Last data update: Sep 23, 2024. (Total: 47723 publications since 2009)
Records 1-30 (of 40 Records) |
Query Trace: Masters N [original query] |
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Appropriateness of immunoglobulin M testing for measles, mumps, and rubella
Filardo TD , Masters NB , Leung J , Baca S , Egwuogu H , Guevara OR , Raykin J , Sugerman DE . Am J Prev Med 2024 INTRODUCTION: Testing for immunity to measles, mumps, and rubella should include only IgG; IgM testing is appropriate only if acute illness is suspected. The appropriateness of measles, mumps, and rubella IgM testing was evaluated in a national administrative dataset. METHODS: Laboratory testing for measles, mumps, and rubella during 2019-2022 was analyzed in 2024 using HealthVerity administrative claims and laboratory data. IgG, IgM, and reverse-transcriptase polymerase chain reaction (RT-PCR) testing are described by year, demographics, and region. IgM testing was examined for appropriateness, defined as an IgM test combined with diagnostic codes indicative of acute illness. RESULTS: During 2019-2022, IgM testing represented a small proportion of serologic testing (measles: 3.3%, mumps: 2.4%, rubella: 2.1%) but appeared to be appropriately performed in only 15.4% of cases for measles, 32.8% of cases for mumps, and 10.2% of cases for rubella. IgM testing was more commonly performed for female patients, with the largest discrepancy seen for rubella (90.5% female vs 9.5% male). IgM for measles and mumps was more often performed appropriately for persons aged 0-19 years (37.6% and 60.1%) compared with persons aged 20-49 years (11.8% and 22.0%) and 50+ years (16.5% and 33.8%). CONCLUSIONS: The majority of IgM testing for measles, mumps, and rubella during this period appeared inappropriate. Clinicians and health systems could ensure that IgG testing alone is performed when evaluating for immunity through modifications to electronic medical records and commercial laboratories could ensure that providers are able to test for IgG alone when evaluating immunity. |
Characteristics of reported mumps cases in the United States: 2018-2023
Tappe J , Leung J , Mathis AD , Oliver SE , Masters NB . Vaccine 2024 BACKGROUND: This paper highlights recent clinical complications of mumps reported in the United States and summarizes appropriate confirmatory testing for mumps, encouraging vigilance for mumps disease, an endemic vaccine-preventable illness. METHODS: Surveillance data from jurisdictions reporting confirmed and probable cases of mumps in the United States were descriptively analyzed to assess epidemiologic trends from January 1, 2018 - December 31, 2023. Data were reported to the National Notifiable Disease Surveillance System and the Epidemiology and Laboratory Capacity Project O. Cases were classified according to the Council of State and Territorial Epidemiologists 2011 mumps case definition. RESULTS: From 2018-2023, United States health departments reported 8,006 confirmed and probable mumps cases to the National Notifiable Disease Surveillance System, of which 85.4% occurred during January 1, 2018-April 4, 2020 and 14.6% during April 5, 2020-December 31, 2023. The incidence of mumps was highest among those aged 18-24 years during 2018-2020 (maximum of 4.54 cases per 100,000 persons in 2019), and highest among those aged 1-4 years during 2021-2023 (maximum 0.67 per 100,000 persons in 2023). Incidence among all age groups during 2021-2023 remained below levels during 2018-2020. Fewer than 12% of mumps cases were confirmed during 2021-2023, compared to >50% during 2018-2019. CONCLUSIONS: Although incidence has declined since the COVID-19 pandemic, these surveillance data highlight that mumps remains endemic in the United States. Therefore, maintaining high MMR vaccination coverage is essential to prevent future vaccine-preventable outbreaks and minimize severe complications from infection. |
Identifying a level of neutralizing antibody that correlates with protection from clinical mumps disease during a 2017 mumps outbreak among military service members
Sowers SB , Clemmons NS , Mercader S , Nielsen L , Colley H , Jordan NN , Bettger CC , Masters NB , Markelz AE , Hickman CJ . Open Forum Infect Dis 2024 11 (7) ofae329 BACKGROUND: In 2017, a mumps outbreak occurred in a US military barracks. Serum collected at service entry was used to compare pre-exposure with presumptive vaccine-induced antibody levels from persons who developed mumps (cases) and potentially exposed persons who did not develop mumps (non-cases). Sufficient information to determine levels of exposure during the outbreak was not available. METHODS: Pre-outbreak serum samples from the Department of Defense Serum Repository were available from 254 potentially exposed service members. Twelve developed clinical symptoms and had post-outbreak serum collected. All sera were tested with a mumps-specific enzyme immunoassay for immunoglobulin M, immunoglobulin G (IgG), and IgG avidity. The neutralizing antibodies to vaccine strain (Jeryl Lynn [JL], genotype A) and wildtype virus (genotype G) was assessed by a plaque reduction neutralization test. A Fisher exact test and receiver operator characteristic curve were used to analyze the antibody response for non-cases and mumps cases. RESULTS: Eight mumps cases were laboratory confirmed. Pre-outbreak neutralizing antibody titers to JL and genotype G mumps virus and pre-outbreak IgG index values were proportionately lower for most cases as compared with exposed non-cases. When compared with potentially exposed non-cases, cases with clinical symptoms had greater odds of having a pre-outbreak JL titer <41 and a genotype G titer <16. CONCLUSIONS: We identified potential correlates of protection for mumps neutralizing antibody titers against JL and genotype G mumps viruses. |
Carbapenem-resistant and extended-spectrum β-Lactamase-producing enterobacterales in children, United States, 2016-2020
Grome HN , Grass JE , Duffy N , Bulens SN , Ansari U , Campbell D , Lutgring JD , Gargis AS , Masters T , Kent AG , McKay SL , Smith G , Wilson LE , Vaeth E , Evenson B , Dumyati G , Tsay R , Phipps E , Flores K , Wilson CD , Czaja CA , Johnston H , Janelle SJ , Lynfield R , O'Malley S , Vagnone PS , Maloney M , Nadle J , Guh AY . Emerg Infect Dis 2024 30 (6) 1104-1114 |
Sociodemographic trends and correlation between parental hesitancy towards pediatric COVID-19 vaccines and routine childhood immunizations in the United States: 2021-2022 National Immunization Survey-Child COVID Module
Olusanya OA , Masters NB , Zhang F , Sugerman DE , Carter RJ , Weiss D , Singleton JA . Vaccines (Basel) 2024 12 (5) Multiple factors may influence parental vaccine hesitancy towards pediatric COVID-19 vaccines and routine childhood immunizations (RCIs). Using the United States National Immunization Survey-Child COVID Module data collected from parents/guardians of children aged 5-11 years, this cross-sectional study (1) identified the trends and prevalence estimates of parental hesitancy towards pediatric COVID-19 vaccines and RCIs, (2) examined the relationship between hesitancy towards pediatric COVID-19 vaccines and RCIs, and (3) assessed trends in parental hesitancy towards RCIs by sociodemographic characteristics and behavioral and social drivers of COVID-19 vaccination. From November 2021 to July 2022, 54,329 parents or guardians were interviewed. During this 9-month period, the proportion of parents hesitant about pediatric COVID-19 vaccines increased by 15.8 percentage points (24.8% to 40.6%). Additionally, the proportion of parents who reported RCIs hesitancy increased by 4.7 percentage points from November 2021 to May 2022 but returned to baseline by July 2022. Over nine months, parents' concerns about pediatric COVID-19 infections declined; however, parents were increasingly worried about pediatric COVID-19 vaccine safety and overall importance. Furthermore, pediatric COVID-19 vaccine hesitancy was more prevalent among parents of children who were White (43.2%) versus Black (29.3%) or Hispanic (26.9%) and those residing in rural (51.3%) compared to urban (28.9%) areas. In contrast, RCIs hesitancy was higher among parents of children who were Black (32.0%) versus Hispanic (24.5%) or White (23.6%). Pediatric COVID-19 vaccine hesitancy was 2-6 times as prevalent among parents who were RCIs hesitant compared to those who were RCIs non-hesitant. This positive correlation between parental hesitancy towards pediatric COVID-19 vaccines and RCIs was observed for all demographic and psychosocial factors for unadjusted and adjusted prevalence ratios. Parent-provider interactions should increase vaccine confidence, shape social norms, and facilitate behavior change to promote pediatric vaccination rates. |
Real-time use of a dynamic model to measure the impact of public health interventions on measles outbreak size and duration - Chicago, Illinois, 2024
Masters NB , Holmdahl I , Miller PB , Kumar CK , Herzog CM , DeJonge PM , Gretsch S , Oliver SE , Patel M , Sugerman DE , Bruce BB , Borah BF , Olesen SW . MMWR Morb Mortal Wkly Rep 2024 73 (19) 430-434 Measles is a highly infectious, vaccine-preventable disease that can cause severe illness, hospitalization, and death. A measles outbreak associated with a migrant shelter in Chicago occurred during February-April 2024, in which a total of 57 confirmed cases were identified, including 52 among shelter residents, three among staff members, and two among community members with a known link to the shelter. CDC simulated a measles outbreak among shelter residents using a dynamic disease model, updated in real time as additional cases were identified, to produce outbreak forecasts and assess the impact of public health interventions. As of April 8, the model forecasted a median final outbreak size of 58 cases (IQR = 56-60 cases); model fit and prediction range improved as more case data became available. Counterfactual analysis of different intervention scenarios demonstrated the importance of early deployment of public health interventions in Chicago, with a 69% chance of an outbreak of 100 or more cases had there been no mass vaccination or active case-finding compared with only a 1% chance when those interventions were deployed. This analysis highlights the value of using real-time, dynamic models to aid public health response, set expectations about outbreak size and duration, and quantify the impact of interventions. The model shows that prompt mass vaccination and active case-finding likely substantially reduced the chance of a large (100 or more cases) outbreak in Chicago. |
Measles - United States, January 1, 2020-March 28, 2024
Mathis AD , Raines K , Masters NB , Filardo TD , Kim G , Crooke SN , Bankamp B , Rota PA , Sugerman DE . MMWR Morb Mortal Wkly Rep 2024 73 (14) 295-300 Measles is a highly infectious febrile rash illness and was declared eliminated in the United States in 2000. However, measles importations continue to occur, and U.S. measles elimination status was threatened in 2019 as the result of two prolonged outbreaks among undervaccinated communities in New York and New York City. To assess U.S. measles elimination status after the 2019 outbreaks and to provide context to understand more recent increases in measles cases, CDC analyzed epidemiologic and laboratory surveillance data and the performance of the U.S. measles surveillance system after these outbreaks. During January 1, 2020-March 28, 2024, CDC was notified of 338 confirmed measles cases; 97 (29%) of these cases occurred during the first quarter of 2024, representing a more than seventeenfold increase over the mean number of cases reported during the first quarter of 2020-2023. Among the 338 reported cases, the median patient age was 3 years (range = 0-64 years); 309 (91%) patients were unvaccinated or had unknown vaccination status, and 336 case investigations included information on ≥80% of critical surveillance indicators. During 2020-2023, the longest transmission chain lasted 63 days. As of the end of 2023, because of the absence of sustained measles virus transmission for 12 consecutive months in the presence of a well-performing surveillance system, U.S. measles elimination status was maintained. Risk for widespread U.S. measles transmission remains low because of high population immunity. However, because of the increase in cases during the first quarter of 2024, additional activities are needed to increase U.S. routine measles, mumps, and rubella vaccination coverage, especially among close-knit and undervaccinated communities. These activities include encouraging vaccination before international travel and rapidly investigating suspected measles cases. |
Nowcasting and forecasting the 2022 U.S. Mpox outbreak: Support for public health decision making and lessons learned
Charniga K , Madewell ZJ , Masters NB , Asher J , Nakazawa Y , Spicknall IH . Epidemics 2024 47 100755 In June of 2022, the U.S. Centers for Disease Control and Prevention (CDC) Mpox Response wanted timely answers to important epidemiological questions which can now be answered more effectively through infectious disease modeling. Infectious disease models have shown to be valuable tools for decision making during outbreaks; however, model complexity often makes communicating the results and limitations of models to decision makers difficult. We performed nowcasting and forecasting for the 2022 mpox outbreak in the United States using the R package EpiNow2. We generated nowcasts/forecasts at the national level, by Census region, and for jurisdictions reporting the greatest number of mpox cases. Modeling results were shared for situational awareness within the CDC Mpox Response and publicly on the CDC website. We retrospectively evaluated forecast predictions at four key phases (early, exponential growth, peak, and decline) during the outbreak using three metrics, the weighted interval score, mean absolute error, and prediction interval coverage. We compared the performance of EpiNow2 with a naïve Bayesian generalized linear model (GLM). The EpiNow2 model had less probabilistic error than the GLM during every outbreak phase except for the early phase. We share our experiences with an existing tool for nowcasting/forecasting and highlight areas of improvement for the development of future tools. We also reflect on lessons learned regarding data quality issues and adapting modeling results for different audiences. |
Restaurant and staff characteristics related to practices that could contribute to cross-contamination
Rickamer Hoover E , Masters M , Johnson J , McKelvey W , Hedeen N , Ripley D , Brown L . J Food Prot 2023 86 (12) 100182 Foodborne illness is a persistent public health concern in the U.S.; over 800 foodborne illness outbreaks are reported to the Centers for Disease Control and Prevention (CDC) annually. Most of these outbreaks (60%) are linked with restaurants. Contamination of food with foodborne pathogens during preparation and storage is a significant contributing factor to many of these outbreaks. The CDC's Environmental Health Specialists Network (EHS-Net) collected data to identify restaurant characteristics, policies, and practices associated with contamination prevention practices. Data collectors interviewed managers and conducted kitchen observations in 312 restaurants across six EHS-Net sites in five states. Data collectors observed at least one food worker action that could lead to contamination in 63.1% of restaurants. The most frequently observed action that could lead to contamination was bare hand or dirty glove contact with ready-to-eat food (35.9%). The estimated mean number of observed potential contamination actions was greater in restaurants that were independently owned (does not share a name and operations with other restaurants), did not require managers to be certified in food safety, did not have workers trained in food safety, did not have a handwashing policy, did not have a policy minimizing bare-hand contact with ready-to-eat foods, and had a manager with more than two years of experience at their current restaurant. These results suggest that to improve contamination prevention, the foodservice industry and food safety officials can consider supporting and encouraging strong food safety training and policies, particularly concerning hand hygiene, and targeting interventions to independent restaurants. |
Notes from the field: Measles outbreak - central Ohio, 2022-2023
Tiller EC , Masters NB , Raines KL , Mathis AD , Crooke SN , Zwickl RC , French GK , Alexy ER , Koch EM , Tucker NE , Wilson EM , Krauss TS , Leasure E , Budd J , Billing LM , Dewart C , Tarter K , Dickerson K , Iyer R , Jones AN , Halabi KC , Washam MC , Sugerman DE , Roberts MW . MMWR Morb Mortal Wkly Rep 2023 72 (31) 847-849 On November 5, 2022, Columbus Public Health, Ohio and the Ohio Department of Health were notified of two children aged 2 years who were admitted to a central Ohio hospital with rash, fever, cough, and congestion, suggestive of measles. Both children were undergoing medical evaluation and treatment for other etiologies before measles was considered in the differential diagnosis. Neither child had received measles, mumps, and rubella (MMR) vaccine, and neither had known contact with a person with measles. Each patient subsequently received a positive measles real-time reverse transcription–polymerase chain reaction (RT-PCR) test result. Neither child had traveled internationally, but during June 12–October 8, 2022, four internationally imported measles cases had been confirmed among unvaccinated Franklin County, Ohio residents who had traveled to areas in East Africa where measles outbreaks were ongoing (1). Investigation of the U.S.-acquired measles cases identified additional measles cases, and local and state health departments confirmed a community outbreak on November 9, 2022. During this community measles outbreak in central Ohio, 85 locally acquired measles cases were confirmed with rash onsets during October 22–December 24, 2022; however, no definitive link to the previous international importations was established. The outbreak was declared over on February 4, 2023, 42 days (two measles incubation periods) after the last reported case. |
Measles virus transmission patterns and public health responses during Operation Allies Welcome: a descriptive epidemiological study
Masters NB , Beck AS , Mathis AD , Leung J , Raines K , Paul P , Stanley SE , Weg AL , Pieracci EG , Gearhart S , Jumabaeva M , Bankamp B , Rota PA , Sugerman DE , Gastañaduy PA . Lancet Public Health 2023 8 (8) e618-e628 BACKGROUND: On Aug 29, 2021, Operation Allies Welcome (OAW) was established to support the resettlement of more than 80 000 Afghan evacuees in the USA. After identification of measles among evacuees, incoming evacuee flights were temporarily paused, and mass measles vaccination of evacuees aged 6 months or older was introduced domestically and overseas, with a 21-day quarantine period after vaccination. We aimed to evaluate patterns of measles virus transmission during this outbreak and the impact of control measures. METHODS: We conducted a measles outbreak investigation among Afghan evacuees who were resettled in the USA as part of OAW. Patients with measles were defined as individuals with an acute febrile rash illness between Aug 29, 2021, and Nov 26, 2021, and either laboratory confirmation of infection or epidemiological link to a patient with measles with laboratory confirmation. We analysed the demographics and clinical characteristics of patients with measles and used epidemiological information and whole-genome sequencing to track transmission pathways. A transmission model was used to evaluate the effects of vaccination and other interventions. FINDINGS: 47 people with measles (attack rate: 0·65 per 1000 evacuees) were reported in six US locations housing evacuees in four states. The median age of patients was 1 year (range 0-26); 33 (70%) were younger than 5 years. The age distribution shifted during the outbreak towards infants younger than 12 months. 20 (43%) patients with wild-type measles virus had rash onset after vaccination. No fatalities or community spread were identified, nor further importations after flight resumption. In a non-intervention scenario, transmission models estimated that a median of 5506 cases (IQR 10-5626) could have occurred. Infection clusters based on epidemiological criteria could be delineated into smaller clusters using phylogenetic analyses; however, sequences with few substitution count differences did not always indicate single lines of transmission. INTERPRETATION: Implementation of control measures limited measles transmission during OAW. Our findings highlight the importance of integration between epidemiological and genetic information in discerning between individual lines of transmission in an elimination setting. FUNDING: US Centers for Disease Control and Prevention. |
Poliovirus outbreak in New York State, August 2022: qualitative assessment of immediate public health responses and priorities for improving vaccine coverage
Kasstan B , Mounier-Jack S , Chantler T , Masters N , Flores SA , Stokley S , Meek H , Easton D , De Luna-Evans T , Souto M , Punjabi C , Ruppert PS , Rosenberg E , Routh J . Epidemiol Infect 2023 151 e120 In 2022, a case of paralysis was reported in an unvaccinated adult in Rockland County (RC), New York. Genetically linked detections of vaccine-derived poliovirus type 2 (VDPV2) were reported in multiple New York counties, England, Israel, and Canada. The aims of this qualitative study were to: i) review immediate public health responses in New York to assess the challenges in addressing gaps in vaccination coverage; ii) inform a longer-term strategy to improving vaccination coverage in under-vaccinated communities, and iii) collect data to support comparative evaluations of transnational poliovirus outbreaks. Twenty-three semi-structured interviews were conducted with public health professionals, healthcare professionals, and community partners. Results indicate that i) addressing suboptimal vaccination coverage in RC remains a significant challenge after recent disease outbreaks; ii) the poliovirus outbreak was not unexpected and effort should be invested to engage mothers, the key decision-makers on childhood vaccination; iii) healthcare providers (especially paediatricians) received technical support during the outbreak, and may require resources and guidance to effectively contribute to longer-term vaccine engagement strategies; vi) data systems strengthening is required to help track under-vaccinated children. Public health departments should prioritize long-term investments in appropriate communication strategies, countering misinformation, and promoting the importance of the routine immunization schedule. |
Nowcasting and Forecasting the 2022 U.S. Mpox Outbreak: Support for Public Health Decision Making and Lessons Learned (preprint)
Charniga K , Madewell ZJ , Masters NB , Asher J , Nakazawa Y , Spicknall IH . medRxiv 2023 17 Mpox is a zoonotic disease endemic in Central and West Africa. In May 2022, an outbreak of mpox characterized by human-to-human transmission was detected in multiple non-endemic countries. We performed nowcasting and forecasting for the 2022 mpox outbreak in the United States using the R package EpiNow2. We generated nowcasts/forecasts at the national level, by Census region, and for jurisdictions reporting the greatest number of mpox cases. Modeling results were shared for situational awareness within the Centers for Disease Control and Prevention (CDC) Mpox Response and publicly on the CDC website. We retrospectively evaluated forecast predictions at four key phases during the outbreak using three metrics, the weighted interval score, mean absolute error, and prediction interval coverage. We compared the performance of EpiNow2 with a naive Bayesian generalized linear model (GLM). The EpiNow2 model had less probabilistic error than the GLM during every outbreak phase except for the early phase. We share our experiences with an existing tool for nowcasting/forecasting and highlight areas of improvement for the development of future tools. We also reflect on lessons learned regarding data quality issues and adapting modeling results for different audiences. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license. |
Serial interval and incubation period estimates of monkeypox virus infection in 12 U.S. jurisdictions, May - August 2022 (preprint)
Madewell ZJ , Charniga K , Masters NB , Asher J , Fahrenwald L , Still W , Chen J , Kipperman N , Bui D , Shea M , Saathoff-Huber L , Johnson S , Harbi K , Berns AL , Perez T , Gateley E , Spicknall IH , Nakazawa Y , Gift TL . medRxiv 2022 30 Using data collected by 12 U.S. health departments, we report mean estimated serial interval for monkeypox virus infection of 8.5 (95% CrI: 7.3 - 9.9) days for symptom onset from 57 case pairs and mean estimated incubation period of 5.6 (4.3 - 7.8) days from 35 case pairs for symptom onset. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license. |
Estimating the incubation period of monkeypox virus during the 2022 multi-national outbreak (preprint)
Charniga K , Masters NB , Slayton RB , Gosdin L , Minhaj FS , Philpott D , Smith D , Gearhart S , Alvarado-Ramy F , Brown C , Waltenburg MA , Hughes CM , Nakazawa Y . medRxiv 2022 23 Monkeypox is a zoonotic disease endemic in Central and West Africa. In May 2022, an outbreak of monkeypox characterized by human-to-human transmission was detected in multiple non-endemic countries. We estimated the incubation period for monkeypox using information from 22 probable (N = 1) and confirmed (N = 21) monkeypox cases in patients reported in the United States through June 6, 2022. We pooled U.S. patient data with the data from 18 confirmed cases in patients reported from the Netherlands through May 31, 2022. The mean incubation period from exposure to first symptom onset was 7.6 days (95% credible interval: 6.2 - 9.7), and the 95th percentile was 17.1 days (95% CrI: 12.7-24.3). These findings align with current CDC recommendations for monitoring close contacts of people with monkeypox for 21 days after their last exposure. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license. |
Factors Associated with Receipt and Parental Intent for COVID-19 Vaccination of Children Ages 5-11 years (preprint)
Santibanez TA , Lendon JP , Singleton JA , Black CL , Zhou T , Kriss JL , Jain A , Elam-Evans LD , Masters NB , Peacock G . medRxiv 2022 27 Background and Objectives COVID-19 vaccine was first recommended for children ages 5-11 years on November 2, 2021. This report describes COVID-19 vaccination coverage and parental intent to vaccinate their child ages 5-11 years, overall, by sociodemographic characteristics, and by social and behavioral drivers of vaccination, the fourth month after recommendation. Methods We analyzed data from 5,438 interviews conducted in February 2022 from the National Immunization Survey-Child COVID Module (NIS-CCM), a national random-digit-dial cellular telephone survey of households with children. Results 30.9% of children ages 5-11 were vaccinated with >=1 dose of COVID-19 vaccine, 35.2% were unvaccinated and the parent reported they probably or definitely would get the child vaccinated or were unsure, and 33.9% were unvaccinated and the parent probably or definitely would not get the child vaccinated. Vaccination coverage and parental intent differed by sociodemographic variables, including income, health insurance status, and rurality. Parental intent to vaccinate children also differed by ethnicity and race. Concern about the child getting COVID-19 and confidence in vaccine importance and safety were positively associated with vaccination receipt and intent to get the child vaccinated. Conclusions By the fourth month of the COVID-19 vaccination program for children ages 5-11 years, less than one-third were vaccinated, and coverage was lower for some sociodemographic subgroups. An additional one-third of children had a parent who was open to vaccinating the child. Efforts to address parental concerns regarding vaccine safety and to convey the importance of the vaccine might improve vaccination coverage. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license. |
Characteristics of the moveable middle: Opportunities among adults open to COVID-19 vaccination
Omari A , Boone KD , Zhou T , Lu PJ , Kriss JL , Hung MC , Carter RJ , Black C , Weiss D , Masters NB , Lee JT , Brewer NT , Szilagyi PG , Singleton JA . Am J Prev Med 2023 64 (5) 734-741 INTRODUCTION: Focusing on subpopulations that express the intention to receive a COVID-19 vaccination but are unvaccinated may improve the yield of COVID-19 vaccination efforts. METHODS: A nationally representative sample of 789,658 U.S. adults aged 18 years participated in the National Immunization Survey Adult COVID Module from May 2021 to April 2022. The survey assessed respondents' COVID-19 vaccination status and intent by demographic characteristics (age, urbanicity, educational attainment, region, insurance, income, and race/ethnicity). This study compared composition and within-group estimates of those who responded that they definitely or probably will get vaccinated or are unsure (moveable middle) from the first and last month of data collection. RESULTS: Because vaccination uptake increased over the study period, the moveable middle declined among persons aged 18 years. Adults aged 18-39 years and suburban residents comprised most of the moveable middle in April 2022. Groups with the largest moveable middles in April 2022 included persons with no insurance (10%), those aged 18-29 years (8%), and those with incomes below poverty (8%), followed by non-Hispanic Native Hawaiian or other Pacific Islander (7%), non-Hispanic multiple or other race (6%), non-Hispanic American Indian or Alaska Native persons (6%), non-Hispanic Black or African American persons (6%), those with below high school education (6%), those with high school education (5%), and those aged 30-39 years (5%). CONCLUSIONS: A sizable percentage of adults open to receiving COVID-19 vaccination remain in several demographic groups. Emphasizing engagement of persons who are unvaccinated in some racial/ethnic groups, aged 18-39 years, without health insurance, or with lower income may reach more persons open to vaccination. |
Serial interval and incubation period estimates of monkeypox virus infection in 12 jurisdictions, United States, May-August 2022
Madewell ZJ , Charniga K , Masters NB , Asher J , Fahrenwald L , Still W , Chen J , Kipperman N , Bui D , Shea M , Saunders K , Saathoff-Huber L , Johnson S , Harbi K , Berns AL , Perez T , Gateley E , Spicknall IH , Nakazawa Y , Gift TL . Emerg Infect Dis 2023 29 (4) 818-821 Using data from 12 US health departments, we estimated mean serial interval for monkeypox virus infection to be 8.5 (95% credible interval 7.3-9.9) days for symptom onset, based on 57 case pairs. Mean estimated incubation period was 5.6 (95% credible interval 4.3-7.8) days for symptom onset, based on 35 case pairs. |
Behavioral and social drivers of COVID-19 vaccination in the United States, August-November 2021
Bonner KE , Vashist K , Abad NS , Kriss JL , Meng L , Lee JT , Wilhelm E , Lu PJ , Carter RJ , Boone K , Baack B , Masters NB , Weiss D , Black C , Huang Q , Vangala S , Albertin C , Szilagyi PG , Brewer NT , Singleton JA . Am J Prev Med 2023 INTRODUCTION: COVID-19 vaccines are safe, effective, and widely available, but many adults in the U.S. have not been vaccinated for COVID-19. This study examined the associations between behavioral and social drivers of vaccination with COVID-19 vaccine uptake in the U.S. adults and their prevalence by region. METHODS: A nationally representative sample of U.S. adults participated in a cross-sectional telephone survey in August-November 2021; the analysis was conducted in January 2022. Survey questions assessed self-reported COVID-19 vaccine initiation, demographics, and behavioral and social drivers of vaccination. RESULTS: Among the 255,763 respondents, 76% received their first dose of COVID-19 vaccine. Vaccine uptake was higher among respondents aged ≥75 years (94%), females (78%), and Asian non-Hispanic people (94%). The drivers of vaccination most strongly associated with uptake included higher anticipated regret from nonvaccination, risk perception, and confidence in vaccine safety and importance, followed by work- or school-related vaccination requirements, social norms, and provider recommendation (all p<0.05). The direction of association with uptake varied by reported level of difficulty in accessing vaccines. The prevalence of all of these behavioral and social drivers of vaccination was highest in the Northeast region and lowest in the Midwest and South. CONCLUSIONS: This nationally representative survey found that COVID-19 vaccine uptake was most strongly associated with greater anticipated regret, risk perception, and confidence in vaccine safety and importance, followed by vaccination requirements and social norms. Interventions that leverage these social and behavioral drivers of vaccination have the potential to increase COVID-19 vaccine uptake and could be considered for other vaccine introductions. |
Cluster analysis of adults unvaccinated for COVID-19 based on behavioral and social factors, National Immunization Survey-Adult COVID Module, United States.
Meng L , Masters NB , Lu PJ , Singleton JA , Kriss JL , Zhou T , Weiss D , Black CL . Prev Med 2022 107415 By the end of 2021, approximately 15% of U.S. adults remained unvaccinated against COVID-19, and vaccination initiation rates had stagnated. We used unsupervised machine learning (K-means clustering) to identify clusters of unvaccinated respondents based on Behavioral and Social Drivers (BeSD) of COVID-19 vaccination and compared these clusters to vaccinated participants to better understand social/behavioral factors of non-vaccination. The National Immunization Survey Adult COVID Module collects data on U.S. adults from September 26-December 31,2021 (=187,756). Among all participants, 51.6% were male, with a mean age of 61years, and the majority were non-Hispanic White (62.2%), followed by Hispanic (17.2%), Black (11.9%), and others (8.7%). K-means clustering procedure was used to classify unvaccinated participants into three clusters based on 9 survey BeSD items, including items assessing COVID-19 risk perception, social norms, vaccine confidence, and practical issues. Among unvaccinated adults (N=23,397), 3 clusters were identified: the "Reachable" (23%), "Less reachable" (27%), and the "Least reachable" (50%). The least reachable cluster reported the lowest concern about COVID-19, mask-wearing behavior, perceived vaccine confidence, and were more likely to be male, non-Hispanic White, with no health conditions, from rural counties, have previously had COVID-19, and have not received a COVID-19 vaccine recommendation from a healthcare provider. This study identified, described, and compared the characteristics of the three unvaccinated subgroups. Public health practitioners, healthcare providers and community leaders can use these characteristics to better tailor messaging for each sub-population. Our findings may also help inform decisionmakers exploring possible policy interventions. |
Geographic Heterogeneity in Behavioral and Social Drivers of COVID-19 Vaccination.
Masters NB , Zhou T , Meng L , Lu PJ , Kriss JL , Black C , Omari A , Boone K , Weiss D , Carter RJ , Brewer NT , Singleton JA . Am J Prev Med 2022 63 (6) 883-893 INTRODUCTION: Little is known about how the drivers of COVID-19 vaccination vary across the U.S. To inform vaccination outreach efforts, this study explores geographic variation in correlates of COVID-19 nonvaccination among adults. METHODS: Participants were a nationally representative sample of U.S. adults identified through random-digit dialing for the National Immunization Survey-Adult COVID Module. Analyses examined the geographic and temporal landscape of constructs in the Behavioral and Social Drivers of Vaccination Framework among unvaccinated respondents from May 2021 to December 2021 (n=531,798) and sociodemographic and geographic disparities and Behavioral and Social Drivers of Vaccination predictors of COVID-19 nonvaccination from October 2021 to December 2021 (n=187,756). RESULTS: National coverage with at least 1 dose of COVID-19 vaccine was 79.3% by December 2021, with substantial geographic heterogeneity. Regions with the largest proportion of unvaccinated persons who would probably get a COVID-19 vaccine or were unsure resided in the Southeast and Midwest (Health and Human Services Regions 4 and 5). Both regions had similar temporal trends regarding concerns about COVID-19 and confidence in vaccine importance, although the Southeast had especially low confidence in vaccine safety in December 2021, lowest in Florida (5.5%) and highest in North Carolina (18.0%). The strongest Behavioral and Social Drivers of Vaccination correlate of not receiving a COVID-19 vaccination was lower confidence in COVID-19 vaccine importance (adjusted prevalence ratio=5.19, 95% CI=4.93, 5.47; strongest in the Northeast, Southwest, and Mountain West and weakest in the Southeast and Midwest). Other Behavioral and Social Drivers of Vaccination correlates also varied by region. CONCLUSIONS: Contributors to nonvaccination showed substantial geographic heterogeneity. Strategies to improve COVID-19 vaccination uptake may need to be tailored regionally. |
Wastewater Testing and Detection of Poliovirus Type 2 Genetically Linked to Virus Isolated from a Paralytic Polio Case - New York, March 9-October 11, 2022.
Ryerson AB , Lang D , Alazawi MA , Neyra M , Hill DT , St George K , Fuschino M , Lutterloh E , Backenson B , Rulli S , Ruppert PS , Lawler J , McGraw N , Knecht A , Gelman I , Zucker JR , Omoregie E , Kidd S , Sugerman DE , Jorba J , Gerloff N , Ng TFF , Lopez A , Masters NB , Leung J , Burns CC , Routh J , Bialek SR , Oberste MS , Rosenberg ES . MMWR Morb Mortal Wkly Rep 2022 71 (44) 1418-1424 In July 2022, a case of paralytic poliomyelitis resulting from infection with vaccine-derived poliovirus (VDPV) type 2 (VDPV2)(§) was confirmed in an unvaccinated adult resident of Rockland County, New York (1). As of August 10, 2022, poliovirus type 2 (PV2)(¶) genetically linked to this VDPV2 had been detected in wastewater** in Rockland County and neighboring Orange County (1). This report describes the results of additional poliovirus testing of wastewater samples collected during March 9-October 11, 2022, and tested as of October 20, 2022, from 48 sewersheds (the community area served by a wastewater collection system) serving parts of Rockland County and 12 surrounding counties. Among 1,076 wastewater samples collected, 89 (8.3%) from 10 sewersheds tested positive for PV2. As part of a broad epidemiologic investigation, wastewater testing can provide information about where poliovirus might be circulating in a community in which a paralytic case has been identified; however, the most important public health actions for preventing paralytic poliomyelitis in the United States remain ongoing case detection through national acute flaccid myelitis (AFM) surveillance(††) and improving vaccination coverage in undervaccinated communities. Although most persons in the United States are sufficiently immunized, unvaccinated or undervaccinated persons living or working in Kings, Orange, Queens, Rockland, or Sullivan counties, New York should complete the polio vaccination series as soon as possible. |
Modeling the impact of sexual networks in the transmission of monkeypox virus among gay, bisexual, and other men who have sex with men - United States, 2022
Spicknall IH , Pollock ED , Clay PA , Oster AM , Charniga K , Masters N , Nakazawa YJ , Rainisch G , Gundlapalli AV , Gift TL . MMWR Morb Mortal Wkly Rep 2022 71 (35) 1131-1135 What is already known about this topic? The 2022 monkeypox outbreak is associated with sexual and intimate contact. Survey data suggest that gay, bisexual, and other men who have sex with men (MSM), who have been disproportionately affected, are reducing one-time partnerships. What is added by this report? Modeling of sexual infection transmission between men indicates that one-time partnerships, which account for 3% of daily sexual partnerships and 16% of daily sex acts, account for approximately 50% of daily Monkeypox virus (MPXV) transmission. A 40% reduction in one-time partnerships might delay the spread of monkeypox and reduce the percentage of persons infected by 20% to 31%. What are the implications for public health practice? Reductions in one-time partnerships, already being reported by MSM, might significantly reduce MPXV transmission. © 2022 Department of Health and Human Services. All rights reserved. |
Public health response to a case of paralytic poliomyelitis in an unvaccinated person and detection of poliovirus in wastewater - New York, June-August 2022
Link-Gelles R , Lutterloh E , Schnabel Ruppert P , Backenson PB , St George K , Rosenberg ES , Anderson BJ , Fuschino M , Popowich M , Punjabi C , Souto M , McKay K , Rulli S , Insaf T , Hill D , Kumar J , Gelman I , Jorba J , Ng TFF , Gerloff N , Masters NB , Lopez A , Dooling K , Stokley S , Kidd S , Oberste MS , Routh J . MMWR Morb Mortal Wkly Rep 2022 71 (33) 1065-1068 On July 18, 2022, the New York State Department of Health (NYSDOH) notified CDC of detection of poliovirus type 2 in stool specimens from an unvaccinated immunocompetent young adult from Rockland County, New York, who was experiencing acute flaccid weakness. The patient initially experienced fever, neck stiffness, gastrointestinal symptoms, and limb weakness. The patient was hospitalized with possible acute flaccid myelitis (AFM). Vaccine-derived poliovirus type 2 (VDPV2) was detected in stool specimens obtained on days 11 and 12 after initial symptom onset. To date, related Sabin-like type 2 polioviruses have been detected in wastewater* in the patient's county of residence and in neighboring Orange County up to 25 days before (from samples originally collected for SARS-CoV-2 wastewater monitoring) and 41 days after the patient's symptom onset. The last U.S. case of polio caused by wild poliovirus occurred in 1979, and the World Health Organization Region of the Americas was declared polio-free in 1994. This report describes the second identification of community transmission of poliovirus in the United States since 1979; the previous instance, in 2005, was a type 1 VDPV (1). The occurrence of this case, combined with the identification of poliovirus in wastewater in neighboring Orange County, underscores the importance of maintaining high vaccination coverage to prevent paralytic polio in persons of all ages. |
Prevalence of bipolar disorder in perinatal women: A systematic review and meta-analysis
Masters GA , Hugunin J , Xu L , Ulbricht CM , Moore Simas TA , Ko JY , Byatt N . J Clin Psychiatry 2022 83 (5) Objective: To estimate overall prevalence of bipolar disorder (BD) and the prevalence and timing of bipolar-spectrum mood episodes in perinatal women. Data Sources: Databases (PubMed, Scopus, PsycINFO, CINAHL, Cochrane, ClincalTrials.gov) were searched from inception to March 2020. Study Selection: Included studies were original research in English that had (1) populations of perinatal participants (pregnant or within 12 months postpartum), aged ≥ 18 years, and (2) a screening/diagnostic tool for BD. Search terms described the population (eg, perinatal), illness (eg, bipolar disorder), and detection (eg, screen, identify). Data Extraction: Study design data, rates, and timing of positive screens/diagnoses and mood episodes were extracted by 3 independent reviewers. Pooled prevalences were estimated using random-effects meta-analyses. Results: Twenty-two articles were included in qualitative review and 12 in the meta-analysis. In women with no known psychiatric illness preceding the perinatal period, pooled prevalence of BD was 2.6% (95% CI, 1.2%-4.5%) and prevalence of bipolar-spectrum mood episodes (including depressed, hypomanic/manic, mixed) during pregnancy and the postpartum period was 20.1% (95% CI, 16.0%-24.5%). In women with a prior BD diagnosis, 54.9% (95% CI, 39.2%-70.2%) were found to have at least one bipolar-spectrum mood episode occurrence in the perinatal period. Conclusions: Our review suggests that the perinatal period is associated with high rates of bipolar-spectrum mood episodes and that pregnant and postpartum women represent a special risk population. This review may help to inform clinical care recommendations, thus helping to identify those who may have. |
Public health actions to control measles among Afghan evacuees during Operation Allies Welcome - United States, September-November 2021
Masters NB , Mathis AD , Leung J , Raines K , Clemmons NS , Miele K , Balajee SA , Lanzieri TM , Marin M , Christensen DL , Clarke KR , Cruz MA , Gallagher K , Gearhart S , Gertz AM , Grady-Erickson O , Habrun CA , Kim G , Kinzer MH , Miko S , Oberste MS , Petras JK , Pieracci EG , Pray IW , Rosenblum HG , Ross JM , Rothney EE , Segaloff HE , Shepersky LV , Skrobarcek KA , Stadelman AM , Sumner KM , Waltenburg MA , Weinberg M , Worrell MC , Bessette NE , Peake LR , Vogt MP , Robinson M , Westergaard RP , Griesser RH , Icenogle JP , Crooke SN , Bankamp B , Stanley SE , Friedrichs PA , Fletcher LD , Zapata IA , Wolfe HO , Gandhi PH , Charles JY , Brown CM , Cetron MS , Pesik N , Knight NW , Alvarado-Ramy F , Bell M , Talley LE , Rotz LD , Rota PA , Sugerman DE , Gastañaduy PA . MMWR Morb Mortal Wkly Rep 2022 71 (17) 592-596 On August 29, 2021, the United States government oversaw the emergent establishment of Operation Allies Welcome (OAW), led by the U.S. Department of Homeland Security (DHS) and implemented by the U.S. Department of Defense (DoD) and U.S. Department of State (DoS), to safely resettle U.S. citizens and Afghan nationals from Afghanistan to the United States. Evacuees were temporarily housed at several overseas locations in Europe and Asia* before being transported via military and charter flights through two U.S. international airports, and onward to eight U.S. military bases,(†) with hotel A used for isolation and quarantine of persons with or exposed to certain infectious diseases.(§) On August 30, CDC issued an Epi-X notice encouraging public health officials to maintain vigilance for measles among Afghan evacuees because of an ongoing measles outbreak in Afghanistan (25,988 clinical cases reported nationwide during January-November 2021) (1) and low routine measles vaccination coverage (66% and 43% for the first and second doses, respectively, in 2020) (2). |
Use of recombinant zoster vaccine in immunocompromised adults aged 19 years: Recommendations of the Advisory Committee on Immunization Practices - United States, 2022
Anderson TC , Masters NB , Guo A , Shepersky L , Leidner AJ , Lee GM , Kotton CN , Dooling KL . MMWR Morb Mortal Wkly Rep 2022 71 (3) 80-84 Zoster Vaccine Recombinant, Adjuvanted (Shingrix, GlaxoSmithKline [GSK]) is a 2-dose (0.5 mL each) subunit vaccine containing recombinant glycoprotein E in combination with adjuvant (AS01(B)) that was licensed in the United States for prevention of herpes zoster for adults aged ≥50 years by the Food and Drug Administration (FDA) and recommended for immunocompetent adults aged ≥50 years by the Advisory Committee on Immunization Practices (ACIP) in 2017* (1). On July 23, 2021, the FDA expanded the indication for recombinant zoster vaccine (RZV) to include adults aged ≥18 years who are or will be at increased risk for herpes zoster because of immunodeficiency or immunosuppression caused by known disease or therapy (2). On October 20, 2021, ACIP recommended 2 doses of RZV for the prevention of herpes zoster and related complications in adults aged ≥19 years(†) who are or will be immunodeficient or immunosuppressed because of disease or therapy. RZV is the first herpes zoster vaccine approved for use in immunocompromised persons. With moderate to high vaccine efficacy and an acceptable safety profile, RZV has the potential to prevent considerable herpes zoster incidence and related complications. This report updates previous ACIP recommendations for the prevention of herpes zoster (1,3). |
Development of the Practice Readiness to Evaluate and address Perinatal Depression (PREPD) assessment
Masters GA , Brenckle L , Sankaran P , Moore Simas TA , Person SD , Allison J , Ziedonis D , Ko J , Robbins C , Byatt N . Psychiatry Res 2021 302 114032 OBJECTIVE: Perinatal depression is a common pregnancy complication and universal screening is recommended. The Practice Readiness to Evaluate and address Perinatal Depression (PREPD) was developed to measure obstetric practice readiness to integrate depression care into workflows. Objectives were to describe: (1) the PREPD; (2) associated characteristics by readiness level; and (3) use of the assessment to measure change. METHOD: The PREPD has four components, each scored to a 16-point maximum: (1) Environmental Scan (10% of PREPD); (2) Depression Detection, Assessment, and Treatment Questionnaire (30%); (3) Depression-related Policies Questionnaire (10%); and (4) Chart Abstraction (50%). Components were weighted and summed for an overall score. Summary and component scores were calculated by patient, practice, and provider. RESULTS: Average overall PREPD score was 7.3/16 (range: 4.8-9.9); scores varied between practices. The Environmental Scan averaged 2.0/16 (range: 0-5.2); Detection, Assessment, and Treatment averaged 8.3/16 (range: 3.0-11.5); Chart Abstraction averaged 7.2/16 (range: 5.1-9.6); and Depression-related Policies averaged 10.4/16 (range: 7.5-15). CONCLUSION: We found wide variation in obstetric practices' readiness to implement interventions for depression; most were minimally prepared. These data may be used to tailor practice intervention goals and as benchmarks with which to measure changes in integration of depression care over time. |
Impact of the COVID-19 pandemic on mental health, access to care, and health disparities in the perinatal period.
Masters GA , Asipenko E , Bergman AL , Person SD , Brenckle L , Moore Simas TA , Ko JY , Robbins CL , Byatt N . J Psychiatr Res 2021 137 126-130 BACKGROUND: The COVID-19 pandemic has affected mental health and created barriers to healthcare. In this study, we sought to elucidate the pandemic's effects on mental health and access to care for perinatal individuals. METHODS: This cross-sectional study of individuals in Massachusetts who were pregnant or up to three months postpartum with a history of depressive symptoms examined associations between demographics and psychiatric symptoms (via validated mental health screening instruments) and the COVID-19 pandemic's effects on mental health and access to care. Chi-square associations and multivariate regression models were used. RESULTS: Of 163 participants, 80.8% perceived increased symptoms of depression and 88.8% of anxiety due to the pandemic. Positive screens for depression, anxiety, and/or PTSD at time of interview, higher education, and income were associated with increased symptoms of depression and anxiety due to the pandemic. Positive screens for depression, anxiety, and/or PTSD were also associated with perceived changes in access to mental healthcare. Compared to non-Hispanic White participants, participants of color (Black, Asian, Multiracial, and/or Hispanic/Latinx) were more likely to report that the pandemic changed their mental healthcare access (aOR:3.25, 95%CI:1.23, 8.59). LIMITATIONS: Limitations included study generalizability, given that participants have a history of depressive symptoms, and cross-sectional design. CONCLUSIONS: The pandemic has increased symptoms of perinatal depression and anxiety and impacted perceived access to care. Self-reported increases in depression and anxiety and changes to healthcare access varied by education, race/ethnicity, income, and positive screens. Understanding these differences is important to address perinatal mental health and provide equitable care. |
Developing excellence in biostatistics leadership, training and science in Africa: How the Sub-Saharan Africa Consortium for Advanced Biostatistics (SSACAB) trainingunites expertise to deliver excellence
Chirwa TF , Matsena Zingoni Z , Munyewende P , Manda SO , Mwambi H , Kandala NB , Kinyanjui S , Young T , Musenge E , Simbeye J , Musonda P , Mahande MJ , Weke P , Onyango NO , Kazembe L , Tumwesigye NM , Zuma K , Yende-Zuma N , Omanyondo Ohambe MC , Kweku EN , Maposa I , Ayele B , Achia T , Machekano R , Thabane L , Levin J , Eijkemans MJC , Carpenter J , Chasela C , Klipstein-Grobusch K , Todd J . AAS Open Res 2020 3 51 The increase in health research in sub-Saharan Africa (SSA) has led to a high demand for biostatisticians to develop study designs, contribute and apply statistical methods in data analyses. Initiatives exist to address the dearth in statistical capacity and lack of local biostatisticians in SSA health projects. The Sub-Saharan African Consortium for Advanced Biostatistics (SSACAB) led by African institutions was initiated to improve biostatistical capacity according to the needs identified by African institutions, through collaborative masters and doctoral training in biostatistics. SACCAB has created a critical mass of biostatisticians and a network of institutions over the last five years and has strengthened biostatistics resources and capacity for health research studies in SSA. SSACAB comprises 11 universities and four research institutions which are supported by four European universities. In 2015, only four universities had established Masters programmes in biostatistics and SSACAB supported the remaining seven to develop Masters programmes. In 2019 the University of the Witwatersrand became the first African institution to gain Royal Statistical Society accreditation for a Biostatistics Masters programme. A total of 150 fellows have been awarded scholarships to date of which 123 are Masters fellowships (41 female) of whom 58 have already graduated. Graduates have been employed in African academic (19) and research (15) institutions and 10 have enrolled for PhD studies. A total of 27 (10 female) PhD fellowships have been awarded; 4 of them are due to graduate by 2020. To date, SSACAB Masters and PhD students have published 17 and 31 peer-reviewed articles, respectively. SSACAB has also facilitated well-attended conferences, face-to-face and online short courses. Pooling of limited biostatistics resources in SSA combined with co-funding from external partners has shown to be an effective strategy for the development and teaching of advanced biostatistics methods, supervision and mentoring of PhD candidates. |
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