which may indicate circadian disruption.

OBJECTIVES: Testing for human immunodeficiency virus (HIV) is the key first step in HIV treatment and prevention. In 2006, the Centers for Disease Control and Prevention (CDC) recommended annual HIV testing for people at high risk for HIV infection. We evaluated HIV testing among men with high-risk heterosexual (HRH) contact and sexually active men who have sex with men (MSM) before and after the CDC recommendations. METHODS: We used data from the National Survey of Family Growth, 2002 and 2006-2010, to assess proportions of HRH respondents and MSM reporting HIV testing in the prior 12 months, compare rates of testing before and after release of the 2006 CDC HIV testing guidelines, and examine demographic variables and receipt of health-care services as correlates of HIV testing. RESULTS: Among MSM, the proportion tested was 37.2% (95% confidence interval [CI] 28.2, 47.2) in 2002, 38.2% (95% CI 25.9, 52.2) in 2006-2008, and 41.7% (95% CI 29.2, 55.3) in 2008-2010; among HRH respondents, the proportion was 23.7% (95% CI 20.5, 27.3) in 2002, 24.5% (95% CI 20.9, 28.7) in 2006-2008, and 23.9% (95% CI 20.2, 28.1) in 2008-2010. HIV testing was more likely among MSM and HRH respondents who received testing or treatment for sexually transmitted disease in the prior 12 months, received a physical examination in the prior 12 months (MSM only), or were incarcerated in the prior 12 months. CONCLUSIONS: The rate of annual HIV testing was low for men with sexual risk for HIV infection, and little improvement took place from 2002 to 2006-2010. Interventions aimed at men at risk, especially MSM, in both nonmedical and health-care settings, likely could increase HIV testing.

BACKGROUND: Menu labeling can help people select foods and beverages with fewer calories and is a potential population-based strategy to reduce obesity and diet-related chronic diseases in the United States. OBJECTIVE: The aim of this cross-sectional study was to examine the prevalence of menu-labeling use among adults and its association with sociodemographic, behavioral, and policy factors. METHODS: The 2012 Behavioral Risk Factor Surveillance System data from 17 states, which included 100,141 adults who noticed menu labeling at fast-food or chain restaurants ("When calorie information is available in the restaurant, how often does this information help you decide what to order?") were used. Menu-labeling use was categorized as frequent (always/most of the time), moderate (half the time/sometimes), and never. Multinomial logistic regression was used to examine associations among sociodemographic, behavioral, and policy factors with menu-labeling use. RESULTS: Overall, of adults who noticed menu labeling, 25.6% reported frequent use of menu labeling, 31.6% reported moderate use, and 42.7% reported that they never use menu labeling. Compared with never users, frequent users were significantly more likely to be younger, female, nonwhite, more educated, high-income, adults who were overweight or obese, physically active, former- or never-smokers, less than daily (<1 time/day) consumers of sugar-sweetened beverage, and living in states where menu-labeling legislation was enacted or proposed. CONCLUSIONS: Menu labeling is one method that consumers can use to help reduce their calorie consumption from restaurants. These findings can be used to develop targeted interventions to increase menu-labeling use among subpopulations with lower use.

BACKGROUND: The impact of neuraminidase inhibitors (NAIs) on Influenza-related pneumonia (IRP) is not established. Our objective was to investigate the association between NAI treatment and IRP incidence and outcomes in patients hospitalised with A(H1N1)pdm09 virus infection. METHODS: A worldwide meta-analysis of individual participant data (IPD) from 20,634 hospitalised patients with laboratory confirmed A(H1N1)pdm09 (n=20,021) or clinically diagnosed (n=613) 'pandemic influenza'. The primary outcome was radiologically confirmed influenza-related pneumonia (IRP). Odds ratios (OR) were estimated using generalized linear mixed modelling, adjusting for NAI treatment propensity, antibiotics and corticosteroids. RESULTS: Among 20,634 included participants, 5,978 (29.0%) had IRP; conversely, 3,349 (16.2%) had confirmed absence of radiographic pneumonia (the comparator). Early NAI treatment (within 2 days of symptom onset) versus no NAI was not significantly associated with IRP [adj. OR 0.83 (95%CI 0.64 - 1.06; p=0.136)]. Among the 5,978 patients with IRP, early NAI treatment versus none did not impact on mortality [adj. OR=0.72 (0.44-1.17; p=0.180)] or likelihood of requiring ventilatory support [adj. OR=1.17 (0.71-1.92; p=0.537)]; but early treatment versus later significantly reduced mortality [adj. OR=0.70 (0.55-0.88; p=0.003)] and likelihood of requiring ventilatory support [adj. OR=0.68 (0.54-0.85; p=0.001)]. CONCLUSIONS: Early NAI treatment of patients hospitalised with A(H1N1)pdm09 virus infection versus no treatment did not reduce the likelihood of IRP. However, in patients who developed IRP early NAI treatment versus later reduced the likelihood of mortality and needing ventilatory support.

American Samoa, one of the U.S.-affiliated Pacific Islands, has documented the highest prevalence of adults with obesity (75%) in the world. The nutritionally poor food and beverage environment of food retail venues has been suspected to be a contributing factor, although an evaluation of these venues in American Samoa has not been conducted. In January 2014, American Samoa established an Obesity Task Force to develop policies and strategies to combat obesity. To inform the efforts of the task force, the American Samoa Department of Health and CDC conducted a baseline assessment of the availability, pricing, and promotion of healthful foods at retail food venues. Previously validated food environment assessment tools were modified to incorporate American Samoa foods and administered in a geographically representative sample of 70 stores (nine grocery stores and 61 convenience stores) and 20 restaurants. In convenience stores, healthful items were not found as available as less healthful counterparts, and some healthful items were more expensive than their less healthful counterparts. For restaurants, 70% offered at least one healthful entree, whereas only 30% had healthful side dishes, such as vegetables. Actions to promote healthy eating, such as providing calorie information, were rare among restaurants. Improving availability, affordability, and the promotion of healthful foods in American Samoa stores and restaurants could support healthy eating among American Samoa residents.

Ebola virus disease (Ebola) was first detected in Sierra Leone in May 2014 and was likely introduced into the eastern part of the country from Guinea. The disease spread westward, eventually affecting Freetown, Sierra Leone's densely populated capital. By December 2014, Sierra Leone had more Ebola cases than Guinea and Liberia, the other two West African countries that have experienced widespread transmission. As the epidemic intensified through the summer and fall, an increasing number of infected persons were not being detected by the county's surveillance system until they had died. Instead of being found early in the disease course and quickly isolated, these persons remained in their communities throughout their illness, likely spreading the disease.

As of December 6, 2014, Sierra Leone reported 6,317 laboratory-confirmed cases of Ebola virus disease (Ebola), the highest number of reported cases in the current West Africa epidemic. The Sierra Leone Ministry of Health and Sanitation reported that as of December 6, 2014, there were 1,181 persons who had survived and were discharged. Survivors from previous Ebola outbreaks have reported major barriers to resuming normal lives after release from treatment, such as emotional distress, health issues, loss of possessions, and difficulty regaining their livelihoods. In August 2014, a knowledge, attitude, and practice survey regarding the Ebola outbreak in Sierra Leone, administered by a consortium of partners that included the Ministry of Health and Sanitation, UNICEF, CDC, and a local nongovernmental organization, Focus 1000, found that 96% of the general population respondents reported some discriminatory attitude towards persons with suspected or known Ebola. Access to increased psychosocial support, provision of goods, and family and community reunification programs might reduce these barriers. Survivors also have unique potential to contribute to the Ebola response, particularly because survivors might have some immunity to the same virus strain. In previous outbreaks, survivors served as burial team members, contact tracers, and community educators promoting messages that seeking treatment improves the chances for survival and that persons who survived Ebola can help their communities. As caregivers in Ebola treatment units, survivors have encouraged patients to stay hydrated and eat and inspired them to believe that they, too, can survive. Survivors regaining livelihood through participation in the response might offset the stigma associated with Ebola.

Cryptococcal meningitis (CM) remains a significant HIV-associated opportunistic infection in Southeast Asia and Africa, with a high burden of disease and a high mortality rate despite the availability of antiretroviral therapy (ART). We retrospectively examined the utility of cryptococcal antigen screening to identify risk for CM among 211 Thai women initiating ART. Antigenemia prevalence was 11% (n = 9) among 84 women with a CD4 count <100 cells/mm(3). Screening identified all women who later developed CM. Cryptococcal antigen titers decreased over time with ART. Our study confirmed findings from previous studies in Thailand and South Africa and provided novel observational data regarding the course of cryptococcal antigenemia in patients initiating ART and the poor efficacy of low-dose fluconazole prophylaxis in preventing CM among patients with antigenemia.

Reducing consumption of calories from added sugars is a recommendation of the 2010 Dietary Guidelines for Americans and an objective of Healthy People 2020. Sugar-sweetened beverages (SSB) are major sources of added sugars in the diets of U.S. residents. Daily SSB consumption is associated with obesity and other chronic health conditions, including diabetes and cardiovascular disease. U.S. adults consumed an estimated average of 151 kcal/day of SSB during 2009-2010, with regular (i.e., nondiet) soda and fruit drinks representing the leading sources of SSB energy intake. However, there is limited information on state-specific prevalence of SSB consumption. To assess regular soda and fruit drink consumption among adults in 18 states, CDC analyzed data from the 2012 Behavioral Risk Factor Surveillance System (BRFSS). Among the 18 states surveyed, 26.3% of adults consumed regular soda or fruit drinks or both ≥1 times daily. By state, the prevalence ranged from 20.4% to 41.4%. Overall, consumption of regular soda or fruit drinks was most common among persons aged 1834 years (24.5% for regular soda and 16.6% for fruit drinks), men (21.0% and 12.3%), non-Hispanic blacks (20.9% and 21.9%), and Hispanics (22.6% and 18.5%). Persons who want to reduce added sugars in their diets can decrease their consumption of foods high in added sugars such as candy, certain dairy and grain desserts, sweetened cereals, regular soda, fruit drinks, sweetened tea and coffee drinks, and other SSBs. States and health departments can collaborate with worksites and other community venues to increase access to water and other healthful beverages.

Many persons underestimate the calories in restaurant foods. Increased attention has been given to menu labeling (ML) as a way to provide consumers with point-of-purchase information that can help them reduce calorie intake and make healthier dietary choices. In 2010, a federal law was passed requiring restaurants with 20 or more establishments to display calorie information on menus and menu boards.* The regulations to implement this federal law have not been finalized, but some states and local jurisdictions have implemented their own ML policies, and many restaurants have already begun providing ML. To assess fast food and chain restaurant ML use by state and by demographic subgroup, CDC examined self-reported ML use by adults in 17 states that used the Sugar-Sweetened Beverages and Menu Labeling optional module in the 2012 Behavioral Risk Factor Surveillance System (BRFSS) survey. Based on approximately 97% of adult BRFSS respondents who noticed ML information at restaurants, the estimated overall proportion of ML users in the 17 states was 57.3% (range = 48.7% in Montana to 61.3% in New York). The prevalence of ML use was higher among women than men for all states; the patterns varied by age group and race/ethnicity across states. States and public health professionals can use these findings to track the use of ML and to develop targeted interventions to increase awareness and use of ML among nonusers.

The multidrug-resistant Streptococcus pneumoniae Taiwan19F-14, or PMEN14, clone was first observed with a 19F serotype, which is targeted by the heptavalent polysaccharide conjugate vaccine (PCV7). However, 'vaccine escape' PMEN14 isolates with a 19A serotype became an increasingly important cause of disease post-PCV7. Whole genome sequencing was used to characterise the recent evolution 173 pneumococci of, or related to, PMEN14. This suggested PMEN14 is a single lineage that originated in the late 1980s in parallel with the acquisition of multiple resistances by close relatives. One of the four detected serotype switches to 19A generated representatives of the sequence type (ST) 320 isolates that have been highly successful post-PCV7. A second produced an ST236 19A genotype with reduced resistance to beta-lactams owing to alteration of pbp1a and pbp2x sequences through the same recombination that caused the change in serotype. A third, which generated a mosaic capsule biosynthesis locus, resulted in serotype 19A ST271 isolates. The rapid diversification through homologous recombination seen in the global collection was similarly observed in the absence of vaccination in isolates from the Maela refugee camp in Thailand. This sample also allowed variation to be observed within carriage through longitudinal sampling. This suggests some pneumococcal genotypes generate a pool of standing variation that is sufficiently extensive to result in 'soft' selective sweeps: the emergence of multiple related mutants in parallel upon a change in selection pressure, such as vaccine introduction. The subsequent competition between these mutants makes this phenomenon difficult to detect without deep sampling of individual lineages.

From August to September 2008, the Centers for Disease Control and Prevention (CDC) assisted the Alaska Division of Public Health with an outbreak investigation of campylobacteriosis occurring among the residents of Southcentral Alaska. During the investigation, pulsed-field gel electrophoresis (PFGE) of Campylobacter jejuni isolates from human, raw pea and wild bird fecal samples confirmed the epidemiologic link between illness and the consumption of raw peas contaminated by Sandhill cranes from 15 of 43 epidemiologically-linked human isolates. However, an association between the remaining epidemiologically-linked human infections and the pea and wild bird isolates was not established. To better understand the molecular epidemiology of the outbreak, C. jejuni isolates (n=130; 59 humans, 40 peas and 31 wild birds) were further characterized by multi-locus sequence typing (MLST). Here, we present the molecular evidence to demonstrate the association of many more human C. jejuni infections associated with the outbreak with raw peas and wild bird feces. Among all sequence types (STs) identified, 26 (67%) of 39 were novel and exclusive to the outbreak. Five clusters of overlapping STs (n=32 isolates; 17 humans, 2 peas and 13 wild birds) were identified. In particular, Cluster E (n=7 isolates, ST-5049) consisted of isolates from humans, peas and wild birds. Novel STs clustered closely with isolates typically associated with wild birds and the environment, but distinct from lineages commonly seen in human infections. Novel STs and alleles recovered from human outbreak isolates allowed additional infections caused by these rare genotypes to be attributed to the contaminated raw peas.

BACKGROUND: Neuraminidase inhibitors were widely used during the 2009-10 influenza A H1N1 pandemic, but evidence for their effectiveness in reducing mortality is uncertain. We did a meta-analysis of individual participant data to investigate the association between use of neuraminidase inhibitors and mortality in patients admitted to hospital with pandemic influenza A H1N1pdm09 virus infection. METHODS: We assembled data for patients (all ages) admitted to hospital worldwide with laboratory confirmed or clinically diagnosed pandemic influenza A H1N1pdm09 virus infection. We identified potential data contributors from an earlier systematic review of reported studies addressing the same research question. In our systematic review, eligible studies were done between March 1, 2009 (Mexico), or April 1, 2009 (rest of the world), until the WHO declaration of the end of the pandemic (Aug 10, 2010); however, we continued to receive data up to March 14, 2011, from ongoing studies. We did a meta-analysis of individual participant data to assess the association between neuraminidase inhibitor treatment and mortality (primary outcome), adjusting for both treatment propensity and potential confounders, using generalised linear mixed modelling. We assessed the association with time to treatment using time-dependent Cox regression shared frailty modelling. FINDINGS: We included data for 29 234 patients from 78 studies of patients admitted to hospital between Jan 2, 2009, and March 14, 2011. Compared with no treatment, neuraminidase inhibitor treatment (irrespective of timing) was associated with a reduction in mortality risk (adjusted odds ratio [OR] 0.81; 95% CI 0.70-0.93; p=0.0024). Compared with later treatment, early treatment (within 2 days of symptom onset) was associated with a reduction in mortality risk (adjusted OR 0.48; 95% CI 0.41-0.56; p<0.0001). Early treatment versus no treatment was also associated with a reduction in mortality (adjusted OR 0.50; 95% CI 0.37-0.67; p<0.0001). These associations with reduced mortality risk were less pronounced and not significant in children. There was an increase in the mortality hazard rate with each day's delay in initiation of treatment up to day 5 as compared with treatment initiated within 2 days of symptom onset (adjusted hazard ratio [HR 1.23] [95% CI 1.18-1.28]; p<0.0001 for the increasing HR with each day's delay). INTERPRETATION: We advocate early instigation of neuraminidase inhibitor treatment in adults admitted to hospital with suspected or proven influenza infection. FUNDING: F Hoffmann-La Roche.

SUMMARY: In June 2011, a cluster of suspected cases of Guillain-Barre syndrome (GBS), which can follow Campylobacter jejuni infection, was identified in San Luis Rio Colorado (SLRC), Sonora, Mexico and Yuma County, Arizona, USA. An outbreak investigation identified 26 patients (18 from Sonora, eight from Arizona) with onset of GBS 4 May-21 July 2011, exceeding the expected number of cases (n = 1-2). Twenty-one (81%) patients reported antecedent diarrhoea, and 61% of 18 patients tested were seropositive for C. jejuni IgM antibodies. In a case-control study matched on age group, sex, ethnicity, and neighbourhood of residence, all Arizona GBS patients travelled to SLRC during the exposure period vs. 45% of matched controls (matched odds ratio 8.1, 95% confidence interval 1.5-infinity). Exposure information and an environmental assessment suggested that GBS cases resulted from a large outbreak of C. jejuni infection from inadequately disinfected tap water in SLRC. Binational collaboration was essential in investigating this cross-border GBS outbreak, the first in mainland North America since 1976.

A recent transmission of human immunodeficiency virus (HIV) from a living donor to a kidney recipient revealed a possible limitation in existing screening protocols for HIV infection in living donors. We surveyed kidney and liver transplant centers (N=18) in New York State to assess HIV screening protocols for living donors. While most transplant centers evaluated HIV risk behaviors in living donors, evaluation practices varied widely, as did the extent of HIV testing and prevention counseling. All centers screened living donors for serologic evidence of HIV infection, either during initial evaluation or ≥ 1 month before surgery; however, only 50% of transplant centers repeated HIV testing within 14 days before surgery for all donors or donors with specific risk behaviors. Forty-four percent of transplant centers used HIV nucleic acid testing (NAT) to screen either all donors or donors with recognized risk behaviors, and 55% never performed HIV NAT. Results suggest the need to standardize evaluation of HIV risk behaviors and prevention counseling in NY State to prevent acquisition of HIV by prospective living organ donors, and to conduct HIV antibody testing and NAT as close to the time of donation as possible to prevent HIV transmission to recipients.

OBJECTIVES: Our objectives were to estimate 2009 pandemic influenza A (pH1N1) vaccination coverage among pregnant women and identify associated factors. METHODS: We distributed a multimodal survey to 5341 women who gave birth between November 1, 2009, and January 31, 2010, identified by hospitals in King County, Washington State, with maternity services (n = 11). RESULTS: Of 4205 respondents, 3233 (76.9%) reported that they had received pH1N1 vaccine during pregnancy or within 2 weeks after delivery. Women whose prenatal care provider recommended vaccine had a higher vaccination prevalence than women whose provider did not (81.5% vs 29.6%; adjusted prevalence ratio = 2.1; 95% confidence interval = 1.72, 2.58). Vaccination prevalence was lower among women who had received prenatal care from a midwife only compared with women who had received care from other providers (62.9% vs 78.8%; adjusted prevalence ratio = 0.89; 95% confidence interval = 0.83, 0.96). CONCLUSIONS: Among pregnant women in King County, pH1N1 vaccination coverage was high. To improve coverage during nonpandemic seasons, influenza vaccine should be recommended routinely by prenatal care providers and vaccination provided where prenatal care is received. Barriers to midwives providing vaccination recommendations to patients should be explored.

Campylobacter jejuni is a major zoonotic pathogen. A highly virulent, tetracycline-resistant C. jejuni clone (clone SA) has recently emerged in ruminant reservoirs and has become the predominant cause of sheep abortion in the United States. To determine whether clone SA is associated with human disease, we compared the clinical isolates of clone SA from sheep abortions with the human isolates of the PulseNet National Campylobacter databases at the CDC and the FDA using pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), and serotyping. The combined SmaI and KpnI PFGE pattern designations of clone SA from sheep were indistinguishable from those of 123 (9.03%) human C. jejuni isolates (total, 1,361) in the CDC database, among which 56 were associated with sporadic infections and 67 were associated with outbreaks that occurred in multiple states from 2003 to 2010. Most of the outbreaks were attributed to raw milk, while the sources for most of the sporadic cases were unknown. All clone SA isolates examined, including PFGE-matched human isolates, belong to sequence type 8 (ST-8) by MLST and serotype HS:1,8, further indicating the clonality of the related isolates from different host species. Additionally, C. jejuni clone SA was identified in raw milk, cattle feces, the feces and bile of healthy sheep, and abortion cases of cattle and goats, indicating the broad distribution of this pathogenic clone in ruminants. These results provide strong molecular and epidemiological evidence for zoonotic transmission of this emergent clone from ruminants to humans and indicate that C. jejuni clone SA is an important threat to public health.