This cohort study examines the association of reuse of N95 filtering facepiece respirators and N95 filtration efficiency. | eng

OBJECTIVE: To estimate the national and regional population attributable fraction (PAF) and potential number of preventable anemia cases for three nutritional risk factors (iron, red blood cell folate [RBCF], and vitamin B12 deficiencies) among women of childbearing age in Belize. METHODS: A national probability-based household and micronutrient survey capturing sociodemographic and health information was conducted among 937 nonpregnant Belizean women aged 15-49 years. Blood samples were collected to determine hemoglobin, ferritin, alpha-1-glycoprotein (AGP), RBCF, and vitamin B12 status. All analyses used sample weights and design variables to reflect a complex sample survey. Logistic regression was used to determine adjusted prevalence risk (aPR) ratios, which were then used to estimate national and regional PAF for anemia. RESULTS: The overall prevalence of anemia (hemoglobin <12 g/dL) was 21.2% (95% CI [18.7, 25.3]). The prevalence of anemia was significantly greater among women with iron deficiency (59.5%, 95% CI [48.7, 69.5]) compared to women without iron deficiency (15.2%, 95% CI [12.2, 18.3]; aPR 3.9, 95% CI [2.9, 5.1]). The three nutritional deficiencies examined contributed to 34.6% (95% CI [22.1, 47.1]) of the anemia cases. If all these nutritional deficiencies could be eliminated, then an estimated 5 953 (95% CI [3 807, 8 114]) anemia cases could be prevented. CONCLUSIONS: This study suggests that among women of child-bearing age in Belize, anemia cases might be reduced by a third if three modifiable nutritional risk factors (iron, RBCF, and vitamin B12 deficiencies) could be eliminated. Fortification is one potential strategy to improve nutritional status and reduce the burden of anemia in this population.

Today's ambulatory care providers face numerous challenges as they try to practice efficient, patient-centered medicine. This article explains how community health workers (CHWs) can be engaged to address many patient- and system-related barriers currently experienced in ambulatory care practices. Community health workers are frontline public health workers who serve as a trusted bridge between community members and health care providers. Among their varied roles, CHWs can educate and support patients in managing their risk factors and diseases and link these patients to needed resources. As shown in this overview (CHW 101), including CHWs as members of multidisciplinary care teams has the potential to strengthen both current and emerging models of health care delivery.

BACKGROUND: Folate and vitamin B12 deficiencies in pregnant women are associated with increased risk for adverse maternal and infant health outcomes, including neural tube defects (NTDs). METHODS: A population-based cross-sectional survey was conducted in two rural areas in Ambala District, Haryana, India in 2017 to assess baseline folate and vitamin B12 status among women of reproductive age (WRA) and predict the prevalence of NTDs. We calculated the prevalence of folate and vitamin B12 deficiency and insufficiency by demographic characteristics among 775 non-pregnant, non-lactating WRA (18-49 years). Using red blood cell (RBC) folate distributions and an established Bayesian model, we predicted NTD prevalence. All analyses were conducted using SAS-callable SUDAAN Version 11.0.4 to account for complex survey design. RESULTS: Among WRA, 10.1% (95% CI: 7.9, 12.7) and 9.3% (95% CI: 7.4, 11.6) had serum (<7 nmol/L) and RBC folate (<305 nmol/L) deficiency, respectively. The prevalence of RBC folate insufficiency (<748 nmol/L) was 78.3% (95% CI: 75.0, 81.3) and the predicted NTD prevalence was 21.0 (95% uncertainly interval: 16.9, 25.9) per 10,000 live births. Prevalences of vitamin B12 deficiency (<200 pg/mL) and marginal deficiency (≥200 pg/mL and ≤300 pg/mL) were 57.7% (95% CI: 53.9, 61.4) and 23.5% (95% CI: 20.4, 26.9), respectively. CONCLUSIONS: The magnitude of folate insufficiency and vitamin B12 deficiency in this Northern Indian population is a substantial public health concern. The findings from the survey help establish the baseline against which results from future post-fortification surveys can be compared.

The Democratic Republic of the Congo (DRC) harbors 11% of global malaria cases, yet little is known about the spatial and genetic structure of the parasite population in that country. We sequenced 2537 Plasmodium falciparum infections, including a nationally representative population sample from DRC and samples from surrounding countries, using molecular inversion probes - a novel high-throughput genotyping tool. We identified an east-west divide in haplotypes known to confer resistance to chloroquine and sulfadoxine-pyrimethamine. Furthermore, we identified highly related parasites over large geographic distances, indicative of gene flow and migration. Our results were consistent with a background of isolation by distance combined with the effects of selection for antimalarial drug resistance. This study provides a high-resolution view of parasite genetic structure across a large country in Africa and provides a baseline to study how implementation programs may impact parasite populations.

INTRODUCTION: Tanzania aimed to reduce micronutrient deficiencies and neural tube defects by introducing mandatory fortification of large-scale packaged wheat and maize flour but not for small- and medium-scale mills. OBJECTIVES: Ascertain the proportion of the population in Morogoro region, Tanzania, that consumes packaged maize flour from small-, medium- and large-mills; and understand the impact of monthly apparent purchase and consumption of packaged flour. METHODS: In 2018, a regional, multistage cluster probability study was conducted among residents in Morogoro region living in households that reported consuming maize flour. Interviews collected information on sociodemographic factors and patterns of household flour consumption. Weighted medians estimated daily apparent flour consumption and the estimated average requirement (EAR), according to age. RESULTS: Information was collected on 711 households. Packaged maize flour was purchased 10 to 12 months of the year by 22.9% of households, 6 to 9 months by 17.6% of households, 1 to 5 months by 25.1% of households, and 34.4% did not purchased maize flour. Median apparent daily consumption of maize flour was 209.7 g/d/adult male equivalent (AME). Apparent median daily consumption of maize flour was 230.1 g/d/AME in rural areas and 176.2 g/d/AME in urban areas; 228.7 g/d/AME among males and 196.4 g/d/AME among females. If all packaged maize flour were fortified according to standards, those consuming packaged maize flour 10 to 12 months of the year would apparently consume 199.9 µg folic acid/d representing 49.7% of daily EAR requirements. CONCLUSIONS: Fortifying packaged maize flour at small-, medium- and large-mills is a promising strategy for increasing access to micronutrients, including folic acid.

Many respiratory diseases, including COVID-19, can be spread by aerosols expelled by infected people when they cough, talk, sing, or exhale. Exposure to these aerosols indoors can be reduced by portable air filtration units (air cleaners). Homemade or Do-It-Yourself (DIY) air filtration units are a popular alternative to commercially produced devices, but performance data is limited. Our study used a speaker-audience model to examine the efficacy of two popular types of DIY air filtration units, the Corsi-Rosenthal cube and a modified Ford air filtration unit, in reducing exposure to simulated respiratory aerosols within a mock classroom. Experiments were conducted using four breathing simulators at different locations in the room, one acting as the respiratory aerosol source and three as recipients. Optical particle spectrometers monitored simulated respiratory aerosol particles (0.3-3 μm) as they dispersed throughout the room. Using two DIY cubes (in the front and back of the room) increased the air change rate as much as 12.4 over room ventilation, depending on filter thickness and fan airflow. Using multiple linear regression, each unit increase of air change reduced exposure by 10%. Increasing the number of filters, filter thickness, and fan airflow significantly enhanced the air change rate, which resulted in exposure reductions of up to 73%. Our results show DIY air filtration units can be an effective means of reducing aerosol exposure. However, they also show performance of DIY units can vary considerably depending upon their design, construction, and positioning, and users should be mindful of these limitations.

More than 700 women die each year in the United States from complications related to pregnancy, and considerable racial and ethnic disparities continue to exist. Recognizing the urgent maternal warning signs of pregnancy-related complications, getting an accurate and timely diagnosis and quality care can save lives. In August 2020, the Centers for Disease Control and Prevention, Division of Reproductive Health launched a national communication campaign called "Hear Her" to raise awareness of urgent maternal warning signs during pregnancy and in the year after pregnancy and improve communication between pregnant or postpartum people and their support systems and health care providers. Storytelling is a central strategy to the campaign, which features video stories of women's experiences with pregnancy-related conditions to bring voices to the statistics and to help motivate action. These stories and additional campaign resources are disseminated through a website, digital media, organic (free) and paid social media, earned media, public service announcement distribution, and partners, with increased outreach to disproportionately affected communities. Partners in maternal and child health played an important role from campaign development to outreach and message dissemination. In the first year of the campaign, there were >390,000 unique visitors to the Hear Her website and 180 million impressions (number of times that content was displayed to a user) from digital and social media. Digital media allowed the campaign to reach priority audiences at a time when news and social media had a number of other urgent public health messages related to the COVID-19 pandemic.

Efficacious antimalarials are a cornerstone of the global effort to control and eliminate malaria. However, the spread of drug resistance threatens gains achieved over the early years of this century. Of particular concern is widespread artemisinin resistance in Southeast Asia and its recent emergence in Africa, threatening the efficacy of artemisinin-based combination therapies that currently offer our best treatments for malaria [1]. Prompt identification of the emergence and spread of antimalarial drug resistance is crucial to guarantee effective case management. At a country level, efficacy data are used by ministries of health and their partners to determine national treatment guidelines. Because parasites do not respect political and administrative boundaries, coordination of surveillance and control strategies at the regional and global level is necessary to guide larger containment strategies.

BACKGROUND: Although effective against hepatitis B virus (HBV) infection, hepatitis B (HepB) vaccination is only recommended for infants, children and adults at higher risk. We conducted an economic evaluation of universal HepB vaccination among US adults. METHODS: Using a decision analytic model with Markov disease progression, we compared current vaccination recommendations (baseline) with either 3-dose or 2-dose universal HepB vaccination (intervention strategies). In simulated modeling of one million adults distributed by age and risk groups, we quantified health benefits (quality-adjusted life years, QALYs) and costs for each strategy. Multivariable probabilistic sensitivity analyses identified key inputs. All costs reported in 2019 US dollars. RESULTS: With incremental base-case vaccination coverage up to 50% among persons at lower risk and 0% increment among persons at higher risk, each of two intervention strategies averted nearly one quarter of acute HBV infections (3-dose strategy: 24.8%; 2-dose strategy: 24.6%). Societal incremental cost per QALY gained of $152,722 (Interquartile range: $119,113, $235,086) and $155,429 (Interquartile range: $120,302, $242,226) were estimated for 3-dose and 2-dose strategies, respectively. Risk of acute HBV infection showed the strongest influence. CONCLUSIONS: Universal adult vaccination against HBV may be an appropriate strategy for reducing HBV incidence and improving resulting health outcomes.

BACKGROUND AND OBJECTIVE: Folate and vitamin B12 deficiencies can impair proper growth and brain development in children. Data on the folate and vitamin B12 status of children aged 6-59 months in Guatemala are scarce. Identification of factors associated with higher prevalence of these micronutrient deficiencies within the population is needed for national and regional policymakers. OBJECTIVE: To describe national and regional post-fortification folate and vitamin B12 status of children aged 6-59 months in Guatemala. METHODS: A multistage, cluster probability study was carried out with national and regional representation of children aged 6-59 months. Demographic and health information was collected for 1246 preschool children, but blood samples for red blood cell (RBC) folate and vitamin B12 were collected and analyzed for 1,245 and 1143 preschool children, respectively. We used the following deficiency criteria as cutoff points for the analyses: < 305 nmol/L for RBC folate, < 148 pmol/L for vitamin B12 deficiency, and 148-221 pmol/L for marginal vitamin B12 deficiency. Prevalence of RBC folate deficiency and vitamin B12 deficiency and marginal deficiency were estimated. Prevalence risk ratios of RBC folate and vitamin B12 deficiency were estimated comparing subpopulations of interest. RESULTS: The national prevalence estimates of RBC folate deficiency among children was 33.5% [95% CI 29.1, 38.3]. The prevalence of RBC folate deficiency showed wide variation by age (20.3-46.6%) and was significantly higher among children 6-11 months and 12-23 months (46.6 and 37.0%, respectively), compared to older children aged 48-59 months (20.3%). RBC folate deficiency also varied widely by household wealth index (22.6-42.0%) and geographic region (27.2-46.7%) though the differences were not statistically significant. The national geometric mean for RBC folate concentrations was 354.2 nmol/L. The national prevalences of vitamin B12 deficiency and marginal deficiency among children were 22.5% [95% CI 18.2, 27.5] and 27.5% [95% CI 23.7, 31.7], respectively. The prevalence of vitamin B12 deficiency was significantly higher among indigenous children than among non-indigenous children (34.5% vs. 13.1%, aPRR 2.1 95% CI 1.4, 3.0). The prevalence of vitamin B12 deficiency also significantly varied between the highest and lowest household wealth index (34.3 and 6.0%, respectively). The national geometric mean for vitamin B12 concentrations was 235.1 pmol/L. The geometric means of folate and B12 concentrations were significantly lower among children who were younger, had a lower household wealth index, and were indigenous (for vitamin B12 only). Folate and vitamin B12 concentrations showed wide variation by region (not statistically significant), and the Petén and Norte regions showed the lowest RBC folate and vitamin B12 concentrations, respectively. CONCLUSIONS: In this study, a third of all children had RBC folate deficiency and half were vitamin B12 deficient. Folate deficiency was more common in younger children and vitamin B12 deficiency was more common in indigenous children and those from the poorest families. These findings suggest gaps in the coverage of fortification and the need for additional implementation strategies to address these gaps in coverage to help safeguard the health of Guatemalan children.

PURPOSE: We examined condom use patterns and potential population-level effects of a hypothetical condom intervention on HIV transmission among adolescent sexual minority males (ASMM). METHODS: Using three datasets: national Youth Risk Behavior Survey 2015-2017 (YRBS-National), local YRBS data from 8 jurisdictions with sex of partner questions from 2011-2017 (YRBS-Trends), and American Men's Internet Survey (AMIS) 2014-2017, we assessed associations of condom use with year, age, and race/ethnicity among sexually-active ASMM. Using a stochastic agent-based network epidemic model, structured and parameterized based on the above analyses, we calculated the percent of HIV infections averted over 10 years among ASMM ages 13-18 by an intervention that increased condom use by 37% for 5 years and was delivered to 62% of ASMM at age 14. RESULTS: In YRBS, 51.8% (95% confidence interval [CI] = 41.3-62.3%) and 37.9% (32.7-42.3%) reported condom use at last sexual intercourse in national and trend datasets, respectively. In AMIS, 47.3% (95%CI = 44.6-49.9%) reported condom use at last anal sex with a male partner. Temporal trends were not observed in any dataset (p > 0.1). Condom use varied significantly by age in YRBS-National (p < 0.0001) and YRBS-Trends (p = 0.032) with 13-15-year-olds reporting the lowest use in both; age differences were not significant in AMIS (p = 0.919). Our hypothetical intervention averted a mean of 9.0% (95% simulation interval = -5.4%-21.2%) of infections among ASMM. CONCLUSIONS: Condom use among ASMM is low and appears to have remained stable during 2011-2017. Modeling suggests that condom use increases consistent with previous interventions have potential to avert 1 in 11 new HIV infections among ASMM.

Food fortification has proven to be an effective approach for preventing micronutrient deficiencies in many settings. Factors that lead to successful fortification programs are well established. However, due to the multisectoral nature of fortification and the added complexities present in many settings, the barriers to success are not always evident and the strategies to address them are not always obvious. We developed a systematic process for identifying and addressing gaps in the implementation of a food fortification program. The framework is composed of 4 phases: (1) connect program theory of change to program implementation; (2) develop an implementation research agenda; (3) conduct implementation research; and (4) analyze findings and develop/disseminate recommendations for next steps. We detail steps in each phase to help guide teams through the process. To our knowledge, this is the first attempt to outline a systematic process for applying implementation science research to food fortification. The development of this framework is intended to promote implementation research in the field of food fortification, thus improving access to and effectiveness of this key public health intervention.

All U.S.-bound refugees from sub-Saharan Africa receive presumptive antimalarial treatment before departing for the United States. Among U.S.-bound Congolese refugees, breakthrough malaria cases and persistent splenomegaly have been reported. In response, an enhanced malaria diagnostic program was instituted. Here, we report the prevalence of plasmodial infection among 803 U.S.-bound Congolese refugees who received enhanced diagnostics. Infections by either rapid diagnostic test (RDT) or PCR were detected in 187 (23%) refugees, with 78 (10%) by RDT only, 35 (4%) by PCR only, and 74 (9%) by both. Infections identified by PCR included 103 monoinfections (87 Plasmodium falciparum, eight Plasmodium ovale, seven Plasmodium vivax, and one Plasmodium malariae) and six mixed infections. Splenomegaly was associated with malaria detectable by RDT (odds ratio: 1.8, 95% CI: 1.0-3.0), but not by PCR. Splenomegaly was not strongly associated with parasitemia, indicating that active malaria parasitemia is not necessary for splenomegaly.

BACKGROUND: In October 2015, discharge data coding in the USA shifted to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), necessitating new indicator definitions for drug overdose morbidity. Amid the drug overdose crisis, characterising discharge records that have ICD-10-CM drug overdose codes can inform the development of standardised drug overdose morbidity indicator definitions for epidemiological surveillance. METHODS: Eight states submitted aggregated data involving hospital and emergency department (ED) discharge records with ICD-10-CM codes starting with T36-T50, for visits occurring from October 2015 to December 2016. Frequencies were calculated for (1) the position within the diagnosis billing fields where the drug overdose code occurred; (2) primary diagnosis code grouped by ICD-10-CM chapter; (3) encounter types; and (4) intents, underdosing and adverse effects. RESULTS: Among all records with a drug overdose code, the primary diagnosis field captured 70.6% of hospitalisations (median=69.5%, range=66.2%-76.8%) and 79.9% of ED visits (median=80.7%; range=69.8%-88.0%) on average across participating states. The most frequent primary diagnosis chapters included injury and mental disorder chapters. Among visits with codes for drug overdose initial encounters, subsequent encounters and sequelae, on average 94.6% of hospitalisation records (median=98.3%; range=68.8%-98.8%) and 95.5% of ED records (median=99.5%; range=79.2%-99.8%), represented initial encounters. Among records with drug overdose of any intent, adverse effect and underdosing codes, adverse effects comprised an average of 74.9% of hospitalisation records (median=76.3%; range=57.6%-81.1%) and 50.8% of ED records (median=48.9%; range=42.3%-66.8%), while unintentional intent comprised an average of 11.1% of hospitalisation records (median=11.0%; range=8.3%-14.5%) and 28.2% of ED records (median=25.6%; range=20.8%-40.7%). CONCLUSION: Results highlight considerations for adapting and standardising drug overdose indicator definitions in ICD-10-CM.

BACKGROUND: Rates of adolescent sexual activity have long been declining in the United States. We sought to estimate the number of cases of gonorrhea and chlamydia averted over one decade associated with these declines, and associated costs saved. METHODS: We analyzed data from the CDC's Youth Risk Behavior Survey of US high-school students from 2007-2017 and combined it with epidemiological estimates drawn from the literature to parameterize a dynamic population transmission model. We compared transmissions from observed behavioral trends to a counterfactual scenario that assumed sexual behaviors from 2007 remained constant over 10 years. We calculated outcomes by age and for three racial/ethnic groups (Hispanic, non-Hispanic Black, and non-Hispanic White adolescents) who vary on underlying burden and amount of behavioral change. RESULTS: We estimated 1,118,483 cases of chlamydia and 214,762 cases of gonorrhea were averted (19.5% of burden across all ages). This yielded $474 million (2017 dollars) savings in medical costs over the decade. The largest number of averted cases (767,543) was among Black adolescents, but the largest proportion (28.7%) was among Hispanic adolescents. CONCLUSIONS: Whatever its origins, changing sexual behavior among adolescents results in large estimated reductions in STI burden and medical costs relative to previous cohorts. Although diagnoses among adolescents have not declined at this rate, multiple explanations could make these apparently divergent trends consistent. Efforts to continue supporting effective sex education in and out of school along with STI screening for adolescents should reinforce these gains.

Vaccination is the primary strategy to prevent hepatitis B virus (HBV) infection in the United States. Prior to 2017, most standard hepatitis B vaccine schedules required 3 doses over 6 months. Heplisav-B, approved in 2017, is administered in 2 doses over a 1 month time period but has a higher per-dose cost ($115.75 per dose compared to $57.25 per Engerix-B dose, costs as of June 1, 2019). We aimed to assess the cost-utility of providing the two-dose Heplisav-B vaccine compared to a three-dose Engerix-B vaccine among adult populations currently recommended for vaccination against hepatitis B. We used a decision-tree model with microsimulation and a Markov disease progression process to assess the cost-utility separately for the following populations: adults with diabetes, obesity, chronic kidney disease, HIV; non-responders to previous hepatitis B vaccination; older adults; and persons who inject drugs (PWID). We modeled epidemiologic outcomes (incident HBV infections, sequelae and related deaths), costs (2019 USD) and benefits (quality-adjusted life years, QALYs) and compared them across strategies. Sensitivity analyses assessed the cost-utility at varying estimates of Heplisav-B efficacy. In the base case scenario for each population, vaccination with Heplisav-B resulted in fewer HBV infections (37.5-59.8% averted), sequelae, and HBV-related deaths (36.3-71.4% averted). Heplisav-B resulted in decreased costs and increased benefits compared to Engerix-B for all populations except non-responders. Incremental costs from the baseline strategy ranged from $4746.78 saved (PWID) to $14.15 added cost (non-responders). Incremental benefits per person ranged from 0.00005 QALYs (older adults) to 0.7 QALYs (PWID). For persons with HIV and PWID, Heplisav-B resulted in lower costs and increased benefits in all scenarios in which Heplisav-B series efficacy was at least 80%. Vaccination using Heplisav-B is a cost-saving strategy compared to Engerix-B for adults with diabetes, chronic kidney disease, obesity, and HIV; older adults; and PWID.

During the 2016-2017 Zika virus outbreak, preventing unintended pregnancy was recognized as a primary strategy to reduce adverse Zika-related pregnancy and birth outcomes. To increase awareness and uptake of contraceptive services provided through the Zika Contraception Access Network (Z-CAN) in Puerto Rico, a multi-strategy campaign called Ante La Duda, Pregunta (ALDP) was developed. The principal aim was to increase awareness of Z-CAN services, which included same-day access to the full range of reversible contraceptives at no cost to women living in Puerto Rico who choose to delay or avoid pregnancy during the 2016-2017 Zika virus outbreak. Using diverse strategies, ALDP increased exposure to and engagement with the campaign in order to raise awareness of Z-CAN services in Puerto Rico. The ALDP social marketing campaign played an important role in the overall Z-CAN effort. Of all the strategies utilized, Facebook appears to have reached the most people. While the importance of a social marketing campaign communicating to raise awareness and create demand has long been known, through the ALDP campaign efforts, it was shown that an effective campaign, built on formative research, can be developed and implemented rapidly in an emergency response situation without compromising on content, quality, or reach.

BACKGROUND: A multisystem inflammatory syndrome in children (MIS-C) is associated with coronavirus disease 2019. The New York State Department of Health (NYSDOH) established active, statewide surveillance to describe hospitalized patients with the syndrome. METHODS: Hospitals in New York State reported cases of Kawasaki's disease, toxic shock syndrome, myocarditis, and potential MIS-C in hospitalized patients younger than 21 years of age and sent medical records to the NYSDOH. We carried out descriptive analyses that summarized the clinical presentation, complications, and outcomes of patients who met the NYSDOH case definition for MIS-C between March 1 and May 10, 2020. RESULTS: As of May 10, 2020, a total of 191 potential cases were reported to the NYSDOH. Of 95 patients with confirmed MIS-C (laboratory-confirmed acute or recent severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] infection) and 4 with suspected MIS-C (met clinical and epidemiologic criteria), 53 (54%) were male; 31 of 78 (40%) were black, and 31 of 85 (36%) were Hispanic. A total of 31 patients (31%) were 0 to 5 years of age, 42 (42%) were 6 to 12 years of age, and 26 (26%) were 13 to 20 years of age. All presented with subjective fever or chills; 97% had tachycardia, 80% had gastrointestinal symptoms, 60% had rash, 56% had conjunctival injection, and 27% had mucosal changes. Elevated levels of C-reactive protein, d-dimer, and troponin were found in 100%, 91%, and 71% of the patients, respectively; 62% received vasopressor support, 53% had evidence of myocarditis, 80% were admitted to an intensive care unit, and 2 died. The median length of hospital stay was 6 days. CONCLUSIONS: The emergence of multisystem inflammatory syndrome in children in New York State coincided with widespread SARS-CoV-2 transmission; this hyperinflammatory syndrome with dermatologic, mucocutaneous, and gastrointestinal manifestations was associated with cardiac dysfunction.

Purpose: Adolescents aged 13–18 years bear a large burden of sexually transmitted infections (STIs) and changing adolescent sexual risk behavior is a key component of reducing this burden. We demonstrate a novel publicly available modeling tool (teen-SPARC) to help state and local health departments predict the impact of behavioral change on gonorrhea, chlamydia, and HIV burden among adolescents. Methods: Teen-SPARC is built in Excel for familiarity and ease and parameterized using data from CDC's Youth Risk Behavior Surveillance System. We present teen-SPARC's methods, including derivation of national parameters and instructions to obtain local parameters. We model multiple scenarios of increasing condom use and estimate the impact on gonorrhea, chlamydia, and HIV incidence, comparing national and New York State (NYS) results. Results: A 1% annual increase in condom use (consistent with Healthy People 2020 goals) could prevent nearly 10,000 cases of STIs nationwide. Increases in condom use of 17.1%, 2.2%, and 25.5% in NYS would be necessary to avert 1000 cases of gonorrhea, 1000 cases of chlamydia, and 10 cases of HIV infection, respectively. Additional results disaggregate outcomes by age, sex, partner sex, jurisdiction, and pathogen. Conclusion: Teen-SPARC may be able to assist health departments aiming to tailor behavioral interventions for STI prevention among adolescents.

The Democratic Republic of the Congo (DRC) harbors 11% of global malaria cases, yet little is known about the spatial and genetic structure of the parasite population in that country. We sequence 2537 Plasmodium falciparum infections, including a nationally representative population sample from DRC and samples from surrounding countries, using molecular inversion probes - a high-throughput genotyping tool. We identify an east-west divide in haplotypes known to confer resistance to chloroquine and sulfadoxine-pyrimethamine. Furthermore, we identify highly related parasites over large geographic distances, indicative of gene flow and migration. Our results are consistent with a background of isolation by distance combined with the effects of selection for antimalarial drug resistance. This study provides a high-resolution view of parasite genetic structure across a large country in Africa and provides a baseline to study how implementation programs may impact parasite populations.

Hepatitis C virus (HCV) infection is a leading cause of liver-related morbidity and mortality, and more than 2 million adults in the United States are estimated to be currently infected. Reducing HCV burden will require an understanding of demographic disparities and targeted efforts to reduce prevalence in populations with disproportionate disease rates. We modeled state-level estimates of hepatitis C prevalence among U.S. adults by sex, birth cohort, and race during 2013-2016. National Health and Nutrition Examination Survey data were used in combination with state-level HCV-related and narcotic overdose-related mortality data from the National Vital Statistics System and estimates from external literature review on populations not sampled in the National Health and Nutrition Examination Survey. Nationally, estimated hepatitis C prevalence was 1.3% among males and 0.6% among females (prevalence ratio [PR] = 2.3). Among persons born during 1945 to 1969, prevalence was 1.6% compared with 0.5% among persons born after 1969 (PR = 3.2). Among persons born during 1945 to 1969, prevalence ranged from 0.7% in North Dakota to 3.6% in Oklahoma and 6.8% in the District of Columbia. Among persons born after 1969, prevalence was more than twice as high in Kentucky, New Mexico, Oklahoma, and West Virginia compared with the national average. Hepatitis C prevalence was 1.8% among non-Hispanic black persons and 0.8% among persons of other races (PR = 2.2), and the magnitude of this disparity varied widely across jurisdictions (PR range: 1.3-7.8). Overall, 23% of prevalent HCV infections occurred among non-Hispanic black persons, whereas 12% of the population was represented by this racial group. These estimates provide information on prevalent HCV infections that jurisdictions can use for understanding and monitoring local disease patterns and racial disparities in burden of disease.

BACKGROUND: Biannual mass azithromycin administration to preschool children reduces all-cause mortality, but the mechanism for the effect is not understood. Azithromycin has activity against malaria parasites, and malaria is a leading cause of child mortality in the Sahel. The effect of biannual versus annual azithromycin distribution for trachoma control on serological response to merozoite surface protein 1 (MSP-119), a surrogate for malaria incidence, was evaluated among children in Niger. METHODS: Markers of malaria exposure were measured in two arms of a factorial randomized controlled trial designed to evaluate targeted biannual azithromycin distribution to children under 12 years of age compared to annual azithromycin to the entire community for trachoma control (N = 12 communities per arm). Communities were treated for 36 months (6 versus 3 distributions). Dried blood spots were collected at 36 months among children ages 1-5 years, and MSP-119 antibody levels were assessed using a bead-based multiplex assay to measure malaria seroprevalence. RESULTS: Antibody results were available for 991 children. MSP-119 seropositivity was 62.7% in the biannual distribution arm compared to 68.7% in the annual arm (prevalence ratio 0.91, 95% CI 0.83 to 1.00). Mean semi-quantitative antibody levels were lower in the biannual distribution arm compared to the annual arm (mean difference - 0.39, 95% CI - 0.05 to - 0.72). CONCLUSIONS: Targeted biannual azithromycin distribution was associated with lower malaria seroprevalence compared to that in a population that received annual distribution. Trial Registration Clinicaltrials.gov NCT00792922.

We appreciate Dr. Spaulding and colleagues’ thoughtful commentary on our article. We used national data to provide the most accurate estimate possible of the prevalence of hepatitis C among adults in the United States, but our estimate was dependent on the quality and completeness of the available data. We corrected for the omission of several high-prevalence populations from the National Health and Nutrition Examination Survey (NHANES), but no nationally representative studies of these populations exist. Spaulding and her colleagues raise a number of reasons why our study may underestimate the true prevalence of hepatitis C among incarcerated persons, but unfortunately, no nationwide data exist to assess the magnitude of these potential biases. According to 2016 Bureau of Justice Statistics data, most people arrested are detained in jails for short periods of time(1); thus, most of the number of persons cited in Dr. Spaulding’s reply would be eligible for NHANES sampling. We could not further adjust estimates for potential nonresponse bias beyond those addressed through standard NHANES sample weights without risk of double-counting prevalent cases. | | Varan et al.(2) data were excluded because we decided a priori to include only articles published more recently than those included in the incarcerated prevalence analysis from the Edlin et al. 2015(3) national hepatitis C virus prevalence estimate. With respect to the differential treatment of North Carolina and South Carolina from Schoenbachler et al. (4) (“study 6”), South Carolina data were excluded because “Initially, the South Carolina program targeted detainees…who had obtained tattoos in non-professional or unregulated settings.” Although testing was eventually expanded to include other detainees, Shoenbachler et al. did not indicate at what point that transition occurred or whether the expansion applied to all four South Carolina jails in the study or just one.(4) We determined that the targeted risk-based screening employed met our “sampling higher-risk subpopulations selectively” exclusion criteria, and consequently only included North Carolina data from Schoenbachler et al. in our analysis. | | Incarcerated populations bear a large and disproportionate hepatitis C burden, and incarceration provides an important opportunity to identify cases, provide life-saving curative treatment, and prevent transmission. The Centers for Disease Control and Prevention (CDC) is looking to other systems to collect data for prevention planning and providing more support to traditional and nontraditional surveillance systems both within and outside correctional facilities. Regardless of the exact number, prevention, testing, care, and treatment of incarcerated persons with or at risk for hepatitis C is an important priority for CDC and the nation.

In response to the Zika virus outbreak in Puerto Rico (2015-2016), the Zika Contraception Access Network (Z-CAN) was established to provide same-day access to the full range of reversible contraception at no cost to women. Formative research was conducted to inform the development of a communication campaign about Z-CAN. Ten focus groups with women and men, aged 18 to 49 years, in Puerto Rico were conducted to collect data on contraception awareness, use, and decision making during the Zika outbreak, as well as culturally appropriate messaging and outreach strategies. Thematic analysis was conducted using the constant comparative method. Data showed that there was community awareness regarding Zika in Puerto Rico. However, it was not a motivating factor in contraception decision making; instead, economic factors were the major drivers. Most participants preferred to receive information on contraception, potential side effects, and where to access contraceptive services via Internet-based channels and health care providers. Based on these findings, the Ante La Duda, Pregunta [When in Doubt, Ask] campaign was launched to promote awareness of Z-CAN services among those who chose to prevent pregnancy during the Zika outbreak. Our results underscore the importance of conducting formative research to develop communication initiatives, while also demonstrating that it is feasible to perform these activities as part of an emergency response.

Malaria remains one of the most important infectious diseases in the world. The WHO estimated 435,000 deaths from malaria in 2017, the large majority due to Plasmodium falciparum.1 In the United States, over the last 5 years with available data (2011–2015), between 1,517 and 1,925 cases of malaria have been reported annually, including about 300 cases of severe malaria and between five and 11 deaths each year. In non-immune individuals severe malaria most commonly presents as a rapidly progressive illness, with life-threatening dysfunction of the brain, lungs, kidneys, and other organs. Prompt administration of effective antimalarial therapy is an urgent, potentially life-saving priority.

Importance: Infection with hepatitis C virus (HCV) is a major cause of morbidity and mortality in the United States, and incidence has increased rapidly in recent years, likely owing to increased injection drug use. Current estimates of prevalence at the state level are needed to guide prevention and care efforts but are not available through existing disease surveillance systems. Objective: To estimate the prevalence of current HCV infection among adults in each US state and the District of Columbia during the years 2013 to 2016. Design, Setting, and Participants: This survey study used a statistical model to allocate nationally representative HCV prevalence from the National Health and Nutrition Examination Survey (NHANES) according to the spatial demographics and distributions of HCV mortality and narcotic overdose mortality in all National Vital Statistics System death records from 1999 to 2016. Additional literature review and analyses estimated state-level HCV infections among populations not included in the National Health and Nutrition Examination Survey sampling frame. Exposures: State, accounting for birth cohort, biological sex, race/ethnicity, federal poverty level, and year. Main Outcomes and Measures: State-level prevalence estimates of current HCV RNA. Results: In this study, the estimated national prevalence of HCV from 2013 to 2016 was 0.84% (95% CI, 0.75%-0.96%) among adults in the noninstitutionalized US population represented in the NHANES sampling frame, corresponding to 2035100 (95% CI, 1803600-2318000) persons with current infection; accounting for populations not included in NHANES, there were 231600 additional persons with HCV, adjusting prevalence to 0.93%. Nine states contained 51.9% of all persons living with HCV infection (California [318900], Texas [202500], Florida [151000], New York [116000], Pennsylvania [93900], Ohio [89600], Michigan [69100], Tennessee [69100], and North Carolina [66400]); 5 of these states were in Appalachia. Jurisdiction-level median (range) HCV RNA prevalence was 0.88% (0.45%-2.34%). Of 13 states in the western United States, 10 were above this median. Three of 10 states with the highest HCV prevalence were in Appalachia. Conclusions and Relevance: Using extensive national survey and vital statistics data from an 18-year period, this study found higher prevalence of HCV in the West and Appalachian states for 2013 to 2016 compared with other areas. These estimates can guide state prevention and treatment efforts.

Hepatitis C virus (HCV) infection is the most commonly reported bloodborne infection in the United States, causing substantial morbidity and mortality and costing billions of dollars annually. To update the estimated HCV prevalence among all adults aged >/=18 years in the United States, we analyzed 2013-2016 data from the National Health and Nutrition Examination Survey (NHANES) to estimate the prevalence of HCV in the noninstitutionalized civilian population and used a combination of literature reviews and population size estimation approaches to estimate the HCV prevalence and population sizes for four additional populations: incarcerated people, unsheltered homeless people, active-duty military personnel, and nursing home residents. We estimated that during 2013-2016 1.7% (95% confidence interval [CI], 1.4-2.0%) of all adults in the United States, approximately 4.1 (3.4-4.9) million persons, were HCV antibody-positive (indicating past or current infection) and that 1.0% (95% CI, 0.8-1.1%) of all adults, approximately 2.4 (2.0-2.8) million persons, were HCV RNA-positive (indicating current infection). This includes 3.7 million noninstitutionalized civilian adults in the United States with HCV antibodies and 2.1 million with HCV RNA and an estimated 0.38 million HCV antibody-positive persons and 0.25 million HCV RNA-positive persons not part of the 2013-2016 NHANES sampling frame. Conclusion: Over 2 million people in the United States had current HCV infection during 2013-2016; compared to past estimates based on similar methodology, HCV antibody prevalence may have increased, while RNA prevalence may have decreased, likely reflecting the combination of the opioid crisis, curative treatment for HCV infection, and mortality among the HCV-infected population; efforts on multiple fronts are needed to combat the evolving HCV epidemic, including increasing capacity for and access to HCV testing, linkage to care, and cure.

BACKGROUND: The Study of Healthcare Personnel with Influenza and other Respiratory Viruses in Israel (SHIRI) prospectively follows a cohort of healthcare personnel (HCP) in two hospitals in Israel. SHIRI will describe the frequency of influenza virus infections among HCP, identify predictors of vaccine acceptance, examine how repeated influenza vaccination may modify immunogenicity, and evaluate influenza vaccine effectiveness in preventing influenza illness and missed work. METHODS: Cohort enrollment began in October, 2016; a second year of the study and a second wave of cohort enrollment began in June 2017. The study will run for at least 3 years and will follow approximately 2000 HCP (who are both employees and members of Clalit Health Services [CHS]) with routine direct patient contact. Eligible HCP are recruited using a stratified sampling strategy. After informed consent, participants complete a brief enrollment survey with questions about occupational responsibilities and knowledge, attitudes, and practices about influenza vaccines. Blood samples are collected at enrollment and at the end of influenza season; HCP who choose to be vaccinated contribute additional blood one month after vaccination. During the influenza season, participants receive twice-weekly short message service (SMS) messages asking them if they have acute respiratory illness or febrile illness (ARFI) symptoms. Ill participants receive follow-up SMS messages to confirm illness symptoms and duration and are asked to self-collect a nasal swab. Information on socio-economic characteristics, current and past medical conditions, medical care utilization and vaccination history is extracted from the CHS database. Information about missed work due to illness is obtained by self-report and from employee records. Respiratory specimens from self-collected nasal swabs are tested for influenza A and B viruses, respiratory syncytial virus, human metapneumovirus, and coronaviruses using validated multiplex quantitative real-time reverse transcription polymerase chain reaction assays. The hemagglutination inhibition assay will be used to detect the presence of neutralizing influenza antibodies in serum. DISCUSSION: SHIRI will expand our knowledge of the burden of respiratory viral infections among HCP and the effectiveness of current and repeated annual influenza vaccination in preventing influenza illness, medical utilization, and missed workdays among HCP who are in direct contact with patients. TRIAL REGISTRATION: NCT03331991 . Registered on November 6, 2017.

Inadequate folate status in women of reproductive age (WRA) can lead to adverse health consequences of public health significance, such as megaloblastic anemia (folate deficiency) and an increased risk of neural tube defect (NTD)-affected pregnancies (folate insufficiency). Our review aims to evaluate current data on folate status of WRA. We queried eight databases and the World Health Organization Micronutrients Database, identifying 45 relevant surveys conducted between 2000 and 2014 in 39 countries. Several types of folate assays were used in the analysis of blood folate, and many surveys used folate cutoffs not matched to the assay. To allow better comparisons across surveys, we attempted to account for these differences. The prevalence of folate deficiency was >20% in many countries with lower income economies but was typically <5% in countries with higher income economies. Only 11 surveys reported the prevalence of folate insufficiency, which was >40% in most countries. Overall, folate status data for WRA globally are limited and must be carefully interpreted due to methodological issues. Future surveys would benefit from using the microbiologic assay to assess folate status, along with assay-matched cutoffs to improve monitoring and evaluation of folic acid interventions, thus informing global efforts to prevent NTDs.