BACKGROUND: In the United States, 2 doses of measles-mumps-rubella (MMR)-containing vaccines are recommended routinely during childhood; a third dose may be given under certain circumstances. We present observed seroprotection rates and estimate long-term dynamics of measles, mumps, and rubella neutralizing antibody (nAb) levels among 2- and 3-dose MMR (MMR2 and MMR3, respectively) vaccinees. METHODS: Persons who received MMR2 at age 4-12 years or MMR3 at age 18-31 years were enrolled in 1994-1995 and 2009-2010, respectively. Per cohort, sera were collected before vaccination (baseline) and at various intervals ranging from 1 month to 10 years postvaccination to assess nAb levels. Annual changes in nAb levels per virus and cohort were estimated through 10 years postvaccination using generalized estimating equations. Models were stratified by baseline nAb levels. RESULTS: Among MMR2 participants (n = 621), 93.7%, 73.4%, and 83.9% had protective nAb levels against measles, mumps, and rubella, respectively, at the 10-year visit; among MMR3 participants (n = 665), 90.5%, 69.1%, and 100% had protective nAb levels, respectively, at the 9-11-year visit. Estimated nAb levels declined annually across both cohorts, all viruses, and baseline nAb strata, though patterns and magnitude varied. More than one-quarter of participants had mumps nAb levels below the presumed seroprotection threshold at the terminal visits. CONCLUSIONS: These findings indicate that even when MMR antibodies wane, protection against disease is largely retained. Waning of mumps antibodies was greater than for measles and rubella in both 2- and 3-dose vaccinees, likely because a greater proportion failed to mount a robust initial response.

PROBLEM/CONDITION: Autism spectrum disorder (ASD). PERIOD COVERED: 2022. DESCRIPTION OF SYSTEM: The Autism and Developmental Disabilities Monitoring Network is an active surveillance program that estimates prevalence and characteristics of ASD and monitors timing of ASD identification among children aged 4 and 8 years. In 2022, a total of 16 sites (located in Arizona, Arkansas, California, Georgia, Indiana, Maryland, Minnesota, Missouri, New Jersey, Pennsylvania, Puerto Rico, Tennessee, Texas [two sites: Austin and Laredo], Utah, and Wisconsin) conducted surveillance for ASD among children aged 4 and 8 years and suspected ASD among children aged 4 years. Surveillance included children who lived in the surveillance area at any time during 2022. Children were classified as having ASD if they ever received 1) an ASD diagnostic statement in a comprehensive developmental evaluation, 2) autism special education eligibility, or 3) an ASD International Classification of Diseases, Ninth Revision (ICD-9) code in the 299 range or International Classification of Diseases, Tenth Revision (ICD-10) code of F84.0, F84.3, F84.5, F84.8, or F84.9. Children aged 4 years were classified as having suspected ASD if they did not meet the case definition for ASD but had an evaluator's suspicion of ASD documented in a comprehensive developmental evaluation. RESULTS: Among children aged 8 years in 2022, ASD prevalence was 32.2 per 1,000 children (one in 31) across the 16 sites, ranging from 9.7 in Texas (Laredo) to 53.1 in California. The overall observed prevalence estimate was similar to estimates calculated using Bayesian hierarchical and random effects models. ASD was 3.4 times as prevalent among boys (49.2) than girls (14.3). Overall, ASD prevalence was lower among non-Hispanic White (White) children (27.7) than among Asian or Pacific Islander (A/PI) (38.2), American Indian or Alaska Native (AI/AN) (37.5), non-Hispanic Black or African American (Black) (36.6), Hispanic or Latino (Hispanic) (33.0), and multiracial children (31.9). No association was observed between ASD prevalence and neighborhood median household income (MHI) at 11 sites; higher ASD prevalence was associated with lower neighborhood MHI at five sites.Record abstraction was completed for 15 of the 16 sites for 8,613 children aged 8 years who met the ASD case definition. Of these 8,613 children, 68.4% had a documented diagnostic statement of ASD, 67.3% had a documented autism special education eligibility, and 68.9% had a documented ASD ICD-9 or ICD-10 code. All three elements of the ASD case definition were present for 34.6% of children aged 8 years with ASD.Among 5,292 (61.4% of 8,613) children aged 8 years with ASD with information on cognitive ability, 39.6% were classified as having an intellectual disability. Intellectual disability was present among 52.8% of Black, 50.0% of AI/AN, 43.9% of A/PI, 38.8% of Hispanic, 32.7% of White, and 31.2% of multiracial children with ASD. The median age of earliest known ASD diagnosis was 47 months and ranged from 36 months in California to 69.5 months in Texas (Laredo).Cumulative incidence of ASD diagnosis or eligibility by age 48 months was higher among children born in 2018 (aged 4 years in 2022) than children born in 2014 (aged 8 years in 2022) at 13 of the 15 sites that were able to abstract records. Overall cumulative incidence of ASD diagnosis or eligibility by age 48 months was 1.7 times as high among those born in 2018 compared with those born in 2014 and ranged from 1.4 times as high in Arizona and Georgia to 3.1 times as high in Puerto Rico. Among children aged 4 years, for every 10 children meeting the case definition of ASD, one child met the definition of suspected ASD.Children with ASD who were born in 2018 had more evaluations and identification during ages 0-4 years than children with ASD who were born in 2014 during the 0-4 years age window, with an interruption in the pattern in early 2020 coinciding with onset of the COVID-19 pandemic.Overall, 66.5% of children aged 8 years with ASD had a documented autism test. Use of autism tests varied widely across sites: 24.7% (New Jersey) to 93.5% (Puerto Rico) of children aged 8 years with ASD had a documented autism test in their records. The most common tests documented for children aged 8 years were the Autism Diagnostic Observation Schedule, Autism Spectrum Rating Scales, Childhood Autism Rating Scale, Gilliam Autism Rating Scale, and Social Responsiveness Scale. INTERPRETATION: Prevalence of ASD among children aged 8 years was higher in 2022 than previous years. ASD prevalence was higher among A/PI, Black, and Hispanic children aged 8 years than White children aged 8 years, continuing a pattern first observed in 2020. A/PI, Black, and Hispanic children aged 8 years with ASD were also more likely than White or multiracial children with ASD to have a co-occurring intellectual disability. Identification by age 48 months was higher among children born in 2018 compared with children born in 2014, suggesting increased early identification consistent with historical patterns. PUBLIC HEALTH ACTION: Increased identification of autism, particularly among very young children and previously underidentified groups, underscores the increased demand and ongoing need for enhanced planning to provide equitable diagnostic, treatment, and support services for all children with ASD. The substantial variability in ASD identification across sites suggests opportunities to identify and implement successful strategies and practices in communities to ensure all children with ASD reach their potential.

OBJECTIVES: To systematically review literature on whether hormonal contraception following ulipristal acetate (UPA) for emergency contraception decreases the effectiveness of either drug. STUDY DESIGN: We searched multiple databases through December 2022 for studies assessing the interaction between UPA and hormonal contraception. The primary outcome was contraceptive effectiveness, measured by pregnancy rates or proxy measures (e.g., ovarian activity). We extracted and summarized findings from identified studies, assessed risk of bias for each study, and determined certainty of evidence for all outcomes. RESULTS: Four studies met inclusion criteria; all had low risk of bias. Two studies assessed whether UPA use affected the ability of oral contraceptives (OCs) to inhibit ovulation; no differences were observed in ovarian activity when starting OCs one day after UPA compared with starting OCs one day after placebo. Two studies assessed whether OC use affected the ability of UPA to delay ovulation; both studies observed higher proportions of ovulation when UPA was followed by OC use versus delayed or no OC use. One study assessed ovulation risk when UPA was taken after missed OCs, followed by immediate versus delayed OC resumption; no ovulations occurred within the first five days after UPA administration in either group, but there was greater risk of ovulation beyond five days with delayed versus immediate OC resumption. CONCLUSIONS: While there is no evidence that UPA affects the ability of hormonal contraception to inhibit ovulation, hormonal contraception use immediately or soon after UPA may decrease UPA's ability to delay ovulation. The certainty of evidence ranged from moderate to very low. IMPLICATIONS: If a patient desires hormonal contraception after UPA, an interaction with UPA can be avoided by delaying initiation or resumption of hormonal contraception. The risk of pregnancy due to decreased effectiveness of UPA with immediate hormonal contraception should be balanced against the risk of subsequent pregnancy due to delay or non-start of hormonal contraception.

Persons who work closely with dairy cows, poultry, or other animals with suspected or confirmed infection with highly pathogenic avian influenza (HPAI) A(H5N1) viruses are at increased risk for infection. In September 2024, the California Department of Public Health was notified of the first human case of HPAI A(H5N1) in California through monitoring of workers on farms with infected cows. During September 30-December 24, 2024, a total of 38 persons received positive test results for HPAI A(H5N1) viruses in California; 37 were dairy farm workers with occupational exposure to sick cows, and one was a child aged <18 years with an undetermined exposure, the first pediatric HPAI A(H5N1) case reported in the United States. All patients had mild illness. The identification of cases associated with occupational exposure to HPAI A(H5N1) viruses on dairy farms highlights the continued risk for persons who work with infected animals. The pediatric case was identified through routine surveillance. Given recent increases in the prevalence of HPAI A(H5N1) viruses among some animal populations, public health agencies should continue to investigate cases of HPAI A(H5N1) in humans as part of control measures, pandemic preparedness, to identify concerning genetic changes, and to prevent and detect potential human-to-human transmission of the virus. To date, no human-to-human transmission of HPAI A(H5N1) virus has been identified in the United States.

A previous study demonstrated noninferior efficacy of 4-month rifapentine/moxifloxacin regimen for tuberculosis (TB) treatment compared with the standard regimen. We explored results among study participants with diabetes. Among 2,516 randomized participants, 181 (7.2%) had diabetes. Of 166 participants with diabetes in the microbiologically eligible analysis group, 26.3% (15/57) had unfavorable outcomes in the control regimen, 13.8% (8/58) in the rifapentine/moxifloxacin regimen, and 29.4% (15/51) in the rifapentine regimen. The difference in proportion of unfavorable outcomes between the control and rifapentine/moxifloxacin arms in the microbiologically eligible analysis group was -12.5% (95% CI -27.0% to 1.9%); the difference between the control and rifapentine arms was 3.1% (95% CI -13.8% to 20.0%). Safety outcomes were similar in the rifapentine/moxifloxacin regimen and control arms. Among participants with TB and diabetes, the rifapentine/moxifloxacin arm had fewest unfavorable outcomes and was safe. Our findings indicate that the rifapentine/moxifloxacin regimen can be used in persons with TB and diabetes.

BACKGROUND: Phthalate exposure during pregnancy has been associated with preterm birth, but mechanisms of action may depend on the timing of exposure. OBJECTIVE: Investigate critical periods of susceptibility during pregnancy for associations between urinary phthalate metabolite concentrations and preterm birth. METHODS: Individual-level data were pooled from 16 US cohorts (N = 6045, n = 539 preterm births). We examined trimester-averaged urinary phthalate metabolite concentrations. Most phthalate metabolites had 2248, 3703, and 3172 observations in the first, second, and third trimesters, respectively. Our primary analysis used logistic regression models with generalized estimating equations (GEE) under a multiple informant approach to estimate trimester-specific odds ratios (ORs) of preterm birth and significant (p < 0.20) heterogeneity in effect estimates by trimester. Adjusted models included interactions between each covariate and trimester. RESULTS: Differences in trimester-specific associations between phthalate metabolites and preterm birth were most evident for di-2-ethylhexyl phthalate (DEHP) metabolites. For example, an interquartile range increase in mono (2-ethylhexyl) phthalate (MEHP) during the first and second trimesters was associated with ORs of 1.15 (95 % confidence interval [CI]: 0.99, 1.33) and 1.11 (95 % CI: 0.97, 1.28) for preterm birth, respectively, but this association was null in the third trimester (OR = 0.91 [95 % CI: 0.76, 1.09]) (p-heterogeneity = 0.03). CONCLUSION: The association of preterm birth with gestational biomarkers of DEHP exposure, but not other phthalate metabolites, differed by the timing of exposure. First and second trimester exposures demonstrated the greatest associations. Our study also highlights methodological considerations for critical periods of susceptibility analyses in pooled studies.

During 2023-2024, highly pathogenic avian influenza A(H5N1) viruses from clade 2.3.2.1c caused human infections in Cambodia and from clade 2.3.4.4b caused human infections in the Americas. We assessed the susceptibility of those viruses to approved and investigational antiviral drugs. Except for 2 viruses isolated from Cambodia, all viruses were susceptible to M2 ion channel-blockers in cell culture-based assays. In the neuraminidase inhibition assay, all viruses displayed susceptibility to neuraminidase inhibitor antiviral drugs oseltamivir, zanamivir, peramivir, laninamivir, and AV5080. Oseltamivir was ≈4-fold less potent at inhibiting the neuraminidase activity of clade 2.3.4.4b than clade 2.3.2.1c viruses. All viruses were susceptible to polymerase inhibitors baloxavir and tivoxavir and to polymerase basic 2 inhibitor pimodivir with 50% effective concentrations in low nanomolar ranges. Because drug-resistant viruses can emerge spontaneously or by reassortment, close monitoring of antiviral susceptibility of H5N1 viruses collected from animals and humans by using sequence-based analysis supplemented with phenotypic testing is essential.

Stigma toward homosexuality plays an important role in the increased risk of acquiring or transmitting HIV among men who have sex with men (MSM). This study describes associations between three dimensions of homosexuality-related stigma (enacted, perceived and internalized) and HIV risk behaviors among HIV-negative MSM in Hanoi, Vietnam. A total of 1675 HIV-negative MSM were recruited from the baseline of a cohort study from 2017 to 2019 through respondent-driven, time-location and internet-based sampling strategies. Stigma was measured by a locally validated instrument, with a higher score indicated a higher level of stigma (from 1 to 4). Enacted stigma (mean = 2.10), perceived stigma (mean = 2.62) and internalized stigma (mean = 2.55) were found. About 25% of participants reported group sex and 6.3% reported drug use before or during group sex in the last 6 months. Enacted stigma was significantly associated with group sex (adjusted OR = 1.48; 95% CI 1.20-1.84) and drug use before or during group sex (adjusted OR = 1.68; 95% CI 1.19-2.36). Internalized stigma was significantly associated with group sex (adjusted OR = 1.27; 95% CI 1.05-1.53) and drug use before or during group sex (adjusted OR = 1.44; 95% CI 1.04-1.99). The results highlight the need for multifaced interventions at a multiple socio-ecological levels to reduce stigma toward homosexuality.

BACKGROUND: Women with disability face more stressors around the time of pregnancy than women without disability. Limited research exists on stressors experienced due to the COVID-19 pandemic among pregnant and postpartum women with and without disability. OBJECTIVE: Examine the association between disability status and experiencing certain COVID-19 stressors among women with a recent live birth. METHODS: We analyzed Pregnancy Risk Assessment Monitoring System data from 14 jurisdictions implementing the Disability and Maternal COVID-19 Experiences supplement surveys among women with a live birth from June-December 2020. We examined the prevalence of 12 individual stressors and seven stressor types (any stressor, economic, housing, childcare, food insecurity, mental health, and partner-related), by disability status. For each stressor type, we calculated adjusted prevalence ratios (aPRs) using logistic regression to determine if women with disability were more likely to experience particular stressor types, controlling for respondent age, education, race and ethnicity, marital status, and payment at delivery. RESULTS: Among 5961 respondents, 6.3 % reported a disability. Compared with women without disability, those with disability were more likely to experience any stressor (aPR 1.19, 95 % CI 1.14-1.24), including economic (aPR 1.38, 95 % CI 1.23-1.56), housing (aPR 1.56, 95 % CI 1.09-2.24), childcare (aPR 1.32, 95 % CI 1.11-1.58), food insecurity (aPR 2.18, 95 % CI 1.72-2.78), mental health (aPR 1.49, 95 % CI 1.37-1.62), and partner-related stressors (aPR 2.00, 95 % CI 1.55-2.58). CONCLUSIONS: Findings highlight the challenges experienced by pregnant and postpartum women with disability during public health emergencies and considerations for this population in preparedness planning.

BACKGROUND: The prevalence and risk factors for ongoing symptoms following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [SCV2]) or influenza infection are not well characterized. We conducted a prospective cohort study of households wherein ≥1 individual was infected with SCV2 or influenza to evaluate prevalence of and factors associated with ongoing symptoms at 90 days. METHODS: Index cases and their household contacts provided baseline health and sociodemographic information and collected daily respiratory specimens for 10 days following enrollment. Participants completed a follow-up survey 90 days after enrollment to characterize ongoing symptoms. RESULTS: We analyzed 1967 participants enrolled between December 2021 and May 2023. The risk of ongoing symptoms did not differ by infection status in SCV2 (SCV2-positive: 15.6%; SCV2-negative: 13.9%; odds ratio [OR]: 1.14; 95% CI: .7-1.69) or influenza (influenza-positive: 8.8%; influenza-negative: 10.0%; OR: .87; 95% CI: .45-1.72) households. However, among study participants with a documented infection, SCV2-positive participants had nearly twice the odds of ongoing symptoms as influenza-positive participants (OR: 1.92; 95% CI: 1.27-2.97). CONCLUSIONS: These results suggest that SCV2 households have a significantly higher prevalence of ongoing symptoms compared with influenza households (OR: 1.78; 95% CI: 1.28-2.47). Among participants with SCV2 infection, underlying conditions (adjusted OR [aOR]: 2.65; 95% CI: 1.80-3.90) and coronavirus disease 2019 (COVID-19)-like symptoms (aOR: 2.92; 95% CI: 1.15-7.43) during acute infection increased odds of ongoing symptoms at 90 days, whereas hybrid immunity reduced the odds of ongoing symptoms (aOR: 0.44; 95% CI: .22-.90).

Candida species are the predominant cause of fungal infections in patients treated in hospital, contributing substantially to morbidity and mortality. Candidaemia and other forms of invasive candidiasis primarily affect patients who are immunocompromised or critically ill. In contrast, mucocutaneous forms of candidiasis, such as oral thrush and vulvovaginal candidiasis, can occur in otherwise healthy individuals. Although mucocutaneous candidiasis is generally not life-threatening, it can cause considerable discomfort, recurrent infections, and complications, particularly in patients with underlying conditions such as diabetes or in those taking immunosuppressive therapies. The rise of difficult-to-treat Candida infections is driven by new host factors and antifungal resistance. Pathogens, such as Candida auris (Candidozyma auris) and fluconazole-resistant Candida parapsilosis, pose serious global health risks. Recent taxonomic revisions have reclassified several Candida spp, potentially causing confusion in clinical practice. Current management guidelines are limited in scope, with poor coverage of emerging pathogens and new treatment options. In this Review, we provide updated recommendations for managing Candida infections, with detailed evidence summaries available in the appendix.

This study demonstrated that workers' compensation claims data can provide insights into federal employees' workplace injuries and illnesses. Employing agencies, safety staff, and occupational clinicians can use these data to direct efforts to improve conditions to prevent injuries/illnesses, optimize programs for injured worker treatment, rehabilitation, accommodation, and stay-at-work or return-to-work programs. Objective: The purpose of this study was to understand federal workplace injury/illness trends. Methods: Over 1.5 million federal and Postal Service employee workers' compensation (WC) claims from 2007 to 2022 were linked to employment data and analyzed. Results: From 2007 to 2019, falls, slips, trips represented the highest proportion of claims (30.7%), followed by overexertion and bodily reaction (24.4%), unclassified (16.4%), contact with objects and equipment (13.1%), violence and other injuries by persons or animals (8.8%), transportation incidents (4.0%), exposure to harmful substances or environments (2.5%), and fires and explosions (0.24%). From 2020 to 2022, COVID-19 drove a major shift to exposure to harmful substances or environments representing the highest proportion of claims (44.3%). Conclusions: Claims data represent a potentially rich data source that employing agencies can use to focus prevention and treatment of injury/illness.

The generation time, representing the interval between infections in primary and secondary cases, is essential for understanding and predicting the transmission dynamics of seasonal influenza, including the real-time effective reproduction number (Rt). However, comprehensive generation time estimates for seasonal influenza, especially since the 2009 influenza pandemic, are lacking. We estimated the generation time utilizing data from a 7-site case-ascertained household study in the United States over two influenza seasons, 2021/2022 and 2022/2023. More than 200 individuals who tested positive for influenza and their household contacts were enrolled within 7 days of the first illness in the household. All participants were prospectively followed for 10 days, completing daily symptom diaries and collecting nasal swabs, which were then tested for influenza via RT-PCR. We analyzed these data by modifying a previously published Bayesian data augmentation approach that imputes infection times of cases to obtain both intrinsic (assuming no susceptible depletion) and realized (observed within household) generation times. We assessed the robustness of the generation time estimate by varying the incubation period, and generated estimates of the proportion of transmission occurring before symptomatic onset, the infectious period, and the latent period. We estimated a mean intrinsic generation time of 3.2 (95 % credible interval, CrI: 2.9-3.6) days, with a realized household generation time of 2.8 (95 % CrI: 2.7-3.0) days. The generation time exhibited limited sensitivity to incubation period variation. Estimates of the proportion of transmission that occurred before symptom onset, the infectious period, and the latent period were sensitive to variations in the incubation period. Our study contributes to the ongoing efforts to refine estimates of the generation time for influenza. Our estimates, derived from recent data following the COVID-19 pandemic, are consistent with previous pre-pandemic estimates, and will be incorporated into real-time Rt estimation efforts.

IMPORTANCE: The degree that in-home cannabis smoking can be detected in the urine of resident children is unclear. OBJECTIVE: Test association of in-home cannabis smoking with urinary cannabinoids in children living at home. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used baseline data from Project Fresh Air, a 2012-2016 randomized clinical trial to reduce fine particulate matter levels. Eligible participants were recruited from households in San Diego County, California, with children under age 14 years and an adult tobacco smoker in residence. Children's urine samples were analyzed in 2022. EXPOSURES: In-home cannabis smoking, measured by: parent or guardian report of in-home cannabis smoking; number of daily nonspecific smoking events computed via an air particle count algorithm; and number of daily cannabis smoking events ascertained by residualization, adjusting for air nicotine, tobacco smoking, and other air particle generating or ventilating activities. MAIN OUTCOMES AND MEASURES: Levels of the cannabis biomarker Δ9-tetrahydrocannabinol (THC) and its major metabolites, 11-hydroxy-Δ9-tetrahydrocannabinol and 11-nor-9-carboxy-Δ9-tetrahydrocannabinol. Biomarker molar equivalents were summed to represent total THC equivalents (TTE) in urine. Logistic regression assessed whether in-home smoking was associated with cannabis biomarker detection. For children with detectable urinary cannabinoids, linear regression assessed in-home smoking association with quantity of urinary TTE. RESULTS: A total of 275 children were included in analysis (mean [SD] age, 3.6 [3.6] years; 144 male [52.4%]; 38 Black [13.8%], 132 Hispanic [48.0%], and 52 White [18.9%]). Twenty-nine households (10.6%) reported in-home cannabis smoking in the past 7 days; 75 children [27.3%] had detectable urinary cannabinoids. Odds of detectable TTE in children's urine were significantly higher in households with reported in-home cannabis smoking than households without (odds ratio [OR], 5.0; 95% CI, 2.4-10.4) and with each additional ascertained daily cannabis smoking event (OR, 2.5; 95% CI, 1.6-3.9). Although the point estimate for TTE levels was higher among children with detectable urinary cannabinoids and exposure to more daily cannabis smoking events (increase per event, 35.68%; 95% CI, -7.12% to 98.21%), the difference was not statistically significant. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, in-home cannabis smoking was associated with significantly increased odds of child exposure to cannabis smoke, as assessed by urinary cannabinoid biomarkers. As young children spend most of their time at home, reducing in-home cannabis smoking could substantially reduce their exposure to the toxic and carcinogenic chemicals found in cannabis smoke.

PURPOSE: Alzheimer's disease and related dementias (ADRD) are a significant public health concern characterized by memory decline that, over time, leads to loss of independence. This study reports ADRD diagnosis rates among Medicare beneficiaries aged ≥ 65 years in rural America. METHODS: We conducted a descriptive analysis of Medicare Fee-for-Service (FFS) and Medicare Advantage enrollees using administrative Medicare data from 2020. Combining data from Medicare FFS and Medicare Advantage produces a more complete and representative sample of older adults than previous studies that used FFS data alone. Nonmetropolitan counties were used to define rural. Rural ADRD diagnosis rates, stratified by age, sex, race/ethnicity, and Census region, were adjusted using the 2000 Census population standard. FINDINGS: The study population consisted of 54 million Medicare data Fee-for-Service (FFS) and Medicare Advantage enrollees aged ≥ 65; 5.3 million beneficiaries were diagnosed with ADRD, and 16.2% (n = 861,337) of beneficiaries diagnosed with ADRD resided in rural America. The age-adjusted ADRD diagnosis rate was slightly lower in rural America (9.6 per 100 beneficiaries) than in the United States (10.0 per 100 beneficiaries). The South Census region had the highest rural ADRD diagnosis rates. CONCLUSION: These findings underscore the need for targeted interventions and support mechanisms to address the growing burden of ADRD in rural communities.

BACKGROUND: Long-acting injectable antiretrovirals (LAI-ARVs) for HIV prevention and treatment have been demonstrated in clinical trials to be non-inferior to daily oral medications, providing an additional option to help users overcome the challenges of daily adherence. Approval and implementation of these regimens in low- and middle-income settings have been limited. METHOD: This study describes the anticipated barriers and facilitators to implementing LAI-ARVs in Vietnam to inform future roll-out. From July to August 2022, we conducted 27 in-depth interviews with healthcare workers and public health stakeholders involved in HIV programs at national, provincial, and clinic levels across four provinces in Vietnam. The interviews followed a semi-structured questionnaire and were audio recorded. Data were analyzed using a rapid thematic analysis approach to identify facilitators and barriers to the adoption of LAI-ARVs. RESULTS: In total, 27 participants from 4 provinces were interviewed including 14 (52%) men and 13 (48%) women. Participants median age was 48 years and they had 11.5 years of experience with HIV services and programs. Perceived user-level facilitators included the greater convenience of injectables in comparison to oral regimens, while barriers included the increased frequency of visits, fear of pain and side effects, and cost. Clinic-level facilitators included existing technical capacity to administer injections and physical storage availability in district health centers, while barriers included lack of space and equipment for administering injections for HIV-related services, concerns about cold chain maintenance for LAI-ART, and workload for healthcare workers. Health system-level facilitators included existing mechanisms for medication distribution, while barriers included regulatory approval processes and concerns about supply chain continuity. CONCLUSION: Overall, participants were optimistic about the potential impact of LAI-ARVs but highlighted important considerations at multiple levels needed to ensure successful implementation in Vietnam. CLINICAL TRIAL NUMBER: Not applicable.

BACKGROUND: Few studies have evaluated antibiotic prescribing practices for bacterial enteric infections. Unnecessary antibiotics can result in adverse events and contribute to the emergence of antimicrobial resistance. We assessed treatment practices among patients with laboratory-confirmed enteric infections in a regional healthcare system in Wisconsin, USA. METHODS: We used electronic health records to identify patients with laboratory-confirmed nontyphoidal Salmonella, Shigella, Shiga toxin-producing Escherichia coli (STEC), and Campylobacter infections during 2004-2017. Relevant clinical data, including diagnosis codes for chronic conditions and receipt of immunosuppressive medications and antibiotic prescriptions, were extracted. We defined appropriate treatment based on pathogen, patient characteristics, and practice guidelines for the study period. RESULTS: We identified 2064 patients infected with Campylobacter (1251; 61 %), Salmonella (564; 27 %), STEC (199; 10 %), or Shigella (50; 2 %). Overall, 425 (20 %) patients were immunocompromised, ranging from 17 % with Salmonella to 46 % with STEC. There were 220 (11 %) hospitalizations. Antibiotics were prescribed most frequently for Campylobacter (53 %), followed by Shigella (46 %) and Salmonella (44 %) infections. Among those prescribed antibiotics, prescriptions were appropriate for 71 % of Campylobacter, 100 % of Shigella, and 81 % of Salmonella infections. Antibiotics were prescribed for 24 % of STEC infections, despite recommendations against use. Guideline adherence generally decreased with age, except for Shigella infections, where adherence was highest for adults ≥ 50 years. CONCLUSIONS: Antibiotic prescribing for laboratory-confirmed enteric infections was usually appropriate but did not follow practice guidelines in a substantial minority of cases, presenting opportunity for improvement. Antibiotic stewardship initiatives should address acute bacterial gastrointestinal infections in addition to other common infections.

INTRODUCTION: Intimate partner violence accounts for up to one half of all homicides of women in the United States. Rates of intimate partner homicide are associated with both race/ethnicity and social determinants of health, but their relative contribution is incompletely understood. METHODS: We used negative binomial regression to model the relationship between counties' racial/ethnic composition and their rates of intimate partner homicide of women, controlling for urbanicity, median income, gender pay gap, unemployment, school funding, and violent crime rate. We used data from 49 states and the District of Columbia between 2016 and 2021. Analyses were conducted in 2024. RESULTS: In unadjusted analysis, counties with a lower proportion of White residents experienced higher rates of intimate partner homicide (IRR = 1.11; 95% CI: 1.08 - 1.13). When controlling for social determinants of health, this association was not observed (IRR = 1.01; 95% CI: 0.97 - 1.04). Median income, school funding, and violent crime rate were independent predictors of intimate partner homicide in the multivariate model. CONCLUSIONS: Racial/ethnic composition of a population does not independently predict its rate of intimate partner homicide when controlling for social determinants of health. Racial/ethnic inequities in intimate partner homicide are largely attributable to structural factors, which may be modifiable through policy changes.

Intimate partner violence (IPV) can include emotional, physical, or sexual violence. IPV during pregnancy is a preventable cause of injury and death with negative short- and long-term impacts for pregnant women, infants, and families. Using data from the 2016-2022 Pregnancy Risk Assessment Monitoring System in nine U.S. jurisdictions, CDC examined associations between IPV during pregnancy among women with a recent live birth and the following outcomes: prenatal care initiation, health conditions during pregnancy (gestational diabetes, pregnancy-related hypertension, and depression), substance use during pregnancy, and infant birth outcomes. Overall, 5.4% of women reported IPV during pregnancy. Emotional IPV was most prevalent (5.2%), followed by physical (1.5%) and sexual (1.0%) IPV. All types were associated with delayed or no prenatal care; depression during pregnancy; cigarette smoking, alcohol use, marijuana or illicit substance use during pregnancy; and having an infant with low birth weight. Physical, sexual, and any IPV were associated with having a preterm birth. Physical IPV was associated with pregnancy-related hypertension. Evidence-based prevention and intervention strategies that address multiple types of IPV are important for supporting healthy parents and families because they might reduce pregnancy complications, depression and substance use during pregnancy, and adverse infant outcomes.

BACKGROUND: HIV drug resistance can reduce the effectiveness of antiretroviral drugs in preventing morbidity and mortality, limit options for treatment, and prevention. Our study aimed to assess HIV-1 subtypes and HIV drug resistance among key populations in HIV Sentinel Surveillance Plus Behavior in 2018 and 2020. METHODS: One-stage venue-based cluster sampling was used to recruit participants at hotspots identified for men who have sex with men (MSM) in 7 provinces and sexual minority females and female sex workers (FSW) in 13 provinces. Participants completed a standard questionnaire about risk and preventive behaviors, and antiretroviral therapy history, and provided intravenous blood for HIV testing. HIV drug resistance testing was conducted on HIV-positive samples with viral load >1000 copies/mL. RESULTS: A total of 185 of 435 (42.5%) HIV-positive samples had viral load ≥1000 copies/mL, of which 130 of 136 from MSM and 26 of 49 from FSW were successfully sequenced. Six HIV-1 subtypes were detected (CRF01_AE, A, CRF07/08_BC, B, C, CRF25_cpx), with CRF01_AE (82.7%, 129/156) the most common. Drug resistance mutations were detected in 16.7% of participants overall (26/156), in 15.4% (20/130) of MSM, and in 23.1% (6/26) of FSW. Mutations associated with resistance to non-nucleoside reverse transcriptase inhibitor (NNRTI) were the most frequently detected (73.1%, 19/26). The high level of resistance was presented in NNRTI and nucleoside reverse transcriptase inhibitors classes. There are 10 major resistance mutations detected with nucleoside reverse transcriptase inhibitors (M184VI-25.0%, K65KR-50.0%, Y115F-25%), NNRTI (K103N-21.1%, E138A-10.5%, V106M-5.3%, K101E-5.3%, G190A-5.3%), protease inhibitors (L33F-40.0%, M46L-20.0%). CONCLUSIONS: Vietnam's HIV Sentinel Surveillance Plus system identified an emerging strain of HIV-1 and mutations associated with resistance to multiple drug classes among MSM and FSW.

IMPORTANCE: Influenza vaccine effectiveness (VE) is commonly assessed against prevention of illness that requires medical attention. Few studies have evaluated VE against secondary influenza infections. OBJECTIVE: To determine the estimated effectiveness of influenza vaccines in preventing secondary infections after influenza was introduced into households. DESIGN, SETTINGS, AND PARTICIPANTS: During 3 consecutive influenza seasons (2017-2020), primary cases (the first household members with laboratory-confirmed influenza) and their household contacts in Tennessee and Wisconsin were enrolled into a prospective case-ascertained household transmission cohort study. Participants collected daily symptom diaries and nasal swabs for up to 7 days. Data were analyzed from September 2022 to February 2024. EXPOSURES: Vaccination history, self-reported and verified through review of medical and registry records. MAIN OUTCOMES AND MEASURES: Specimens were tested using reverse transcription-polymerase chain reaction to determine influenza infection. Longitudinal chain binomial models were used to estimate secondary infection risk and the effectiveness of influenza vaccines in preventing infection among household contacts overall and by virus type and subtype and/or lineage. RESULTS: The analysis included 699 primary cases and 1581 household contacts. The median (IQR) age of the primary cases was 13 (7-38) years, 381 (54.5%) were female, 60 (8.6%) were Hispanic, 46 (6.6%) were non-Hispanic Black, 553 (79.1%) were Non-Hispanic White, and 343 (49.1%) were vaccinated. Among household contacts, the median age was 31 (10-41) years, 833 (52.7%) were female, 116 (7.3%) were Hispanic, 78 (4.9%) were non-Hispanic Black, 1283 (81.2%) were non-Hispanic White, 792 (50.1%) were vaccinated, and 356 (22.5%) had laboratory-confirmed influenza during follow-up. The overall secondary infection risk of influenza among household contacts was 18.8% (95% CI, 15.9% to 22.0%). The risk was highest among children and was 20.3% (95% CI, 16.4% to 24.9%) for influenza A and 15.9% (95% CI, 11.8% to 21.0%) for influenza B. The overall estimated VE for preventing secondary infections among unvaccinated household contacts was 21.0% (95% CI, 1.4% to 36.7%) and varied by type; estimated VE against influenza A was 5.0% (95% CI, -22.3% to 26.3%) and 56.4% (95% CI, 30.1% to 72.8%) against influenza B. CONCLUSIONS AND RELEVANCE: After influenza was introduced into households, the risk of secondary influenza among unvaccinated household contacts was approximately 15% to 20%, and highest among children. Estimated VE varied by influenza type, with demonstrated protection against influenza B virus infection.

Objective: The purpose of this study was to understand federal workplace injury/illness trends. Methods: Over 1.5 million federal and Postal Service employee workers' compensation (WC) claims from 2007 to 2022 were linked to employment data and analyzed. Results: From 2007 to 2019, Falls, Slips, Trips represented the highest proportion of claims (30.7%), followed by Overexertion and Bodily Reaction (24.4%), Unclassified (16.4%), Contact with Objects and Equipment (13.1%), Violence and Other Injuries by Persons or Animals (8.8%), Transportation Incidents (4.0%), Exposure to Harmful Substances or Environments (2.5%), and Fires and Explosions (0.24%). From 2020 to 2022, COVID-19 drove a major shift to Exposure to Harmful Substances or Environments representing the highest proportion of claims (44.3%). Conclusions: Claims data represent a potentially rich data source that employing agencies can use to focus prevention and treatment of injury/illness.

PROBLEM/CONDITION: CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and the number of abortion-related deaths in the United States. PERIOD COVERED: 2022. DESCRIPTION OF SYSTEM: Each year, CDC requests abortion data from the central health agencies for the 50 states, the District of Columbia, and New York City. For 2022, a total of 48 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 47 reporting areas provided data each year during 2013-2022. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2021 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS). RESULTS: For 2022, a total of 613,383 abortions were reported to CDC from 48 reporting areas. Among 47 reporting areas with data each year during 2013-2022, in 2022, a total of 609,360 abortions were reported, the abortion rate was 11.2 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 199 abortions per 1,000 live births. From 2021 to 2022, the total number of abortions decreased 2% (from 622,108 total abortions), the abortion rate decreased 3% (from 11.6 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 2% (from 204 abortions per 1,000 live births). From 2013 to 2022, the total number of reported abortions decreased 5% (from 640,154), the abortion rate decreased 10% (from 12.4 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 1% (from 198 abortions per 1,000 live births).In 2022, women in their 20s accounted for more than half of abortions (56.5%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (28.3% and 28.2%, respectively) and had the highest abortion rates (18.1 and 18.7 abortions per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.5 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios were highest among adolescents (aged ≤19 years) and lowest among women aged 30-39 years.From 2021 to 2022, abortion rates decreased among women aged ≥20 years and did not change among adolescents (aged ≤19 years). Abortion rates decreased from 2013 to 2022 among all age groups, except women aged 30-34 years for whom it increased. The decrease in the abortion rate from 2013 to 2022 was highest among adolescents compared with other age groups. From 2021 to 2022, abortion ratios increased for adolescents and decreased among women aged ≥20 years. From 2013 to 2022, abortion ratios increased among adolescents and women aged 20-34 years and decreased among women aged ≥35 years.In 2022, the majority (78.6%) of abortions were performed at ≤9 weeks' gestation, and nearly all (92.8%) were performed at ≤13 weeks' gestation. During 2013-2022, the percentage of abortions performed at >13 weeks' gestation remained low (≤8.7%). In 2022, the highest percentage of abortions were performed by early medication abortion at ≤9 weeks' gestation (53.3%), followed by surgical abortion at ≤13 weeks' gestation (35.5%), surgical abortion at >13 weeks' gestation (6.9%), and medication abortion at >9 weeks' gestation (4.3%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 70.2% of abortions were early medication abortions. In 2021, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, five women died as a result of complications from legal induced abortions. INTERPRETATION: Among the 47 areas that reported data continuously during 2013-2022, overall decreases were observed over this time in the number and rate of reported abortions and an increase was observed in the abortion ratio; in addition, from 2021 to 2022, decreases of 2%-3% were observed across all measures. PUBLIC HEALTH ACTION: Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Medically important pathogenic fungi invade vertebrate tissue and are considered primary when part of their nature life cycle is associated with an animal host and are usually able to infect immunocompetent hosts. Opportunistic fungal pathogens complete their life cycle in environmental habitats or occur as commensals within or on the vertebrate body, but under certain conditions can thrive upon infecting humans. The extent of host damage in opportunistic infections largely depends on the portal and modality of entry as well as on the host's immune and metabolic status. Diseases caused by primary pathogens and common opportunists, causing the top approximately 80% of fungal diseases [D. W. Denning, Lancet Infect Dis, 24:e428-e438, 2024, https://doi.org/10.1016/S1473-3099(23)00692-8], tend to follow a predictive pattern, while those by occasional opportunists are more variable. For this reason, it is recommended that diseases caused by primary pathogens and the common opportunists are named after the etiologic agent, for example, histoplasmosis and aspergillosis, while this should not be done for occasional opportunists that should be named as [causative fungus] [clinical syndrome], for example, Alternaria alternata cutaneous infection. The addition of a descriptor that identifies the location or clinical type of infection is required, as the general name alone may cover widely different clinical syndromes, for example, "rhinocerebral mucormycosis." A list of major recommended human and animal disease entities (nomenclature) is provided in alignment with their causative agents. Fungal disease names may encompass several genera of etiologic agents, consequently being less susceptible to taxonomic changes of the causative species, for example, mucormycosis covers numerous mucormycetous molds.

BACKGROUND: Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae (H. influenzae), and Neisseria meningitidis (N. meningitidis) are leading causes of childhood bacterial meningitis and preventable by vaccines. The aim of this hospital-based sentinel surveillance is to describe the epidemiological characteristics of pneumococcal meningitis, including disease burden, and to provide baseline data on pneumococcal serotype distribution to support decision making for pneumococcal conjugate vaccine (PCV) introduction in Vietnam. METHODS: Surveillance for probable bacterial meningitis in children 1-59 months of age is conducted in three tertiary level pediatric hospitals: one in Hanoi and two in Ho Chi Minh City. Cerebrospinal fluid (CSF) specimens were collected via lumbar puncture from children with suspected meningitis. Specimens were transferred immediately to the laboratory department of the respective hospital for cytology, biochemistry, and microbiology testing, including culture. PCR testing was conducted on CSF specimens for bacterial detection (S. pneumoniae, H. influenzae, and N. meningitidis) and pneumococcal serotyping. RESULTS: During 2015-2018, a total of 1,803 children with probable bacterial meningitis were detected; 1,780 had CSF specimens available for testing. Of 245 laboratory-confirmed positive cases, the majority were caused by S. pneumoniae (229,93.5%). Of those with S. pneumoniae detected, over 70% were caused by serotypes included in currently available PCV products; serotypes 6 A/6B (27.1%), 14 (19.7%), and 23 F (16.2%) were the most common serotypes. Children with laboratory-confirmed pneumococcal meningitis were more likely to live in Hanoi (p < 0.0001) and children 12-23 months of age were at greater odds (OR = 1.65, 95% CI: 1.11, 2.43; p = 0.006) of having confirmed pneumococcal meningitis compared to children < 12 months of age when compared to those without laboratory-confirmed bacterial meningitis. Additionally, children with confirmed pneumococcal meningitis were more likely to exhibit signs and symptoms consistent with clinical meningitis compared to negative laboratory-confirmed meningitis cases (p < 0.0001) and had a greater odds of death (OR = 6.18, 95% CI: 2.98, 12.86; p < 0.0001). CONCLUSIONS: Pneumococcal meningitis contributes to a large burden of bacterial meningitis in Vietnamese children. A large proportion are caused by serotypes covered by PCVs currently available. Introduction of PCV into the routine immunization program could reduce the burden of pneumococcal meningitis in Viet Nam.

Since 2013, a total of 167 human infections with swine-origin (variant) influenza A viruses of A(H1N1)v, A(H1N2)v, and A(H3N2)v subtypes have been reported in the United States. Analysis of 147 genome sequences revealed that nearly all had S31N substitution, an M2 channel blocker-resistance marker, whereas neuraminidase inhibitor-resistance markers were not found. Two viruses had a polymerase acidic substitution (I38M or E199G) associated with decreased susceptibility to baloxavir, an inhibitor of viral cap-dependent endonuclease (CEN). Using phenotypic assays, we established subtype-specific susceptibility baselines for neuraminidase and CEN inhibitors. When compared with either baseline or CEN-sequence-matched controls, only the I38M substitution decreased baloxavir susceptibility, by 27-fold. Human monoclonal antibodies FI6v3 and CR9114 targeting the hemagglutinin's stem showed variable (0.03 to >10 µg/mL) neutralizing activity toward variant viruses, even within the same clade. Methodology and interpretation of laboratory data described in this study provide information for risk assessment and decision-making on therapeutic control measures.

In 2021, the U.S. Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), and state partners investigated a multi-state sample-initiated retrospective outbreak investigation (SIROI) consisting of a cluster of nine Salmonella Weltevreden illnesses associated with frozen, pre-cooked shrimp imported from India. Import surveillance testing identified Salmonella Weltevreden recovered from a cooked shrimp sample from Supplier B. In total, nine patients with clinical isolates highly related via whole genome sequencing were reported in four states with illness onset dates between February 26 and July 17, 2021. Epidemiologic data was gathered by state partners for seven patients, whom all reported exposure to shrimp. Five patients reported consuming shrimp cocktail from the same retailer. A traceback investigation for five of the six patients converged on Supplier B. This evidence demonstrated that the outbreak of Salmonella Weltevreden illnesses was caused by the consumption of cooked, ready-to-eat shrimp manufactured by Supplier B. At the time of the investigation, outbreak and recall information was shared with Indian competent authorities. In March 2022, a follow up inspection of Supplier B's facility in India was conducted, and insanitary conditions and practices were observed. This outbreak investigation highlighted the importance of multidisciplinary national and international public health partnerships. The lessons learned from this investigation should continue to inform investigational activities and food safety guidance for industry.

Understanding whether influenza vaccine promotion strategies produce community-wide indirect effects is important for establishing vaccine coverage targets and optimizing vaccine delivery. Empirical epidemiologic studies and mathematical models have been used to estimate indirect effects of vaccines but rarely for the same estimand in the same dataset. Using these approaches together could be a powerful tool for triangulation in infectious disease epidemiology because each approach is subject to distinct sources of bias. We triangulated evidence about indirect effects from a school-located influenza vaccination program using two approaches: a difference-in-difference (DID) analysis, and an age-structured, deterministic, compartmental model. The estimated indirect effect was substantially lower in the mathematical model than in the DID analysis (2.1% (95% Bayesian credible intervals 0.4 - 4.4%) vs. 22.3% (95% CI 7.6% - 37.1%)). To explore reasons for differing estimates, we used sensitivity analyses and probabilistic bias analyses. When we constrained model parameters such that projections matched the DID analysis, results only aligned with the DID analysis with substantially lower pre-existing immunity among school-age children and older adults. Conversely, DID estimates corrected for potential bias only aligned with mathematical model estimates under differential outcome misclassification. We discuss how triangulation using empirical and mathematical modelling approaches could strengthen future studies.

Elevated body mass index (BMI) has been linked to severe influenza illness and impaired vaccine immunogenicity, but the relationship between BMI and clinical vaccine effectiveness (VE) is less well described. This secondary analysis of data from a test-negative study of outpatients with acute respiratory illness assessed BMI and VE against medically attended, PCR-confirmed influenza over seven seasons (2011-12 through 2017-18). Vaccination status was determined from electronic medical records (EMR) and self-report; BMI was estimated from EMR-documented height and weight categorized for adults as obesity (≥ 30 kg/m(2)), overweight (25-29 kg/m(2)), or normal and for children based on standardized z-scales. Current season VE by virus type/subtype was estimated separately for adults and children. Pooled VE for all seasons was calculated as 1-adjusted odds ratios from logistic regression with an interaction term for BMI and vaccination. Among 28,089 adults and 12,380 children, BMI category was not significantly associated with VE against outpatient influenza for any type/subtype. Adjusted VE against A/H3N2, A/H1N1pdm09, and B in adults ranged from 16-31, 46-54, and 44-57%, and in children from 29-34, 57-65, and 50-55%, respectively, across the BMI categories. Elevated BMI was not associated with reduced VE against laboratory confirmed, outpatient influenza illness.