BACKGROUND: Coccidioidomycosis is a fungal infection that poses a serious risk when transmitted through organ transplantation. We analyzed cases reported to the Organ Procurement and Transplantation Network ad hoc Disease Transmission Advisory Committee from 2013 to 2022. METHODS: Donors and/or recipients who had positive Coccidioides immitis/posadasii serology, pathology, and/or culture were included in this study. Cases adjudicated as 'proven' or 'probable' were analyzed for donor infection risk factors, the timing of infection, transmission by organ type, clinical manifestations, and recipient outcomes. Patient and facility identifiers were removed prior to review. RESULTS: During this time period, 73 potential instances of Coccidioides donor disease transmission events were reported. Among them, infection was transmitted from seven deceased donors to eight recipients. All seven deceased donors had prior infection or exposure to regions where coccidioidomycosis is endemic. Of 20 individuals receiving organs from these donors, eight developed infection, resulting in a 40% transmission rate. The median time to diagnosis post-transplant was 39 days. Disseminated disease occurred in six recipients, five of whom died from the infection. Notably, none of the recipients who received prophylactic antifungal treatment died from the infection. CONCLUSION: Despite its rarity, donor-derived Coccidioides infection is a serious concern, particularly due to the high mortality rate in the early post-transplant period. To mitigate these risks, a thorough assessment of donor exposure history, coupled with donor serology and bronchoalveolar lavage cultures, can effectively guide post-transplant antifungal prophylaxis. Prompt reporting is crucial to prevent Coccidioides infections among other recipients.

The 37(th) International Conference on Antiviral Research (ICAR) was held in Gold Coast, Australia, May 20-24, 2024. ICAR 2024 featured over 75 presentations along with two poster sessions and special events, including those specifically tailored for trainees and early-career scientists. The meeting served as a platform for the exchange of cutting-edge research, with presentations and discussions covering novel antiviral compounds, vaccine development, clinical trials, and therapeutic advancements. A comprehensive array of topics in antiviral science was covered, from the latest breakthroughs in antiviral drug development to innovative strategies for combating emerging viral threats. The keynote presentations provided fascinating insight into two diverse areas fundamental to medical countermeasure development and use, including virus emergence at the human-animal interface and practical considerations for bringing antivirals to the clinic. Additional sessions addressed a variety of timely post-pandemic topics, such as the hunt for broad spectrum antivirals, combination therapy, pandemic preparedness, application of in silico tools and AI in drug discovery, the virosphere, and more. Here, we summarize all the presentations and special sessions of ICAR 2024 and introduce the 38(th) ICAR, which will be held in Las Vegas, USA, March 17-21, 2025.

Introduction: Heart disease poses a significant health and economic burden in the U.S., with considerable variations in outcomes across different racial and ethnic groups. The COVID-19 pandemic has further highlighted the disparities in healthcare utilization and costs associated with heart disease. Methods: The authors used the 2021 Merative MarketScan Medicaid claims database to estimate the medical costs and healthcare utilization associated with heart disease by racial and ethnic groups and COVID-19 diagnosis status. This study focused on individuals aged ≥18 years continuously enrolled in a noncapitated insurance plan in 2021. The outcome measures included total medical expenditures and healthcare utilization, including the numbers of emergency department visits and inpatient admissions and length of inpatient stay. The authors employed a generalized linear model with a family of gamma and log links for medical costs, and a negative binomial regression was used for healthcare utilization. Three-way interactions of heart disease, COVID-19 diagnosis, and race and ethnicity categories were implemented after adjusting for age, sex, and comorbidities. The authors reported average marginal effects with 95% CIs. Results: Among 1,008,166 Medicaid beneficiaries, 8% had heart disease in 2021. The cost associated with heart disease was $10,819 per beneficiary in 2021 (95% CI=10,292; 11,347; p<0.001). The cost was $15,840 (95% CI=14,389; 17,291; p<0.001) for non-Hispanic Black individuals; $9,945 (95% CI=9,172; 10,718; p<0.001) for non-Hispanic White; and $8,511 (95% CI=7,490; 9,531; p<0.001) for Hispanic individuals. Individuals with a COVID-19 diagnosis ($19,638) had $9,541 (95% CI=7,049; 12,032; p<0.001) higher costs associated with heart disease than those without COVID-19 ($10,098) (p<0.001). Individuals with heart disease had higher numbers of emergency department visits (0.937 per beneficiary, 95% CI=0.913; 0.960), inpatient admissions (0.463 per beneficiary, 95% CI=0.455; 0.471), and average length of stay (2.541 days per admission, 95% CI=2.405; 2.677) than those without heart disease. Conclusions: The study's findings showed that costs and healthcare utilization associated with heart disease are substantial in all racial and ethnic groups and the highest among non-Hispanic Black individuals. Furthermore, individuals with a COVID-19 diagnosis had approximately 2 times higher costs associated with heart disease than individuals without a COVID-19 diagnosis. © 2024

Cache Valley virus (CVV), a mosquito-borne orthobunyavirus, causes epizootics in ruminants characterized by congenital malformations and fetal death in North America. Only seven human infections have been identified; limited information exists on its potential as a human teratogen. Diagnosis of CVV infections relies on the plaque reduction neutralization test (PRNT), which requires live virus, is time-consuming, and cannot differentiate between recent and past infections. To improve diagnostics for CVV, we developed an IgM antibody capture ELISA (MAC-ELISA) for detection of anti-CVV human IgM in diagnostic specimens that can be performed faster than PRNT and is specific to IgM, which is essential to determine the timing of infection. Conjointly, a cell line constitutively expressing human-murine chimeric antibody with the variable regions of monoclonal antibody CVV-17 and constant regions of human IgM was developed to provide positive control material. The new cell line produced antibody with reactivity in the assay equivalent to that of a human serum sample positive for anti-CVV IgM. Five of seven archived human specimens diagnostically confirmed as CVV positive tested positive in the MAC-ELISA, whereas 44 specimens confirmed positive for another arboviral infection tested negative, showing good initial correlation of the CVV MAC-ELISA. Two of 27 previously collected serum samples from febrile patients in Yucatán, Mexico, who tested negative for a recent flaviviral or alphaviral infection were positive in both the MAC-ELISA and PRNT, indicating a possible recent infection with CVV or related orthobunyavirus. The MAC-ELISA described here will aid in making diagnostics more widely available for CVV in public health laboratories.

BACKGROUND: In 2012, the U.S. Preventive Services Task Force (USPSTF) recommended against prostate cancer screening using the prostate-specific antigen (PSA) test for all age groups. In 2018 the USPSTF's recommendation shifted from a "D" (not recommended) to a "C" (selectively offering PSA-based screening based on professional judgment and patient preferences) in men ages 55-69. Limited reliable county-level prostate cancer screening data is available for cancer surveillance purposes. METHODS: Utilizing data from the National Health Interview Survey (NHIS) and Behavioral Risk Factor Surveillance System (BRFSS) collected in 2012-2019, state- and county-level small area models were developed for estimating PSA testing. Model diagnosis, internal validation, and external validation examining associations of PSA testing and prostate cancer incidence were conducted. RESULTS: Model-based estimates of PSA testing rate were produced for all U.S. states and 3,142 counties for two data periods: 2012-2016 and 2018-2019. Geographic variations across counties were demonstrated through maps. Moderate positive correlations between PSA-based screening and prostate cancer incidence were observed, for example, the state-level weighted Pearson's correlation coefficients were 0.5025 (p-value=0.0002) and 0.3691 (p-value=0.0077) for 2012-2016 and 2018-2019, respectively. CONCLUSIONS: These modeled estimates showed improved precision and adjusted for the differences between BRFSS and NHIS. The approach of combining NHIS and BRFSS utilized strengths of the larger sample size of BRFSS and generally higher response rates and better household coverage from the NHIS. IMPACT: The resulting small area estimates offer a valuable resource for the cancer surveillance community, aiding in targeted interventions, decision-making, and further research endeavors.

BACKGROUND: The COVID-19 pandemic has generated a demand for timely data, resulting in a surge of mobile phone surveys for tracking the impacts of and responses to the pandemic. Mobile phone surveys have become a preferred mode of data collection across low- and middle-income countries. OBJECTIVE: This study piloted 2 population-based, cross-sectional mobile phone surveys among Sri Lankan residents in 2020 and 2021 during the COVID-19 pandemic. The surveys aimed to gather data on knowledge, attitudes, and practices, vaccine acceptability, availability, and barriers to COVID-19 testing, and use of a medicine distribution service. METHODS: The study used Surveda, an open-source survey tool developed by the NCD (noncommunicable disease) Mobile Phone Survey Data 4 Health Initiative, for data collection and management. The surveys were conducted through interactive voice response using automated, prerecorded messages in Sinhala, Tamil, and English. The sample design involved random sampling of mobile phone numbers, stratified by sex, proportional to the general population. Eligibility criteria varied between surveys, targeting adults aged 35 years and older with any noncommunicable disease for the first survey and all adults for the second survey. The data were adjusted to population estimates, and statistical analysis was conducted using SAS (SAS Institute) and R software (R Core Team). Descriptive statistics, Rao-Scott chi-square tests, and z tests were used to analyze the data. Response rates, cooperation rates, and productivity of the sampling approach were calculated. RESULTS: In the first survey, n=5001, the overall response rate was 7.5%, with a completion rate of 85.6%. In the second survey, n=1250, the overall response rate was 10.9%, with a completion rate of 61.9%. Approximately 3 out of 4 adults reported that they avoided public places (888/1175, 75.6%), more than two-thirds avoided public transportation (808/1173, 68.9%), and 9 out of 10 practiced physical distancing (1046/1167, 89.7%). Approximately 1 out of 10 Sri Lankan persons reported being tested for COVID-19, and the majority of those received a polymerase chain reaction test (112/161, 70%). Significantly more males than females reported being tested for COVID-19 (98/554, 17.8% vs 61/578, 10.6%, respectively; P<.001). Finally, the majority of adult Sri Lankan people reported that they definitely or probably would get the COVID-19 vaccination (781/1190, 65.7%). CONCLUSIONS: The surveys revealed that, overall, the adult Sri Lankan population adhered to COVID-19 mitigation strategies. These findings underscore the use of mobile phone surveys in swiftly and easily providing essential data to inform a country's response during the COVID-19 pandemic, obviating the need for face-to-face data collection.

BACKGROUND: With accumulating evidence of single-dose human papillomavirus (HPV) vaccine efficacy in young women, we conducted a community vaccine effectiveness study comparing HPV single-dose and 2-dose regimens (0 and 6 months) of a bivalent HPV vaccine among grade 8 schoolgirls (aged 13-14 years) in Thailand. METHODS: In 2018, eligible grade 8 schoolgirls in Udon Thani (single dose) and Buri Ram (2 doses) provinces were offered HPV vaccine per assigned dose regimen. Concurrently, a cross-sectional survey for measuring baseline HPV prevalence was conducted in grade 10 (n = 2600) and grade 12 unvaccinated schoolgirls (n = 2000) in each province. HPV infection was assessed in first-void urine samples, tested by DNA polymerase chain reaction on the cobas 4800 system (Roche Molecular Diagnostics, Pleasanton, CA). All samples positive on the cobas system and an equal number of negative samples were also tested by Anyplex II HPV28 Detection (Seegene, Seoul, South Korea). The surveys were repeated in 2020 and 2022, when vaccinated grade 8 schoolgirls reached grade 10, and then subsequently grade 12, respectively. Vaccine effectiveness was estimated by comparing the weighted prevalence of HPV-16 or HPV-18 between grade-matched unvaccinated schoolgirls on the baseline survey (2018) and vaccinated schoolgirls in the year-2 (2020) and year-4 (2022) surveys. Adjustment methods were used in the analysis to account for potential differences in sexual behavior due to the noncontemporaneous comparison. RESULTS: The prevalence of HPV-16 and HPV-18 on the baseline survey among unvaccinated grade 10/grade 12 schoolgirls was 2.90% (95% confidence interval [CI] = 2.54% to 3.31%)/3.98% (95% CI = 3.52% to 4.49%) for Udon Thani and 3.87% (95% CI = 3.46% to 4.34%)/6.13% (95% CI = 5.56% to 6.75%) for Buri Ram. On the year-2 survey, the prevalence among vaccinated grade 10 schoolgirls was 0.57% (95% CI = 0.42% to 0.77%) for Udon Thani and 0.31% (95% CI = 0.21% to 0.47%) for Buri Ram. The 2-year postvaccination crude vaccine effectiveness for the single-dose regimen was estimated at 80.4% (95% CI = 73.9% to 86.9%), and for the 2-dose regimen at 91.9% (95% CI = 88.5% to 95.4%). On the year-4 survey, the prevalence among vaccinated grade 12 schoolgirls was 0.37% (95% CI = 0.25% to 0.56%) for Udon Thani and 0.28% (95% CI = 0.18% to 0.45%) for Buri Ram. Four-year postvaccination crude vaccine effectiveness for the single-dose regimen was estimated at 90.6% (95% CI = 86.6% to 94.6%) and for the 2-dose regimen was estimated at 95.4% (95% CI = 93.2% to 97.6%). All adjustment methods minimally affected vaccine effectiveness for the single-dose and 2-dose regimens. At 4 years after vaccination, the difference in crude vaccine effectiveness between the single-dose and 2-dose regimens was ‒4.79% (95% CI = ‒9.32% to ‒0.25%), meeting the study's noninferiority criteria. CONCLUSIONS: Our study demonstrated that both single-dose and 2-dose HPV vaccination significantly decreased HPV-16/18 point prevalence 2 years and 4 years after vaccination. Crude vaccine effectiveness at 4 years after vaccination was greater than 90% for both the single-dose and 2-dose regimens; the single-dose regimen was not inferior to the 2-dose regimen. These data show that a single dose of HPV vaccine provides high levels of protection when administered to schoolgirls younger than 15 years of age.

BACKGROUND: Hypertension affects nearly half of US adults yet remains inadequately controlled in over three-quarters of these cases. This study aimed to assess the association between adherence to antihypertensive medications and total medical costs, health care use, and productivity-related outcomes. METHODS AND RESULTS: We conducted cross-sectional analyses using MarketScan databases, which included individuals aged 18 to 64 years with noncapitated health insurance plans in 2019. Adherence was defined as ≥80% medication possession ratio for prescribed antihypertensive medications. We used a generalized linear model to estimate total medical costs, a negative binomial model to estimate health care use (emergency department visits and inpatient admissions), an exponential hurdle model to estimate productivity-related outcomes (number of sick absences, short-term disability, long-term disability), and a 2-part model to estimate productivity-related costs in 2019 US dollars. All models were adjusted for age, sex, urbanicity, census region, and comorbidities. We reported average marginal effects for outcomes related to antihypertensive medication adherence. Among 379 503 individuals with hypertension in 2019, 54.4% adhered to antihypertensives. Per person, antihypertensive medication adherence was associated with $1441 lower total medical costs, $11 lower sick absence costs, $291 lower short-term disability costs, and $69 lower long-term disability costs. Per 1000 individuals, medication adherence was associated with lower health care use, including 200 fewer emergency department visits and 90 fewer inpatient admissions, and productivity-related outcomes, including 20 fewer sick absence days and 442 fewer short-term disability days. CONCLUSIONS: Adherence to antihypertensives was consistently associated with lower total medical costs, reduced health care use, and improved productivity-related outcomes.

Common methods to collect data include quantitative, qualitative, and mixed method approaches. Although it is common to complete data collection in-person, the onset of COVID-19 has resulted in the increased use of online modalities. Qualitative research is commonly gathered through individual or focus group interviews. However, best practices outlining strategies when conducting online focus groups and approaches to address issues specific to online research (i.e., scammers) are limited. Due to the growing use of data collection through such means, it is imperative to draw out specific strategies that could regulate data quality and reduce the chances of scamming. The current article addresses this practical gap by providing a synthesis of the available literature on online focus groups that document best practices and suggestions to deal with scammers which is currently missing from the literature. The goal was to provide initial suggestions to improve data quality of online focus groups by examining the available literature that outlines best practices, addresses the issues of scammers, and to provide a concise and comprehensive overview of identified literature The article is organized beginning with a review of the literature. The research is then synthesized including an outline of best practices and strategies to address scammers when engaging in online focus groups. The article closes with a discussion of the significance of the review, limitations, and article summary. Scammers are prevalent in online spaces. Although this article provides a preliminary outline of suggestions from the literature, more research is necessary that provides specific examples of how challenges have been addressed and the impact of including the recommended strategies on the research process and outcomes. © 2024, Ludomedia EN. All rights reserved.

Legionnaires disease is a serious pneumonia caused by Legionella bacteria. During November 2022-June 2024, CDC was notified of 12 cases of Legionnaires disease among travelers on two cruise ships; eight on cruise ship A and four on cruise ship B. CDC, in collaboration with the cruise lines, initiated investigations to ascertain the potential sources of on-board exposure after notification of the second potentially associated case for each ship. Epidemiologic data collected from patient interviews and environmental assessment and sampling results identified private hot tubs on selected cabin balconies as the most likely exposure source. To minimize Legionella growth, both cruise lines modified the operation and maintenance of these devices by removing the heating elements, draining water between uses, and increasing the frequency of hyperchlorination and cleaning. Hot tubs offer favorable conditions for Legionella growth and transmission when maintained and operated inadequately, regardless of location. Private hot tubs on cruise ships are not subject to the same maintenance requirements as are public hot tubs in common areas. Given the range of hot tub-type devices offered as amenities across the cruise industry, to reduce risk for Legionella growth and transmission, it is important for cruise ship water management program staff members to inventory and assess private balcony hot tubs and adapt public hot tub maintenance and operations protocols for use on private outdoor hot tubs.

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

Use of tobacco products in any form is unsafe, and nearly all tobacco product use begins during adolescence. CDC and the Food and Drug Administration (FDA) analyzed data from the 2024 National Youth Tobacco Survey to determine tobacco product use among U.S. middle school (grades 6-8) and high school (grades 9-12) students. In 2024, current (previous 30-day) use of any tobacco product was reported by 10.1% of high school students (representing 1.58 million students) and 5.4% of middle school students (representing 640,000 students). Among all students, e-cigarettes were the most commonly reported tobacco product currently used (5.9%), followed by nicotine pouches (1.8%), cigarettes (1.4%), cigars (1.2%), smokeless tobacco (1.2%), other oral nicotine products (1.2%), heated tobacco products (0.8%), hookahs (0.7%), and pipe tobacco (0.5%). During 2023-2024, among all students, the estimated number who reported current use of any tobacco product decreased from 2.80 to 2.25 million students; e-cigarette use decreased (from 2.13 to 1.63 million students); and hookah use decreased (from 290,000 to 190,000 students). Among high school students, current use of any tobacco product decreased from 12.6% to 10.1% of students, and e-cigarette use decreased from 10.0% to 7.8%. Among middle school students, no statistically significant changes occurred. Evidence-based strategies can help prevent initiation and promote cessation of tobacco product use among U.S. youths.

BACKGROUND: Transgender women continue to face a significant burden of health disparities with HIV infection as a critical public health concern. Substance use is higher among transgender women compared to cisgender women. However, little is known about transgender women who inject drugs and risk for HIV in the United States. The objectives were to explore HIV prevalence, injection-related behaviors, and HIV prevention and care outcomes among transgender women who inject drugs and to compare transgender women to a general sample of people who inject drugs (PWID). METHODS: Participants from National HIV Behavioral Surveillance were recruited via respondent-driven sampling, interviewed, and tested for HIV infection in 2019-2020. Log-linked Poisson regression models were used to test for associations between injection drug use and selected characteristics. RESULTS: Among 1,561 transgender women, 7% injected drugs in the past 12 months. HIV prevalence was higher among transgender women who inject (aPR=1.5, 95%CI=1.2-1.8) than those who do not. Multiple psychosocial conditions were associated with injection drug use. Among transgender women with HIV, those who inject were less likely to take antiretroviral therapy (aPR=0.8, 95%CI=0.7-1.0) than those who do not. Methamphetamine was the most commonly injected drug (67%); most accessed a syringe services program (66%). CONCLUSION: Transgender women who inject have substantial challenges related to health outcomes including high HIV prevalence and exposure to psychosocial conditions, such as homelessness, incarceration, and exchange sex, that may exacerbate risks associated with injection drug use. This population may benefit from increased access to non-judgmental and culturally competent harm reduction services.

INTRODUCTION: An error grid compares measured versus reference glucose concentrations to assign clinical risk values to observed errors. Widely used error grids for blood glucose monitors (BGMs) have limited value because they do not also reflect clinical accuracy of continuous glucose monitors (CGMs). METHODS: Diabetes Technology Society (DTS) convened 89 international experts in glucose monitoring to (1) smooth the borders of the Surveillance Error Grid (SEG) zones and create a user-friendly tool-the DTS Error Grid; (2) define five risk zones of clinical point accuracy (A-E) to be identical for BGMs and CGMs; (3) determine a relationship between DTS Error Grid percent in Zone A and mean absolute relative difference (MARD) from analyzing 22 BGM and nine CGM accuracy studies; and (4) create trend risk categories (1-5) for CGM trend accuracy. RESULTS: The DTS Error Grid for point accuracy contains five risk zones (A-E) with straight-line borders that can be applied to both BGM and CGM accuracy data. In a data set combining point accuracy data from 18 BGMs, 2.6% of total data pairs equally moved from Zones A to B and vice versa (SEG compared with DTS Error Grid). For every 1% increase in percent data in Zone A, the MARD decreased by approximately 0.33%. We also created a DTS Trend Accuracy Matrix with five trend risk categories (1-5) for CGM-reported trend indicators compared with reference trends calculated from reference glucose. CONCLUSION: The DTS Error Grid combines contemporary clinician input regarding clinical point accuracy for BGMs and CGMs. The DTS Trend Accuracy Matrix assesses accuracy of CGM trend indicators.

OBJECTIVES: Public health emergencies can elevate the risk for intimate partner violence (IPV). Our objectives were 2-fold: first, to assess the prevalence of physical IPV and increased aggression from a husband or partner that occurred during pregnancy and was perceived to be due to the COVID-19 pandemic; second, to examine associations between these experiences and (1) COVID-19-related stressors and (2) postpartum outcomes. METHODS: We used data from the Pregnancy Risk Assessment Monitoring System that were collected in 29 US jurisdictions among individuals with a live birth in 2020. We estimated the prevalence of violence during pregnancy by demographic characteristics and COVID-19-related stressors. We calculated adjusted prevalence ratios (APRs) to examine associations of physical IPV or increased aggression with COVID-19-related stressors, postpartum outcomes, and infant birth outcomes. RESULTS: Among 14 154 respondents, 1.6% reported physical IPV during pregnancy, and 3.1% reported increased aggression by a husband or partner due to the COVID-19 pandemic. Respondents experiencing any economic, housing, or childcare COVID-19-related stressors reported approximately twice the prevalence of both types of violence as compared with those without COVID-19-related stressors. Physical IPV and increased aggression were associated with a higher prevalence of postpartum depressive symptoms (APRs, 1.73 and 2.28, respectively) and postpartum cigarette smoking (APRs, 1.74 and 2.19). Physical IPV was associated with a lower prevalence of attending postpartum care visits (APR, 1.84). CONCLUSIONS: Our findings support the need for ongoing efforts to prevent IPV during pregnancy and to ensure the availability of resources during public health emergencies.

Immigrants and refugees seeking admission to the United States must first undergo an overseas medical exam, overseen by the US Centers for Disease Control and Prevention (CDC), during which all persons ≥15 years old receive a chest x-ray to look for signs of tuberculosis. Although individual screening sites often implement quality control (QC) programs to ensure radiographs are interpreted correctly, the CDC does not currently have a method for conducting similar QC reviews at scale. We obtained digitized chest radiographs collected as part of the overseas immigration medical exam. Using radiographs from applicants 15 years old and older, we trained deep learning models to perform three tasks: identifying abnormal radiographs; identifying abnormal radiographs suggestive of tuberculosis; and identifying the specific findings (e.g., cavities or infiltrates) in abnormal radiographs. We then evaluated the models on both internal and external testing datasets, focusing on two classes of performance metrics: individual-level metrics, like sensitivity and specificity, and sample-level metrics, like accuracy in predicting the prevalence of abnormal radiographs. A total of 152,012 images (one image per applicant; mean applicant age 39 years) were used for model training. On our internal test dataset, our models performed well both in identifying abnormalities suggestive of TB (area under the curve [AUC] of 0.97; 95% confidence interval [CI]: 0.95, 0.98) and in estimating sample-level counts of the same (-2% absolute percentage error; 95% CIC: -8%, 6%). On the external test datasets, our models performed similarly well in identifying both generic abnormalities (AUCs ranging from 0.89 to 0.92) and those suggestive of TB (AUCs from 0.94 to 0.99). This performance was consistent across metrics, including those based on thresholded class predictions, like sensitivity, specificity, and F1 score. Strong performance relative to high-quality radiological reference standards across a variety of datasets suggests our models may make reliable tools for supporting chest radiography QC activities at CDC.

PURPOSE: The etiopathogenesis of coronal nonsyndromic craniosynostosis (cNCS), a congenital condition defined by premature fusion of 1 or both coronal sutures, remains largely unknown. METHODS: We conducted the largest genome-wide association study of cNCS followed by replication, fine mapping, and functional validation of the most significant region using zebrafish animal model. RESULTS: Genome-wide association study identified 6 independent genome-wide-significant risk alleles, 4 on chromosome 7q21.3 SEM1-DLX5-DLX6 locus, and their combination conferred over 7-fold increased risk of cNCS. The top variants were replicated in an independent cohort and showed pleiotropic effects on brain and facial morphology and bone mineral density. Fine mapping of 7q21.3 identified a craniofacial transcriptional enhancer (eDlx36) within the linkage region of the top variant (rs4727341; odds ratio [95% confidence interval], 0.48[0.39-0.59]; P = 1.2E-12) that was located in SEM1 intron and enriched in 4 rare risk variants. In zebrafish, the activity of the transfected human eDlx36 enhancer was observed in the frontonasal prominence and calvaria during skull development and was reduced when the 4 rare risk variants were introduced into the sequence. CONCLUSION: Our findings support a polygenic nature of cNCS risk and functional role of craniofacial enhancers in cNCS susceptibility with potential broader implications for bone health.

INTRODUCTION: Approximately 49,000 persons died by suicide in the United States in 2022, and provisional data indicate that a similar number died by suicide in 2023. A comprehensive approach that addresses upstream community risk and protective factors is an important component of suicide prevention. A better understanding of the role of these factors is needed, particularly among disproportionately affected populations. METHODS: Suicide deaths were identified in the 2022 National Vital Statistics System. County-level factors, identified from federal data sources, included health insurance coverage, household broadband Internet access, and household income. Rates and levels of factors categorized by tertiles were calculated and presented by race and ethnicity, sex, age, and urbanicity. RESULTS: In 2022, the overall suicide rate was 14.2 per 100,000 population; rates were highest among non-Hispanic American Indian or Alaska Native (AI/AN) persons (27.1), males (23.0), and rural residents (20.0). On average, suicide rates were lowest in counties in the top one third of percentage of persons or households with health insurance coverage (13.0), access to broadband Internet (13.3), and income >100% of the federal poverty level (13.5). These factors were more strongly associated with lower suicide rates in some disproportionately affected populations; among AI/AN persons, suicide rates in counties in the highest tertile of these factors were approximately one half the rates of counties in the lowest tertile. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Higher levels of health insurance coverage, household broadband Internet access, and household income in communities might play a role in reducing suicide rates. Upstream programs, practices, and policies detailed in CDC's Suicide Prevention Resource for Action can be implemented by decision-makers, government agencies, and communities as they work together to address community-specific needs and save lives.

BACKGROUND: There are no recent estimates for hypertension-associated medical expenditures. This study aims to estimate hypertension-associated incremental medical expenditures among privately insured US adults. METHODS: We conducted a retrospective cohort study using IQVIA's Ambulatory Electronic Medical Records-US data set linked with PharMetrics Plus claims data. Among privately insured adults aged 18 to 64 years, hypertension was identified as having ≥1 diagnosis code or ≥2 blood pressure measurements of ≥140/90 mm Hg, or ≥1 antihypertensive medication in 2021. Annual total expenditures (in 2021 $US) were estimated using a generalized linear model with gamma distribution and log-link function adjusting for demographic characteristics and cooccurring conditions. Out-of-pocket expenditures were estimated using a 2-part model that included logistic and generalized linear model regression. Overlap propensity score weights from logistic regression were used to obtain a balanced sample on hypertension status. RESULTS: Among the 393 018 adults, 156 556 (40%) were identified with hypertension. Compared with individuals without hypertension, those with hypertension had $2926 (95% CI, $2681-$3170) higher total expenditures and $328 (95% CI, $300-$355) higher out-of-pocket expenditures. Adults with hypertension had higher total inpatient ($3272 [95% CI, $1458-$5086]) and outpatient ($2189 [95% CI, $2009-$2369]) expenditures when compared with those without hypertension. Hypertension-associated incremental total expenditures were higher for women ($3242 [95% CI, $2915-$3569]) than for men ($2521 [95% CI, $2139-$2904]). CONCLUSIONS: Among privately insured US adults, hypertension was associated with higher medical expenditures, including higher inpatient and out-of-pocket expenditures. These findings may help assess the economic value of interventions effective in preventing hypertension.

CONTEXT: Schools vary in their capacity to implement recommended strategies to prevent infectious diseases, such as COVID-19. Professional development (PD) and technical assistance (TA) are well-established tools used to strengthen school capacity and infrastructure for healthier school environments. OBJECTIVE: The authors examined the relationship between PD and TA received by districts and schools and their implementation of COVID-19 prevention strategies during the 2020-2021 school year. DESIGN AND SETTING: We conducted a descriptive analysis of survey responses collected during Spring 2021 from selected districts and schools in 9 participating states. The survey assessed the implementation of 10 COVID-19 prevention strategies recommended by the Centers for Disease Control and Prevention and whether district or school staff received PD and/or TA on topics related to COVID-19 during the same year. PARTICIPANTS: Survey responses were received from designated contacts in 310 districts and 931 schools across 9 states. MAIN OUTCOME MEASURES: The dependent variable was the number of COVID-19 prevention strategies that were reported as "in place" by each district and school ranging from 0 to 10. RESULTS: On average, districts and schools reported implementing 7 of 10 recommended COVID-19 prevention strategies during the 2020-2021 school year. Schools that received PD on at least 1 of 12 topics reported implementing 7.61 COVID-19 prevention strategies, whereas schools that did not receive PD reported implementing 6.34 strategies. Similarly, schools that received TA on at least 1 topic reported higher COVID-19 implementation scores (7.51) than schools that did not receive any TA (7.20). CONCLUSIONS: Findings reveal a positive relationship between receiving PD and/or TA and implementation of COVID-19 prevention strategies in school settings.

Current e-cigarette use among U.S. youth has declined considerably since 2019*; however, approximately 2.13 million youths used e-cigarettes in 2023 (1). As sales of nicotine pouches (small, dissolvable, flavored pouches containing nicotine derived from tobacco that users place in the mouth between the lip and gum)(†) have continued to rise nationally since 2016, their use among U.S. youths has become concerning (2,3). All pouches and most e-cigarettes contain nicotine,(§) which is highly addictive and can harm the developing adolescent brain (4,5).

Background: The first licensed malaria vaccine, RTS,S/AS01<inf>E</inf>, confers moderate protection against symptomatic disease. Because many malaria infections are asymptomatic, we conducted a large-scale longitudinal parasite genotyping study of samples from a clinical trial exploring how vaccine dosing regimen affects vaccine efficacy. Method(s): Between Sept 28, 2017, and Sept 25, 2018, 1500 children aged 5-17 months were randomly assigned (1:1:1:1:1) to receive four different RTS,S/AS01<inf>E</inf> regimens or a rabies control vaccine in a phase 2b open-label clinical trial in Ghana and Kenya. Participants in the four RTS,S groups received two full doses at month 0 and month 1 and either full doses at month 2 and month 20 (group R012-20); full doses at month 2, month 14, month 26, and month 38 (group R012-14); fractional doses at month 2, month 14, month 26, and month 38 (group Fx012-14; early fourth dose); or fractional doses at month 7, month 20, and month 32 (group Fx017-20; delayed third dose). We evaluated the time to the first new genotypically detected infection and the total number of new infections during two follow-up periods (12 months and 20 months) in more than 36 000 dried blood spot specimens from 1500 participants. To study vaccine effects on time to the first new infection, we defined vaccine efficacy as one minus the hazard ratio (HR; RTS,S vs control) of the first new infection. We performed a post-hoc analysis of vaccine efficacy based on malaria infection status at first vaccination and force of infection by month 2. This trial (MAL-095) is registered with ClinicalTrials.gov, NCT03281291. Finding(s): We observed significant and similar vaccine efficacy (25-43%; 95% CI union 9-53) against first new infection for all four RTS,S/AS01<inf>E</inf> regimens across both follow-up periods (12 months and 20 months). Each RTS,S/AS01<inf>E</inf> regimen significantly reduced the mean number of new infections in the 20-month follow-up period by 1.1-1.6 infections (95% CI union 0.6-2.1). Vaccine efficacy against first new infection was significantly higher in participants who were infected with malaria (68%; 95% CI 50-80) than in those who were uninfected (37%; 23-48) at the first vaccination (p=0.0053). Interpretation(s): All tested dosing regimens blocked some infections to a similar degree. Improved vaccine efficacy in participants infected during vaccination could suggest new strategies for highly efficacious malaria vaccine development and implementation. Funding(s): GlaxoSmithKline Biologicals SA, PATH, Bill & Melinda Gates Foundation, and the German Federal Ministry of Education and Research. Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

Information on microorganisms in indoor air of various institutional and commercial buildings has significant value in a public health management perspective. However, there is a lack of prior research comparing indoor airborne microbiota across different categories of those buildings. We characterized indoor airborne bacteria in 10 buildings (two for each of five categories: train station, parking garage, mart, public library, and daycare center) during summer and winter. The 16S rRNA gene in the bacterial gDNA extracted from samples was quantified using quantitative real-time polymerase chain reaction and sequenced with the Illumina MiSeq™ platform for characterizing community composition. We collected information on temperature, relative humidity, CO2 concentration, and particulate matter (PM) concentrations by particle size (<1 µm, 1–2.5 µm, 2.5–10 µm) indoors. We performed a multivariate regression analysis to identify factors influencing bacterial quantity and Permutational Multivariate Analysis of Variance (PERMANOVA) to determine factors affecting cluster dissimilarity. We found that bacterial concentration was significantly (p-values < 0.05) associated with season and CO2 concentration. The PERMANOVA analyses showed the significant (p-values < 0.05) associations of bacterial cluster dissimilarity with season, building category, and CO2. Our study indicated that the season, and CO2 concentrations may be important factors associated with the indoor airborne bacterial concentration and composition. Building category and usage appeared to significantly influence the bacterial community composition but not the concentration. Our study may provide basic data on bacterial community composition and their concentration that are needed for properly managing microbial exposures in occupants or customers of the studied institutional and commercial buildings. Copyright © 2024 American Association for Aerosol Research. © 2024 American Association for Aerosol Research.

During routine clinical practice, infectious disease physicians encounter patients with difficult-to-diagnose clinical syndromes and may order advanced molecular testing to detect pathogens. These tests may identify potential infectious causes for illness and allow clinicians to adapt treatments or stop unnecessary antimicrobials. Cases of pathogen-agnostic disease testing also provide an important window into known, emerging, and reemerging pathogens and may be leveraged as part of national sentinel surveillance. A survey of Emerging Infections Network members, a group of infectious disease providers in North America, was conducted in May 2023. The objective of the survey was to gain insight into how and when infectious disease physicians use advanced molecular testing for patients with difficult-to-diagnose infectious diseases, as well as to explore the usefulness of advanced molecular testing and barriers to use. Overall, 643 providers answered at least some of the survey questions; 478 (74%) of those who completed the survey had ordered advanced molecular testing in the last two years, and formed the basis for this study. Respondents indicated that they most often ordered broad-range 16S rRNA gene sequencing, followed by metagenomic next-generation sequencing and whole genome sequencing; and commented that in clinical practice, some, but not all tests were useful. Many physicians also noted several barriers to use, including a lack of national guidelines and cost, while others commented that whole genome sequencing had potential for use in outbreak surveillance. Improving frontline physician access, availability, affordability, and developing clear national guidelines for interpretation and use of advanced molecular testing could potentially support clinical practice and public health surveillance.

Wisdom is the hallmark of social judgment, but how people across cultures recognize wisdom remains unclear-distinct philosophical traditions suggest different views of wisdom's cardinal features. We explore perception of wise minds across 16 socio-economically and culturally diverse convenience samples from 12 countries. Participants assessed wisdom exemplars, non-exemplars, and themselves on 19 socio-cognitive characteristics, subsequently rating targets' wisdom, knowledge, and understanding. Analyses reveal two positively related dimensions-Reflective Orientation and Socio-Emotional Awareness. These dimensions are consistent across the studied cultural regions and interact when informing wisdom ratings: wisest targets-as perceived by participants-score high on both dimensions, whereas the least wise are not reflective but moderately socio-emotional. Additionally, individuals view themselves as less reflective but more socio-emotionally aware than most wisdom exemplars. Our findings expand folk psychology and social judgment research beyond the Global North, showing how individuals perceive desirable cognitive and socio-emotional qualities, and contribute to an understanding of mind perception.

BACKGROUND: Limited data about acute respiratory illness (ARI) and respiratory virus circulation are available in congregate community settings, specifically schools. To better characterize the epidemiology of ARI and respiratory viruses in schools, we developed School Knowledge of Infectious Diseases in Schools (School KIDS). METHODS: School KIDS is a prospective, respiratory viral testing program in a large metropolitan school district (pre-kindergarten-12th grade) in Kansas City, Missouri. During the 2022-2023 school year, all students and staff were eligible to participate in surveillance respiratory viral testing at school by submitting observed self-administered nasal swabs monthly. Participants could also submit a nasal swab for on-demand symptomatic testing when experiencing ≥1 ARI symptom, including cough, fever, nasal congestion, runny nose, shortness of breath, sore throat, and/or wheezing. Swabs were tested in a research laboratory using multipathogen respiratory polymerase chain reaction assays. Participants were evaluated for ongoing viral shedding by collecting two weekly nasal swabs (i.e., convalescent), following initial on-demand symptomatic testing. Participants were asked to complete an electronic survey to capture the presence and type of ARI symptom(s) before the collection of respiratory swabs. RESULTS: From 31 October 2022 to 29 June 2023, School KIDS enrolled 978 participants, including 700 students, representing 3.4% of the district student population, and 278 staff members. Participants submitted a median of six surveillance, one symptomatic, and two convalescent specimens during the study period. A total of 6,315 respiratory specimens, including 4,700 surveillance, 721 on-demand symptomatic, and 894 convalescent specimens, were tested. Overall, a virus was detected in 1,168 (24.9%) surveillance and 363 (50.3%) symptomatic specimens. Of the 5,538 symptom surveys sent to participants before scheduled surveillance testing, 4,069 (73.5%) were completed; ARI symptoms were reported on 1,348 (33.1%) surveys. CONCLUSION: Respiratory surveillance testing in schools is feasible and provides novel information about respiratory virus detections in students and staff attending school. Schools are an important community setting, and better knowledge of respiratory virus circulation in schools may be useful to identify respiratory virus transmission in the community and assess the impact of effective infection prevention measures.

Accurate forecasts can enable more effective public health responses during seasonal influenza epidemics. For the 2021-22 and 2022-23 influenza seasons, 26 forecasting teams provided national and jurisdiction-specific probabilistic predictions of weekly confirmed influenza hospital admissions for one-to-four weeks ahead. Forecast skill is evaluated using the Weighted Interval Score (WIS), relative WIS, and coverage. Six out of 23 models outperform the baseline model across forecast weeks and locations in 2021-22 and 12 out of 18 models in 2022-23. Averaging across all forecast targets, the FluSight ensemble is the 2(nd) most accurate model measured by WIS in 2021-22 and the 5(th) most accurate in the 2022-23 season. Forecast skill and 95% coverage for the FluSight ensemble and most component models degrade over longer forecast horizons. In this work we demonstrate that while the FluSight ensemble was a robust predictor, even ensembles face challenges during periods of rapid change.

BACKGROUND: Telehealth has emerged as an effective tool for managing common chronic conditions such as hypertension, especially during the COVID-19 pandemic. However, the impact of state telehealth payment and coverage parity laws on hypertension medication adherence remains uncertain. METHODS: Data from the 2016 to 2021 Merative MarketScan Commercial Claims and Encounters Database were used to construct the study cohort, which included nonpregnant individuals aged 25 to 64 years with hypertension. We coded telehealth parity laws related to hypertension management in all 50 US states and the District of Columbia, distinguishing between payment and coverage parity laws. The primary outcomes were measures of antihypertension medication adherence: the average medication possession ratio; medication adherence (medication possession ratio ≥80%); and average number of days of drug supply. We used a generalized difference-in-differences design to examine the impact of these laws. RESULTS: Among 353 220 individuals (mean [SD] age, 49.5 (7.1) years; female, 45.55%), states with payment parity laws were significantly linked to increased average medication possession ratio by 0.43 percentage point (95% CI, 0.07-0.79), and an increase of 0.46 percentage point (95% CI, 0.06-0.92) in the probability of medication adherence. Payment parity laws also led to an average increase of 2.14 days (95% CI, 0.11-4.17) in prescription supply, after controlling for state-fixed effects, year-fixed effects, individual sociodemographic characteristics and state time-varying covariates including unemployment rates, gross domestic product per capita, and poverty rates. In contrast, coverage parity laws were associated with a 2.13-day increase (95% CI, 0.19-4.07) in days of prescription supply but did not significantly increase the average medication possession ratio or probability of medication adherence. CONCLUSIONS: State telehealth payment parity laws were significantly associated with greater medication adherence, whereas coverage parity laws were not. With the increasing adoption of telehealth parity laws across states, these findings may support policymakers in understanding potential implications on management of hypertension.