Drug-resistant shigellosis is increasing, particularly among men who have sex with men (MSM). During July-October 2022, an extended-spectrum beta-lactamase producing Shigella sonnei cluster of 9 patients was identified in Chicago, of whom 8 were MSM and 6 were festival attendees. The cluster also included 4 domestic travelers to Chicago. Sexual health care for MSM should include shigellosis diagnosis and prevention.

Wearing a facemask can help to decrease the transmission of COVID-19. We investigated self-reported mask use among subjects aged 18 years and older participating in the COVID-19 Community Research Partnership (CRP), a prospective longitudinal COVID-19 surveillance study in the mid-Atlantic and southeastern United States. We included those participants who completed >=5 daily surveys each month from December 1, 2020 through August 31, 2021. Mask use was defined as self-reported use of a face mask or face covering on every interaction with others outside the household within a distance of less than 6 feet. Participants were considered vaccinated if they reported receiving >=1 COVID-19 vaccine dose. Participants (n=17,522) were 91% non-Hispanic White, 68% female, median age 57 years, 26% healthcare workers, with 95% self-reported receiving >=1 COVID-19 vaccine dose through August; mean daily survey response was 85%. Mask use was higher among vaccinated than unvaccinated participants across the study period, regardless of the month of the first dose. Mask use remained relatively stable from December 2020 through April (range 71-80% unvaccinated; 86-93% vaccinated) and declined in both groups beginning in mid-May 2021 to 34% and 42% respectively in June 2021; mask use has increased again since July 2021. Mask use by all was lower during weekends and on Christmas and Easter, regardless of vaccination status. Independent predictors of higher mask use were vaccination, age >=65 years, female sex, racial or ethnic minority group, and healthcare worker occupation, whereas a history of self-reported prior COVID-19 illness was associated with lower use. 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.

Air pollution is a known environmental health hazard. A major source of air pollution includes diesel exhaust (DE). Initially, research on DE focused on respiratory morbidities; however, more recently, exposures to DE have been associated with neurological developmental disorders and neurodegeneration. In this study, we investigated the effects of sub-chronic inhalation exposure to DE on neuroinflammatory markers in two inbred mouse strains and both sexes, including whole transcriptome examination of the medial prefrontal cortex. We exposed aged male and female C57BL/6J (B6) and DBA/2J (D2) mice to DE, which was cooled and diluted with HEPA-filtered compressed air for 2 h per day, 5 days a week, for 4 weeks. Control animals were exposed to HEPA-filtered air on the same schedule as DE-exposed animals. The prefrontal cortex was harvested and analyzed for proinflammatory cytokine gene expression (Il1ß, Il6, Tnfa) and transcriptome-wide response by RNA-seq. We observed differential cytokine gene expression between strains and sexes in the DE-exposed vs. control-exposed groups for Il1ß, Tnfa, and Il6. For RNA-seq, we identified 150 differentially expressed genes between air and DE treatment related to natural killer cell-mediated cytotoxicity per Kyoto Encyclopedia of Genes and Genomes pathways. Overall, our data show differential strain-related effects of DE on neuroinflammation and neurotoxicity and demonstrate that B6 are more susceptible than D2 to gene expression changes due to DE exposures than D2. These results are important because B6 mice are often used as the default mouse model for DE studies and strain-related effects of DE neurotoxicity warrant expanded studies.

BACKGROUND: A major challenge for antibiotic stewardship programs is the lack of accurate and accessible electronic data to target interventions. We developed and validated separate electronic algorithms to identify inappropriate antibiotic use for adult outpatients with bronchitis and pharyngitis. METHODS: We used International Classification of Diseases, 10th Revision, diagnostic codes to identify patient encounters for acute bronchitis and pharyngitis at outpatient practices between 3/15/17 and 3/14/18. Exclusion criteria included immunocompromising conditions, complex chronic conditions, and concurrent infections. We randomly selected 300 eligible subjects each with bronchitis and pharyngitis. Inappropriate antibiotic use based on chart review served as the gold standard for assessment of the electronic algorithm, which was constructed using only data in the electronic data warehouse. Criteria for appropriate prescribing, choice of antibiotic, and duration were based on established guidelines. RESULTS: Of 300 subjects with bronchitis, 167 (55.7%) received an antibiotic inappropriately based on chart review. The electronic algorithm demonstrated 100% sensitivity and 95.3% specificity for detection of inappropriate prescribing. Of 300 subjects with pharyngitis, 94 (31.3%) had an incorrect prescribing decision. Among 29 subjects with a positive rapid streptococcal antigen test, 27 (93.1%) received an appropriate antibiotic and 29 (100%) received the correct duration. The electronic algorithm demonstrated very high sensitivity and specificity for all outcomes. CONCLUSIONS: Inappropriate antibiotic prescribing for bronchitis and pharyngitis is common. Electronic algorithms for identifying inappropriate prescribing, antibiotic choice, and duration showed excellent test characteristics. These algorithms could be used to efficiently assess prescribing among practices and individual clinicians. Interventions based on these algorithms should be tested in future work.

Laws play an important role in emergency response capacity. During the COVID-19 outbreak, experts have noted both a lack of law where it is needed and a problematic use of laws that exist. To address those challenges, policymakers revising public health emergency laws can examine how existing laws were used during the COVID-19 response to address problems that arose during their application. Judicial opinions can provide a source of data for this review. This study used legal epidemiology methods to perform an environmental scan of global judicial opinions, published from March 1 through August 31, 2020, from 23 countries, related to government-issued COVID-19 mitigation measures. The opinions were coded, and findings categorize the measures based on: (1) the World Health Organization's May 2020 publication, Overview of Public Health and Social Measures in the Context of COVID-19, and (2) related legal challenges brought in courts, including disputes about authority; conflicts of law; rationality, proportionality, or necessity; implementation; and enforcement. The findings demonstrate how judicial review of emergency measures has played a role in the COVID-19 response. In some cases, court rulings required mitigation measures to be amended or stopped. In others, court rulings required the government to issue a measure not yet in place. These findings provide examples for understanding issues related to the application of law during an emergency response.

BACKGROUND: Men who have sex with men (MSM) experience high rates of gonococcal infection at extragenital (rectal and pharyngeal) anatomic sites, which often are missed without asymptomatic screening and may be important for onward transmission. Implementing an express pathway for asymptomatic MSM seeking routine screening at their clinic may be a cost-effective way to improve extragenital screening by allowing patients to be screened at more anatomic sites through a streamlined, less costly process. METHODS: We modified an agent-based model of anatomic site-specific gonococcal infection in U.S. MSM to assess the cost-effectiveness of an express screening pathway in which all asymptomatic MSM presenting at their clinic were screened at the urogenital, rectal, and pharyngeal sites but forewent a provider consultation and physical exam and self-collected their own samples. We calculated the cumulative health effects expressed as gonococcal infections and cases averted over five years, labor and material costs, and incremental cost effectiveness ratios (ICER) for express versus traditional scenarios. RESULTS: The express scenario averted more infections and cases in each intervention year. The increased diagnostic costs of triple-site screening were largely offset by the lowered visit costs of the express pathway and, from the end of year 3 onward, this pathway generated small cost savings. However, in a sensitivity analysis of assumed overhead costs, cost savings under the express scenario disappeared in the majority of simulations once overhead costs exceeded 7% of total annual costs. CONCLUSIONS: Express screening may be a cost-effective option for improving multi-site anatomic screening among U.S. MSM.

Public health and law are inextricably intertwined. Law is the foundation of governmental public health practice, delineating the duties and authority to protect and promote conditions necessary for population health. 1 Law is also a social and structural determinant of health, because laws shape the physical, social, and economic environments that directly impact population health. 2 Public health laws at all levels of government enshrine public health strategies, are critical to addressing emerging issues, and are the means through which interventions are implemented and enforced.

INTRODUCTION: on January 30, 2020, the World Health Organization declared the novel coronavirus outbreak a Public Health Emergency of International Concern. As of October 5, 2020, there were over 34.8 million reported cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and more than 1 million reported deaths from coronavirus disease 2019 (COVID-19), globally. Non-pharmaceutical interventions, such as social distancing policies, hand hygiene, and mask use, are key public health measures to control COVID-19. In response to, or in some cases even before, the first wave of SARS-CoV-2 infections were reported in their countries, policy makers across Africa issued various social distancing policies. METHODS: we describe social distancing policies issued from March 1 to April 24, 2020 in 22 Anglophone countries of sub-Saharan Africa. We reviewed policies identified online. RESULTS: though all 22 countries closed schools and banned gatherings, they took a variety of approaches to sizes of gatherings banned and to stay-at-home orders, with 13 countries issuing national stay-at-home orders, four issuing subnational stay-at-home orders, and five not issuing stay-at-home orders. Enforcement provisions varied by country, as did funeral and health care exceptions. CONCLUSION: movement restrictions, business restrictions, and school closures can have substantial negative impacts on economies, education, nutrition, and routine health care. Yet easing or lifting of COVID-19 social distancing policies can lead to increased transmission. Our review documents a wide variety of policy alternatives used in Africa and can inform future adjustments as countries ease, lift, and reapply measures in response to their evolving epidemics.

A painless skin delivery of vaccine for disease prevention is of great advantage in improving compliance in patients. To test this idea as a proof of concept, we utilized a pDNA vaccine construct, pDNAg333-2GnRH that has a dual function of controlling rabies and inducing immunocontraception in animals. The pDNA was administered to mice in a nanoparticulate form delivered through the skin using the P.L.E.A.S.E.® (Precise Laser Epidermal System) microporation laser device. Laser application was well tolerated, and mild skin reaction was healed completely in 8 days. We demonstrated that adjuvanted nanoparticulate pDNA vaccine significantly upregulated the expression of co-stimulatory molecules in dendritic cells. After topical administration of the adjuvanted nano-vaccine in mice, the high avidity serum for GnRH antibodies were induced and maintained up to 9 weeks. The induced immune response was of a mixed Th1/Th2 profile as measured by IgG subclasses (IgG2a and IgG1) and cytokine levels (IFN-γ and IL-4). Using flow cytometry, we revealed an increase of CD8(+) T-cells and CD45R B cells upon the administration of the adjuvanted vaccine. Our previous study used the same pDNA nanoparticulate vaccine through an IM route, and a comparable immune response was induced using P.L.E.A.S.E. However, the vaccine dose in the current study was four-fold less than what was applied through the IM route. We concluded that laser-assisted skin vaccination has a potential of becoming a safe and reliable vaccination tool for rabies vaccination in animals or even in humans for pre- or post-exposure prophylaxis.

As countries face public health emergencies, building public health capacity to prevent, detect, and respond to threats is a priority. In recent years, national public health institutes (NPHIs) have emerged to play a critical role in strengthening public health systems and to accelerate and achieve implementation of the International Health Regulations (IHR 2005). NPHIs are science-based government institutions that provide national leadership and expertise for the country's efforts to protect and improve health. Providing a Legal Framework for a National Public Health Institute is a recently released Africa CDC publication intended to support NPHI development throughout Africa. Here we present a legal mapping analysis of sampled legal domains for 5 countries, using the "Menu of Considerations for an NPHI Legal Framework." The analysis delineates the types of legal authorities countries may use to establish or enhance NPHIs and demonstrates how legal mapping can be used to review legal instruments for NPHIs. It also demonstrates variability among legal approaches countries take to establish and enable public health functions for NPHIs. This article examines how the legal framework and menu of considerations can help countries understand the nuances around creating and implementing the laws that will govern their organizations and how countries can better engage stakeholders to identify or address potential areas for opportunity where law may be used as a tool to strengthen public health infrastructure.

Legal Perspectives is aimed at informing healthcare providers, emergency planners, public health practitioners, and other decision makers about important legal issues related to public health and healthcare preparedness and response. The articles describe these potentially challenging topics and conclude with the authors' suggestions for further action. The articles do not provide legal advice. Therefore, those affected by the issues discussed in this column should seek further guidance from legal counsel. Readers may submit topics of interest to the column's editor, Lainie Rutkow, JD, PhD, MPH, at lrutkow@jhu.edu. Governors play a fundamental role in emergency preparedness and can help facilitate rapid responses to emergencies. However, laws that operate successfully under normal circumstances can inadvertently create barriers during emergencies, delaying a timely response. State laws could thus limit, or even prohibit, necessary response efforts. To combat this risk, legislatures have passed emergency powers laws in each state granting governors the authority to declare a state of emergency and to exercise certain emergency powers to meet the needs of the emergency. Researchers conducted a 50-state legal assessment, which identified and examined state laws that give governors the discretion to modify existing laws or create new laws to respond effectively to any type of declared emergency. This article outlines the findings of that assessment, which identified 35 states that explicitly permit governors to suspend or amend both statutes and regulations; 7 states in which governors are permitted to amend regulations during a declared emergency but are not explicitly authorized to modify or remove statutes; and 8 states and the District of Columbia that provide no explicit authority to governors to change statutes or regulations during a declared emergency. The article also provides examples of how this power has been used in the past to demonstrate the utility and scope of this authority in a variety of public health threats.

In an increasingly globalized world, countries face infectious disease threats and public health emergencies that transcend borders, making health security of paramount importance. Legal frameworks, at both the international and national levels, can empower governments to strengthen public health and preparedness systems to better detect and respond to infectious disease threats and public health emergencies. The development of the International Health Regulations (IHR) (2005) and the Global Health Security Agenda (GHSA), and the resulting Joint External Evaluation (JEE), are examples of coordinated global efforts to build capacity to prevent, detect, and respond to the international spread of disease. This article uses 3 case studies to describe a role for law in IHR implementation. It highlights the Centers for Disease Control and Prevention's (CDC's) Global Health Security Public Health Law Project and describes how legal mapping data and the resources developed are being used by countries to strengthen health systems and support IHR implementation.

BACKGROUND: Tuberculosis (TB) patients face substantial delays prior to treatment initiation, and out of pocket (OOP) expenditures often surpass the economic productivity of the household. We evaluated the pre-diagnostic cost and health seeking behaviour of new adult pulmonary TB patients registered at Primary Health Centres (PHCs) in Vellore district, Tamil Nadu, India. METHODS: This descriptive study, part of a randomised controlled trial conducted in three rural Tuberculosis Units from Dec 2012 to Dec 2015, collected data on number of health facilities, dates of visits prior to the initiation of anti-tuberculosis treatment, and direct OOP medical costs associated with TB diagnosis. Logistic regression analysis examined the factors associated with delays in treatment initiation and OOP expenditures. RESULTS: Of 880 TB patients interviewed, 34.7% presented to public health facilities and 65% patients sought private health facilities as their first point of care. The average monthly individual income was $77.79 (SD 57.14). About 69% incurred some pre-treatment costs at an average of $39.74. Overall, patients experienced a median of 6 days (3-11 IQR) of time to treatment initiation and 21 days (10-30 IQR) of health systems delay. Age </= 40 years (aOR: 1.73; CI: 1.22-2.44), diabetes (aOR: 1.63; CI: 1.08-2.44) and first visit to a private health facility (aOR: 17.2; CI: 11.1-26.4) were associated with higher direct OOP medical costs, while age </= 40 years (aOR: 0.64; CI: 0.48-0.85) and first visit to private health facility (aOR: 1.79, CI: 1.34-2.39) were associated with health systems delay. CONCLUSION: The majority of rural TB patients registering at PHCs visited private health facilities first and incurred substantial direct OOP medical costs and delays prior to diagnosis and anti-tuberculosis treatment initiation. This study highlights the need for PHCs to be made as the preferred choice for first point of contact, to combat TB more efficiently.

OBJECTIVES: In all health system sectors, electronic health information (EHI) is created, used, released, and reused. We examined states' efforts to address EHI uses in law to provide an understanding of the EHI legal environment. METHODS: Attorney researchers used WestlawNext to search for EHI-related statutes and regulations of the US states, US territories, and the District of Columbia in effect as of January 2014. The researchers independently catalogued provisions by the EHI use described in the law. Researchers resolved discrepancies through peer review meetings and recorded the consensus codes for each law. RESULTS: This study identified 2364 EHI-related laws representing 49 EHI uses in 54 jurisdictions. A total of 18 EHI uses were regulated by ≥10 jurisdictions. More than 750 laws addressed 2 or more EHI uses. Jurisdictions varied by the number of EHI laws in effect, with a mean of 44 laws. Texas had the most EHI laws (n = 145). Hawaii and South Carolina had the fewest (n = 14 each). CONCLUSIONS: The EHI legal landscape is complex. The large quantity and diversity of laws complicate legal analysis, likely delay implementation of public health solutions, and might be detrimental to the development of emerging health information technology. Research is needed to understand the effect of EHI-related laws.

CONTEXT: Public health enabling authorities establish the legal foundation for financing, organizing, and delivering public health services. State laws vary in terms of the content, depth, and breadth of these fundamental public health activities. Given this variance, the Institute of Medicine has identified state public health laws as an area that requires further examination. To respond to this call for further examination, the Centers for Disease Control and Prevention's Public Health Law Program conducted a fundamental activities legal assessment on state public health laws. OBJECTIVE: The goal of the legal assessment was to examine state laws referencing frameworks representing public health department fundamental activities (ie, core and essential services) in an effort to identify, catalog, and describe enabling authorities of state governmental public health systems. DESIGN: In 2013, Public Health Law Program staff compiled a list of state statutes and regulations referencing different commonly-recognized public health frameworks of fundamental activities. The legal assessment included state fundamental activities laws available on WestlawNext as of July 2013. The results related to the 10 essential public health services and the 3 core public health functions were confirmed and updated in June 2016. RESULTS: Eighteen states reference commonly-recognized frameworks of fundamental activities in their laws. Thirteen states have listed the 10 essential public health services in their laws. Eight of these states have also referenced the 3 core public health functions in their laws. Five states reference only the core public health functions. CONCLUSIONS: Several states reference fundamental activities in their state laws, particularly through use of the essential services framework. Further work is needed to capture the public health laws and practices of states that may be performing fundamental activities but without reference to a common framework.

Fever is a major cause of morbidity and mortality among children under 5 years of age in resource-limited countries. Although prevention and treatment of febrile illnesses have improved, the costs-both financial and nonfinancial-remain barriers to care. Using data from the 2009 Uganda Malaria Indicator Survey, we describe the costs associated with the care of a febrile child and assess predictors of care-seeking behavior. Over 80% of caregivers sought care for their febrile child, however less than half did so on either the day of or the day after the development of fever. The odds of seeking care decreased with each additional month of the child's age. Caregivers living in rural areas were more likely to seek care, however were less likely to seek care promptly. Caregivers with at least a primary school education and those familiar with the protective effect of bed nets and the need to seek care promptly were more likely to seek care. Despite government assistance, the majority of caregivers did incur costs (mean 13,173 Ugandan shilling; $6.84 U.S. dollars) associated with medical care. Continued efforts targeting barriers to seeking care, including the economic burden, are necessary.

When the Director-General of WHO declared, on Feb 1, 2016, that recently reported clusters of microcephaly and other neurological disorders are a Public Health Emergency of International Concern (PHEIC),1 it was on the advice of an Emergency Committee of the International Health Regulations and of other experts whom she had previously consulted. We are the members of the Emergency Committee, and we were identified by the Director-General from rosters of experts that had been submitted by WHO Member States. | Our advice to declare a PHEIC was not made on the basis of what is currently known about Zika virus infection. During our discussions it became clear that infection with the Zika virus, unlike other arbovirus infections including dengue and chikungunya, causes a fairly mild disease with fever, malaise, and at times a maculopapular rash, conjunctivitis, or both.2 Additional information from previous outbreaks suggested that about 20% of people infected with Zika virus develop these symptoms, and that the rest are asymptomatic.2 Fatality from Zika virus infection is thought to be rare.2 Our advice to declare a PHEIC was rather made on the basis of what is not known about the clusters of microcephaly, Guillain-Barré syndrome, and possibly other neurological defects reported by country representatives from Brazil and retrospectively from French Polynesia that are associated in time and place with outbreaks of Zika infection.3, 4

BACKGROUND: In the Federated States of Micronesia (FSM) and then the Republic of the Marshall Islands (RMI), levofloxacin pharmacokinetics (PK) were studied in children receiving directly observed once-daily regimens (10 mg/kg, age <5 years; 15 20 mg/kg, age ≤5 years) for either multidrug-resistant tuberculosis (MDR TB) disease or latent infection after MDR TB exposure, to inform future dosing strategies. METHODS: Blood samples were collected at 0 (RMI only), 1, 2, and 6 hours (50 children, aged 6 months to 15 years) after oral levofloxacin at >6 weeks of treatment. Clinical characteristics and levofloxacin Cmax, elimination half-life (t1/2), and area under the curve from 0 to 24 hours (AUC0-24 hours * microg/mL) were correlated to determine optimal dosage and to examine associations. Population PK and target attainment were modeled. With results from FSM, dosages were increased in RMI toward the target maximal drug concentration (Cmax) for Mycobacterium tuberculosis, 8-12 microg/ml. RESULTS: Cmax correlated linearly with per-weight dosage. Neither Cmax nor t1/2 was associated with gender, age, body mass index, concurrent medications, or pre-dose meals. At levofloxacin dosage of 15-20 mg/kg, Cmax ≥ 8 microg/ml was observed, and modeling corroborated a high target attainment across the ratio of the area under the free-concentration-versus-time curve to minimum inhibitory concentration (fAUCss,0-24/MIC) values. CONCLUSIONS: Levofloxacin dosage should be 15-20 mg/kg for Cmax ≥ 8 microg/ml and a high target attainment across fAUCss,0-24/MIC values in children ≥2 years of age.

Anemia in children under 5 years of age, defined by the World Health Organization as a hemoglobin concentration < 11 g/dL, is a global public health problem. According to the 2006 Demographic Health Survey, the prevalence of anemia among children under five in Uganda was 72% in 2006. The 2009 Uganda Malaria Indicator Survey was conducted in late 2009 and revealed that over 60% of children less than 5 years of age were anemic and that over half of children tested positive for malaria via a rapid diagnostic test. Children with concomitant malaria infection, and in households without any type of mosquito net were more likely to be anemic, confirming that children under 5 years, are vulnerable to both the threat of malaria and anemia and the beneficial effect of malaria prevention tools. However, prevention and treatment of other factors associated with the etiology of anemia (e.g., iron deficiency) are likely necessary to combat the toll of anemia in Uganda.

Law establishes the foundation for the "secondary use" of electronic health information (EHI) for public health purposes. Federal law, state law, and legal tools, such as contracts and policies, support data exchange between providers, facilities, and public health departments. This article describes the legal landscape surrounding secondary use of EHI.

The relationship between maternal education and child health has intrigued researchers for decades. This study explored the interaction between maternal education and childhood malaria infection. Cross-sectional survey data from three African countries were used. Descriptive analysis and multivariate logistic regression models were completed in line with identified correlates. Marginal effects and Oaxaca decomposition analysis on maternal education and childhood malaria infection were also estimated. Children with mothers whose education level was beyond primary school were 4.7% less likely to be malaria-positive (P < 0.001). The Oaxaca decomposition analysis exhibited an 8% gap in childhood malaria infection for educated and uneducated mothers. Over 60% of the gap was explained by differences in household wealth (26%), household place of domicile (21%), malaria transmission intensities (14%), and media exposure (12%). All other correlates accounted for only 27%. The full adjusted model showed a robust and significant relationship between maternal education and childhood malaria infection.

OBJECTIVE: Develop classification models of demographic/clinical factors and biomarker data from spontaneous preterm birth (PTB) in African Americans and Caucasians. DESIGN: Secondary analysis of biomarker data using multivariate adaptive regression splines (MARS), a supervised machine learning algorithm method. SETTING: Thirty-six biomarker data analysis from 191 women were reduced by MARS to develop predictive models for preterm birth in African Americans and Caucasians. SAMPLES: Maternal plasma, cord plasma collected at admission for preterm or term labor and amniotic fluid at delivery. METHODS: Data were partitioned into training and testing sets. Variable importance, a relative indicator (0-100%) and area under the receiver operating characteristic curve (AUC) characterized results. RESULTS: MARS generated models for combined and racially stratified biomarker data. Clinical and demographic data did not contribute to the model. Racial stratification of data produced distinct models in all three compartments. In African Americans maternal plasma samples IL1RA, TNFalpha, angiopoietin2, TNFRI, IL5, MIP1alpha, IL1beta, and TGFalpha modeled preterm birth (AUC train: 0.98, AUC test: 0.86). In Caucasians TNFR1, ICAM1, and IL1RA contributed to the model (AUC train: 0.84, AUC test: 0.68). African Americans cord plasma samples produced IL12P70, IL8 (AUC train: 0.82, AUC test: 0.66). Cord plasma in Caucasians modeled IGFII, PDGFBB, TGFbeta1, IL12P70, and TIMP1 (AUC train: 0.99, AUC test: 0.82). Amniotic fluid in African Americans modeled Fas ligand, TNFRII, RANTES, KGF, IGFI (AUC train: 0.95, AUC test: 0.89) and in Caucasians, TNFalpha, MCP3, TGFbeta3, TNFR1, and angiopoietin2 (AUC train: 0.94 AUC test: 0.79). CONCLUSIONS: MARS models multiple biomarkers associated with preterm birth and demonstrated racial disparity. This article is protected by copyright. All rights reserved.

Vibrio vulnificus (Vv) can result in severe disease. Although pre-existing liver disease is a recognized risk factor for serious infection, the relative importance of other comorbidities has not been fully assessed. We analysed reports of Vv infections submitted to CDC from January 1988 to September 2006 in order to assess the role of pre-existing conditions contributing to severe outcomes. A total of 1212 patients with Vv infection were reported. Only patients with liver disease [adjusted odds ratio (aOR) 5.1)] were more likely to become septic when exposure was due to contaminated food. Patients with liver disease (aOR 4.1), a haematological disease (aOR 3.2), or malignancy (aOR 3.2) were more likely to become septic when infection was acquired via a non-foodborne exposure. As such, patients with these pre-existing medical conditions should be advised of the risk of life-threatening illness after eating undercooked contaminated seafood or exposing broken skin to warm seawater.

BACKGROUND: Bacterial contamination of blood components is a potentially life-threatening complication of transfusions. In October 2005, the Centers for Disease Control and Prevention (CDC) noted four Listeria monocytogenes (Lm) isolates cultured from four different units of donated apheresis platelets (PLTs) among Lm isolates sent to the CDC National Listeria Reference Laboratory for subtyping as part of routine surveillance activities. STUDY DESIGN AND METHODS: We describe an investigation to determine possible common sources of infection among donors or factors associated with PLT collection or storage and to determine whether human transfusion-associated listeriosis cases had been reported. We also reviewed all isolates with PLTs as a source sent to the CDC National Listeria Reference Laboratory between November 1, 2005, and December 31, 2011. RESULTS: Each PLT donor-associated isolate had a distinct pulsed-field gel electrophoresis pattern combination. Other than these four cases, no other cases of Lm-contaminated PLTs were identified by the American Red Cross or by CDC during 2005. However, two additional cases of Lm isolated from donated PLTs were detected, one in 2008 and one in 2011. CONCLUSION: Although the source of contamination for these PLT units is unclear, and a source common to all units was not identified, this investigation underscores the value of screening for bacterial contaminants of PLTs.

A clinic-based program to integrate antenatal services with distribution of hygiene kits including safe water storage containers, water treatment solution (brand name WaterGuard), soap, and hygiene education, was implemented in Malawi in 2007 and evaluated in 2010. We surveyed 389 participants at baseline in 2007, and found and surveyed 232 (60%) participants to assess water treatment, test stored drinking water for residual chlorine (an objective measure of treatment), and observe handwashing technique at follow-up in 2010. Program participants were more likely to know correct water treatment procedures (67% versus 36%; P < 0.0001), treat drinking water with WaterGuard (24% versus.2%; P < 0.0001), purchase and use WaterGuard (21% versus 1%; P < 0.001), and demonstrate correct handwashing technique (50% versus 21%; P < 0.001) at the three-year follow-up survey than at baseline. This antenatal-clinic-based program may have contributed to sustained water treatment and proper handwashing technique among program participants.

Access to safe drinking water and improved hygiene are essential for preventing diarrheal diseases. To integrate hygiene improvement with antenatal care, free hygiene kits (water storage containers, water treatment solution, soap) and educational messages were distributed to pregnant women at antenatal clinics in Malawi. We assessed water treatment and hygiene practices of 275 non-pregnant friends and relatives of the hygiene kit recipients at baseline and follow-up nine months later to measure program impact on non-participants in the same communities. At follow-up, friends and relatives who did not receive kits or education were more likely than at baseline to purchase and use water treatment solution (25% versus 1%; P < 0.0001) and demonstrate correct handwashing practices (60% versus 18%; P < 0.0001). This antenatal clinic-based program resulted in improved water treatment and hygiene behaviors among non-pregnant friends and relatives living in the same communities as hygiene kit recipients, suggesting that program benefits extended beyond direct beneficiaries.

We conducted a health facility-based survey to estimate the prevalence of malaria among febrile patients at health facilities (HFs) in Maputo City. Patients answered a questionnaire on malaria risk factors and underwent malaria testing. A malaria case was defined as a positive result for malaria by microscopy in a patient with fever or history of fever in the previous 24 hours. Among 706 patients with complete information, 111 (15.7%) cases were identified: 105 were positive for Plasmodium falciparum only, two for Plasmodium ovale only, and four for both P. falciparum and P. ovale. Fever documented at study enrollment, age ≥ 5 years, rural HF, and travel outside Maputo City were statistically significantly associated with malaria by multivariate analysis. We found a high prevalence of laboratory-confirmed malaria among febrile patients in Maputo City. Further studies are needed to relate these findings with mosquito density to better support malaria prevention and control.

In Indonesia, where diarrhea remains a major cause of mortality among children <5 years, the government promotes boiling of drinking water. We assessed the impact of boiling on water quality in South Sulawesi. We surveyed randomly selected households with at least one child <5 years old in two rural districts and tested source and stored water samples for Escherichia coli contamination. Among 242 households, 96% of source and 51% of stored water samples yielded E. coli. Unboiled water samples, obtained from 15% of households, were more likely to yield E. coli than boiled samples [prevalence ratios (PR) = 2.0, 95% confidence interval (CI) 1.7-2.5]. Water stored in wide-mouthed (PR = 1.4, 95% CI = 1.1-1.8) or uncovered (PR = 1.8, 95% CI = 1.3-2.4) containers, or observed to be touched by the respondent's hands (PR = 1.6, 95% CI = 1.3-2.1) was more likely to yield E. coli. A multivariable model showed that households that did not boil water were more likely to have contaminated stored water than households that did boil water (PR = 1.9, 95% CI = 1.5-2.3). Although this study demonstrated the effectiveness of boiling in reducing contamination, overall impact on water quality was suboptimal. Future studies are needed to identify factors behind the success of boiling water in Indonesia to inform efforts to scale up other effective water treatment practices.

BACKGROUND: Heath facility-based sentinel site surveillance has been proposed as a means of monitoring trends in malaria morbidity but may also provide an opportunity to improve malaria case management. Here we described the impact of a sentinel site malaria surveillance system on promoting laboratory testing and rational antimalarial drug use. METHODOLOGY/PRINCIPAL FINDINGS: Sentinel site malaria surveillance was established at six health facilities in Uganda between September 2006 and January 2007. Data were collected from all patients presenting to the outpatient departments including demographics, laboratory results, diagnoses, and treatments prescribed. Between the start of surveillance and March 2010, a total 424,701 patients were seen of which 229,375 (54%) were suspected of having malaria. Comparing the first three months with the last three months of surveillance, the proportion of patients with suspected malaria who underwent diagnostic testing increased from 39% to 97% (p<0.001). The proportion of patients with an appropriate decision to prescribe antimalarial therapy (positive test result prescribed, negative test result not prescribed) increased from 64% to 95% (p<0.001). The proportion of patients appropriately prescribed antimalarial therapy who were prescribed the recommended first-line regimen artemether-lumefantrine increased from 48% to 69% (p<0.001). CONCLUSIONS/SIGNIFICANCE: The establishment of a sentinel site malaria surveillance system in Uganda achieved almost universal utilization of diagnostic testing in patients with suspected malaria and appropriate decisions to prescribed antimalarial based on test results. Less success was achieved in promoting prescribing practice for the recommended first-line therapy. This system could provide a model for improving malaria case management in other health facilities in Africa.

Knowledge from early outbreaks is limited regarding the virus detection and illness duration of the 2009 pandemic influenza A (H1N1) infections. During the period from April to May 2009 in Texas, we collected serial nasopharyngeal (NP) and stool specimens from 35 participants, testing by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) and culture. The participants were aged 2 months to 71 years; 25 (71%) were under 18. The median duration of measured fever was 3.0 days and of virus detection in NP specimens was 4.2 days; however, few specimens were collected between days 5-9. The duration of virus detection (4.2 days) was similar to the duration of fever (3.5 days) (RR, 1.14; 95% CI, .66-1.95; P=.8), but was shorter than the duration of cough (11.0 days) (RR, .41; 95% CI, .24-.68; P.001). We detected viral RNA in two participants' stools. All cultures were negative. This investigation suggests that the duration of virus detection was likely similar to the seasonal influenza virus.