Introduction: Motor-vehicle crash (MVC) deaths increased by a record 10% from 2020 to 2021 in the United States and disproportionately impacted persons of certain racial/ethnic groups. Methods: Mortality data from the National Vital Statistics System was used to describe MVC death rate trends during 2019–2022 by six racial/ethnic groups: non-Hispanic (NH) American Indian or Alaska Native (AIAN), NH Asian, NH Black, NH Native Hawaiian or Other Pacific Islander (NHOPI), NH White, and Hispanic. Age-adjusted death rates per 100,000 population, 95% confidence intervals (CIs), and annual percent change in rates were calculated. Results: Overall MVC death rates increased during 2019–2022, and rates were highest among NH AIAN and NH Black persons across all years. During 2019–2020, death rates increased the most among NH Black persons (+26.0%). During 2020–2021, rates increased among all racial/ethnic groups, with the greatest increase among NH NHOPI persons (+66.7%) and NH AIAN persons (+27.8%). Conclusions: These findings highlight stark differences by racial/ethnic group in MVC death rates and changes in these rates. Between 2019 and 2022, NH AIAN, NH Black, and NH NHOPI populations experienced the largest increases in MVC death rates, although there was large variation in rates and trends. Widespread adoption of a comprehensive suite of prevention strategies, such as the Safe System approach, while targeting subpopulations with the greatest burden of MVC deaths could reduce these differences and the overall burden of MVCs. Practical Applications: These findings show which subpopulations could experience the greatest impacts from transportation safety investments in reducing overall MVC death rates in the United States. © 2025

IMPORTANCE: Neonates requiring intensive care are at high risk of health care-associated infections. In neonatal intensive care units (NICUs) in low-resource settings, the identification of modifiable risk factors can inform targeted prevention strategies to reduce the global burden of neonatal morbidity and mortality. OBJECTIVE: To describe the incidence of and the risk factors associated with health care-associated bloodstream infections (BSIs) in NICUs in Pune, India. DESIGN, SETTING, AND PARTICIPANTS: This multicenter prospective cohort study enrolled all neonates admitted to 3 NICUs in Pune, India, from May 1, 2017, to July 31, 2019. Neonates were followed up from admission until discharge, transfer, or death. This secondary data analysis included neonates admitted for 3 days or more and was completed on January 31, 2024. MAIN OUTCOMES AND MEASURES: The primary outcome was health care-associated BSIs, defined as a positive blood culture on or after admission day 3. Summary statistics, incidence of health care-associated BSIs, and hazard rate by characteristics of interest were generated. Among neonates admitted for 7 days or longer, the association between antibiotic exposure and infection risk was assessed. RESULTS: A total of 6410 neonates were admitted for 3 days or longer. The median gestational age was 34 weeks (IQR, 32-37 weeks), and 3560 (55.5%) were male. The incidence of health care-associated BSIs was 6.09 per 1000 patient-days. Most isolates were gram-negative organisms (n = 273 [66.3%]), of which 85.5% (202 of 236 isolates tested) were resistant to third- or fourth-generation cephalosporins and 44.8% (117 of 261 isolates tested) were resistant to carbapenems. The hazard rate of health care-associated BSIs was higher among neonates with central venous catheters, respiratory support, or urinary catheters within 3 days preceding infection. Of 3229 neonates admitted for 7 days or longer, 190 (5.8%) had health care-associated BSIs on or after hospital day 7, with an incidence of 3.22 per 1000 patient-days. Antibiotic exposure during the first week of admission was associated with a nearly 3-fold increase in the risk of health care-associated BSIs (adjusted hazard ratio, 2.82 [95% CI, 1.26-6.32]). CONCLUSIONS AND RELEVANCE: In this cohort study of 6410 neonates admitted to 3 NICUs in Pune, India, the risk of health care-associated BSIs was associated with the presence of indwelling devices and prior antibiotic exposure. Future efforts should focus on mitigating the risks associated with indwelling devices and strengthening infection prevention and control and antimicrobial stewardship programs to prevent health care-associated infections.

Introduction: This study describes the prevalence of driving under the influence of alcohol (DUIA), marijuana (DUIM), or other illicit drugs (DUID) in the United States over time. Method: This study analyzed data from 2016–2019 National Survey on Drug Use and Health public-use files. The study sample was limited to drivers aged ≥16 years. Prevalence in 2019 and 2016–2019 trends were assessed overall, by sociodemographic characteristics, and by seatbelt use. Results: The 2019 overall prevalence of DUIA, DUIM, and DUID during the past year was 8.3%, 5.3%, and 0.9%, respectively. DUIA, DUIM, and DUID prevalence was highest for drivers who were male (10.6%, 7.0%, and 1.2%, respectively), not heterosexual (12.3%, 14.7%, and 3.5%, respectively), and did not always wear a seatbelt (12.1%, 11.5%, and 3.1%, respectively). DUIA and DUIM were highest among drivers aged 21–25 years; DUID was highest among drivers aged 21–25 or 26–34 years. From 2016 to 2019, overall DUIA decreased slightly, DUIM increased (4.5% to 5.3%), and DUID did not change; trends differed across sociodemographic groups. Conclusions: DUI is a pervasive public health issue. There are ≥10,000 DUIA crash deaths in the United States annually; proven interventions exist to prevent these deaths. Decision makers can save lives and make our roadways safer by implementing proven strategies to reduce DUIA, including lowering the legal blood alcohol concentration (BAC) for driving. Improved data and more research are needed to understand DUIM and DUID burden and determine effective prevention strategies, especially in the context of increasing DUIM. Practical Applications: There were groups for which changes in behavior patterns were found, which could guide prevention efforts. For drivers who did not always wear a seatbelt, DUIA decreased while DUIM increased. A similar pattern was noted for drivers aged 26–34 years; additionally, DUID increased in this group. © 2024

BACKGROUND AND OBJECTIVES: Blood donor cohorts are an underappreciated resource for surveillance and public health programming for infectious diseases. The incidence of hepatitis C virus (HCV) infection was evaluated in repeat blood donors in Georgia. MATERIALS AND METHODS: Using data from the national hepatitis C screening registry, we calculated overall hepatitis C incidence for 2017-2023 and annual incidence during 2017-2022 among adults who donated blood at least twice and had a nonreactive HCV antibody (anti-HCV) test result upon first screening and a subsequent anti-HCV test conducted in any location. Rates of anti-HCV seroconversion and current infection were calculated by year, sex, age group, and location of last HCV screening and expressed per 100,000 person-years (PY). RESULTS: Of 101,443 blood donors with ≥2 anti-HCV results,775 (0.8%) seroconverted to anti-HCV reactive, of whom 403 (52.0%) had current infection. Incidence of anti-HCV seroconversion decreased from 408 per 100,000 PY in 2017 to 218 per 100,000 PY in 2022 and incidence of infection decreased from 172 per 100,000 PY in 2017 to 118 per 100,000 PY in 2022. Males, persons aged 18-39 years, and people last tested for HCV in prisons had the highest incidence rates for anti-HCV seroconversion and HCV infection, while persons last screened in blood banks and during antenatal care had the lowest. CONCLUSION: Despite the observed decline, incidence of HCV infection among repeat blood donors remains high in specific subgroups. Hepatitis C prevention, screening and treatment interventions need to particularly focus on incarcerated populations and young adults in Georgia.

INTRODUCTION: Disease intervention specialists (DIS) are critical for delivering partner services programs that provide partner notification, counseling, referral, and other services for HIV, sexually transmitted infections (STIs), and other infections. This systematic review of partner services and other DIS-delivered interventions for HIV and STIs was conducted to summarize the effectiveness of these programs and identify evidence gaps. METHODS: A systematic literature review was conducted with a narrative synthesis. Articles were located using keyword searches in MEDLINE, Web of Science, CINAHL, and ProQuest through December 2022 and analyzed in 2023-2024. Included studies addressed an intervention of partner services or other DIS-delivered services for HIV or STIs; a United States setting; primary data collection; and an external comparison group or pre-post design. RESULTS: 1,915 unique records were screened for eligibility, with 30 studies included. Overall, DIS-delivered interventions improved clinical outcomes among index patients and population outcomes. Many studies focused on program process measures rather than population-level epidemiologic outcomes. All but one studies were scored as having low or medium strength of evidence. DISCUSSION: The evidence could be strengthened by establishing a streamlined set of core metrics, assessing impact using rigorous causal inference methodologies, linking program and clinical data systems, and supplementing impact evaluations with evidence on implementation strategies.

Hepatitis B and hepatitis C are leading causes of cirrhosis and liver cancer and caused 1.3 million deaths worldwide in 2022. Hepatitis B is preventable with vaccination, and hepatitis C is curable with direct-acting antivirals. In 2015, in collaboration with CDC and other partners, Georgia, a country at the intersection of Europe and Asia, launched a hepatitis C elimination program to reduce the prevalence of chronic hepatitis C; at that time, the prevalence was 5.4%, more than five times the global average of 1.0%. In 2016, the World Health Assembly endorsed a goal for the elimination of viral hepatitis as a public health problem by 2030. In 2024, 89% of the Georgian adult population have received screening for hepatitis C, 83% of persons with current chronic HCV infection have received a diagnosis, and 86% of those with diagnosed hepatitis C have started treatment. During 2015-2023, vaccination coverage with the hepatitis B birth dose and with 3 doses of hepatitis B vaccine among infants exceeded 90% for most years. In 2021, the prevalence of hepatitis B surface antigen was 0.03% among children and adolescents aged 5-17 years and 2.7% among adults. Georgia has demonstrated substantial progress toward hepatitis B and hepatitis C elimination. Using lessons from the hepatitis C elimination program, scale-up of screening and treatment for hepatitis B among adults would prevent further viral hepatitis-associated morbidity and mortality in Georgia and would accelerate progress toward hepatitis B and hepatitis C elimination by 2030.

BACKGROUND: Mycoplasma genitalium is a major contributor to persistent/recurrent urethritis cases. However, there are limited published studies on recent trends of persistent/recurrent urethritis. METHODS: A retrospective analysis was conducted of men presenting with symptomatic urethritis in 16 sexually transmitted disease (STD) clinics from 2015 to 2019. Poisson regression was used to assess trends in the annual proportions of urethritis episodes with follow-up (FU) characterized with persistent/recurrent urethritis symptoms. Results were also stratified by results of chlamydia (CT) and gonorrhea (NG) testing and treatment prescribed. RESULTS: There were 99,897 urethritis episodes, from 67,546 unique men. The proportion of episodes with persistent/recurrent symptomatic FU visits increased 50.8% over a 4-year period (annual percentage change [APC], 11.3%; 95% confidence interval [CI], 6.5-16.3). Similar trends were observed in nonchlamydial nongonococcal urethritis episodes (APC, 12.7%; 95% CI, 6.8-18.9) but increases among those positive for NG (APC, 12.1%; 95% CI, -2.3 to -28.5) or for CT (APC, 7.3%; 95% CI, -6.7 to 23.5) were not statistically significant. Among episodes who received azithromycin as first-line treatment, increases in the proportion of persistent/recurrent FU visits were observed (APC, 12.6%; 95% CI, 8.6-16.7). For episodes where first-line treatment was doxycycline, no significant increases were detected (APC, 4.3%; 95% CI, -0.3 to 9.2). CONCLUSIONS: We found an increase in the proportion of urethritis episodes with persistent or recurrent symptoms over time. Given these observed trends in episodes negative for NG or CT, an etiology not detectable by routine diagnostics was a likely factor in increased persistence, suggesting patients with urethritis may benefit from diagnostic testing for M. genitalium during an initial symptomatic presentation.

BACKGROUND: Xpert MTB/RIF Ultra (Ultra) is an automated molecular test for the detection of Mycobacterium tuberculosis in sputum. We compared the sensitivity of Ultra to that of mycobacterial growth indicator tube (MGIT) liquid culture, considered the most sensitive assay in routine clinical use. METHODS: In this prospective, multicentre, cross-sectional diagnostic accuracy study, we used a non-inferiority design to assess whether the sensitivity of a single Ultra test was non-inferior to that of a single liquid culture for detection of M tuberculosis in sputum. We enrolled adults (age ≥18 years) with pulmonary tuberculosis symptoms in 11 countries and each adult provided three sputum specimens with a minimum volume of 2 mL over 2 days. Ultra was done directly on sputum 1, and Ultra and MGIT liquid culture were done on resuspended pellet from sputum 2. Results of MGIT and solid media cultures done on sputum 3 were considered the reference standard. The pre-defined non-inferiority margin was 5·0%. FINDINGS: Between Feb 18, 2016, and Dec 4, 2019, we enrolled 2906 participants. 2600 (89%) participants were analysed, including 639 (25%) of 2600 who were positive for tuberculosis by the reference standard. Of the 2357 included in the non-inferiority analysis, 877 (37%) were HIV-positive and 984 (42%) were female. Sensitivity of Ultra performed directly on sputum 1 was non-inferior to that of sputum 2 MGIT culture (MGIT 91·1% vs Ultra 91·9%; difference -0·8 percentage points; 95% CI -2·8 to 1·1). Sensitivity of Ultra performed on sputum 2 pellet was also non-inferior to that of sputum 2 MGIT (MGIT 91·1% vs Ultra 91·9%; difference -0·8 percentage points; -2·7 to 1·0). INTERPRETATION: For the detection of M tuberculosis in sputum from adults with respiratory symptoms, there was no difference in sensitivity of a single Ultra test to that of a single MGIT culture. Highly sensitive, rapid molecular approaches for M tuberculosis detection, combined with advances in genotypic methods for drug resistance detection, have potential to replace culture. FUNDING: US National Institute of Allergy and Infectious Diseases.

Transcriptional regulator MtrR inhibits the expression of the multidrug efflux pump operon mtrCDE in the pathogenic bacterium Neisseria gonorrhoeae. Here, we show that MtrR binds the hormonal steroids progesterone, β-estradiol, and testosterone, which are present at urogenital infection sites, as well as ethinyl estrogen, a component of some hormonal contraceptives. Steroid binding leads to the decreased affinity of MtrR for cognate DNA, increased mtrCDE expression, and enhanced antimicrobial resistance. Furthermore, we solve crystal structures of MtrR bound to each steroid, thus revealing their binding mechanisms and the conformational changes that induce MtrR.

OBJECTIVE: To estimate the number of women who received human immunodeficiency virus (HIV) and sexually transmitted infection (STI) testing and HIV pre-exposure prophylaxis (PrEP) services by race and ethnicity in seven THRIVE (Targeted Highly Effective Interventions to Reverse the HIV Epidemic)-funded jurisdictions and to estimate associations of age and syphilis and gonorrhea diagnoses with receipt of HIV PrEP services. METHODS: We analyzed data collected from 2015 to 2020 in Birmingham, Alabama; Baltimore City, Maryland; Washington, DC, New Orleans, Louisiana; Brooklyn, New York; Philadelphia, Pennsylvania; and Hampton Roads, Virginia. We compared Black women and women of additional racial and ethnic groups by age, HIV status at enrollment, receipt of STI testing and test positivity, and steps in the PrEP continuum (screened, eligible, referred, linked, and prescribed). We also examined the association of age, syphilis, or gonorrhea with the following steps in the PrEP continuum: screened, referred, linked, and prescribed. RESULTS: Black women made up 69.2% (8,758/12,647) of women served in THRIVE. Compared with non-Black women, Black women were more likely to have a positive test result for syphilis (3.3% vs 2.1%), gonorrhea (4.9% vs 3.5%), chlamydia (5.1% vs 1.9%), or more than one STI (1.4% vs 0.3%). Among women with negative HIV test results or unknown HIV status, Black women were more likely to be screened for PrEP eligibility (88.4% vs 64.9%). Among Black women, the proportion screened for PrEP was higher among those diagnosed with syphilis (97.3%) or gonorrhea (100%) than among those without an STI (88.1% and 87.8%, respectively). Among 219 Black women who presented with syphilis, only 10 (4.6%) were prescribed PrEP; among 407 with gonorrhea, only 11 (2.7%) were prescribed PrEP. CONCLUSION: Although most Black women seeking services received STI testing, the proportion of Black women who were eligible for PrEP and prescribed PrEP was low. To achieve national HIV-prevention goals, it is imperative that Black women have access to PrEP information and services.

BACKGROUND: Neonates admitted to the neonatal intensive care unit (NICU) are at risk for healthcare-associated infections, including central line-associated bloodstream infections. We aimed to characterize the epidemiology of bloodstream infections among neonates with central venous catheters admitted to three Indian NICUs. METHODS: We conducted a prospective cohort study in three tertiary NICUs, from May 1, 2017 until July 31, 2019. All neonates admitted to the NICU were enrolled and followed until discharge, transfer, or death. Cases were defined as positive blood cultures in neonates with a central venous catheter in place for greater than 2 days or within 2 days of catheter removal. RESULTS: During the study period, 140 bloodstream infections were identified in 131 neonates with a central venous catheter. The bloodstream infection rate was 11.9 per 1000 central line-days. Gram-negative organisms predominated, with 38.6% of cases caused by Klebsiella spp. and 14.9% by Acinetobacter spp. Antimicrobial resistance was prevalent among Gram-negative isolates, with 86.9% resistant to third- or fourth-generation cephalosporins, 63.1% to aminoglycosides, 61.9% to fluoroquinolones, and 42.0% to carbapenems. Mortality and length of stay were greater in neonates with bloodstream infection than in neonates without bloodstream infection (unadjusted analysis, p <  0.001). CONCLUSIONS: We report a high bloodstream infection rate among neonates with central venous catheters admitted to three tertiary care NICUs in India. Action to improve infection prevention and control practices in the NICU is needed to reduce the morbidity and mortality associated with BSI in this high-risk population.

Objectives. To describe HIV testing among clients in the Targeted Highly Effective Interventions to Reverse the HIV Epidemic (THRIVE) demonstration project and evaluate testing frequency. Methods. We identified factors associated with an average testing frequency of 180 days or less compared with more than 180 days using adjusted Poisson regression models. We performed the Kaplan-Meier survival analysis to compare time to diagnosis by testing frequency. Results. Among 5710 clients with 2 or more tests and no preexposure prophylaxis (PrEP) prescription, 42.4% were tested frequently. Black/African American clients were 21% less likely and Hispanic/Latino clients were 18% less likely to be tested frequently than were White clients. Among 71 Black/African American and Hispanic/Latino cisgender men who have sex with men and transgender women with HIV diagnoses, those with frequent testing had a median time to diagnosis of 137 days, with a diagnostic testing yield of 1.5% compared with those tested less frequently, with 559 days and 0.8% yield. Conclusions. HIV testing at least every 6 months resulted in earlier HIV diagnosis and was efficient. Persons in communities with high rates of HIV who are not on PrEP can benefit from frequent testing, and collaborative community approaches may help reduce disparities. (Am J Public Health. Published online ahead of print July 6, 2023:e1-e9. https://doi.org/10.2105/AJPH.2023.307341).

BACKGROUND: The initial years of the COVID-19 pandemic disrupted sexual healthcare clinic's services. We describe use patterns by patient characteristics, and the use of telehealth (TH) services among a network of sexually transmitted disease (STD) clinics. METHODS: Data were collected using a survey to assess the impact of COVID-19 from March - December 2020 among seven jurisdictions who contribute STD visit-level data as part of the STD Surveillance Network. As a complement to the survey, retrospective data from January 2019 - December 2021 from these seven STD clinics in the same seven jurisdictions were examined for monthly utilization trends by overall visits, patient characteristics, and TH visits. RESULTS: Survey results indicated seven clinics prioritized patients for in-person visits and four jurisdictions reported urgent care centers were the most common referral location. In April 2020 (relative to April 2019) clinic visits and unique patients decreased by 68.0% and 75.8%, respectively. TH were documented in four clinics, beginning in March 2020, peaking in December 2020, and tapering until December 2021. We observed the number of clinic visits (-12.2%) and unique patients presenting for care (-27.2%)in December 2021 had yet to return to levels to that seen in December 2019. CONCLUSION: STD clinics showed fragility and resiliency in their adjustment to the pandemic; allowing for the continuation of services. Overall patient census has been slow to return to pre-pandemic levels, and many patients may still not be seeking timely care. This could result in missed opportunities to screen and treat STIs and increasing the possibility of harmful sequelae.

The National Clinical Care Commission (NCCC) was established by Congress to make recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. The NCCC developed a guiding framework that incorporated elements of the Socioecological and Chronic Care Models. It surveyed federal agencies and conducted follow-up meetings with representatives from 10 health-related and 11 non-health-related federal agencies. It held 12 public meetings, solicited public comments, met with numerous interested parties and key informants, and performed comprehensive literature reviews. The final report, transmitted to Congress in January 2022, contained 39 specific recommendations, including 3 foundational recommendations that addressed the necessity of an all-of-government approach to diabetes, health equity, and access to health care. At the general population level, the NCCC recommended that the federal government adopt a health-in-all-policies approach so that the activities of non-health-related federal agencies that address agriculture, food, housing, transportation, commerce, and the environment be coordinated with those of health-related federal agencies to affirmatively address the social and environmental conditions that contribute to diabetes and its complications. For individuals at risk for type 2 diabetes, including those with prediabetes, the NCCC recommended that federal policies and programs be strengthened to increase awareness of prediabetes and the availability of, referral to, and insurance coverage for intensive lifestyle interventions for diabetes prevention and that data be assembled to seek approval of metformin for diabetes prevention. For people with diabetes and its complications, the NCCC recommended that barriers to proven effective treatments for diabetes and its complications be removed, the size and competence of the workforce to treat diabetes and its complications be increased, and new payment models be implemented to support access to lifesaving medications and proven effective treatments for diabetes and its complications. The NCCC also outlined an ambitious research agenda. The NCCC strongly encourages the public to support these recommendations and Congress to take swift action.

Individuals with an elevated fasting glucose level, elevated glucose level after glucose challenge, or elevated hemoglobin A1c level below the diagnostic threshold for diabetes (collectively termed prediabetes) are at increased risk for type 2 diabetes. More than one-third of U.S. adults have prediabetes but fewer than one in five are aware of the diagnosis. Rigorous scientific research has demonstrated the efficacy of both intensive lifestyle interventions and metformin in delaying or preventing progression from prediabetes to type 2 diabetes. The National Clinical Care Commission (NCCC) was a federal advisory committee charged with evaluating and making recommendations to improve federal programs related to the prevention of diabetes and its complications. In this article, we describe the recommendations of an NCCC subcommittee that focused primarily on prevention of type 2 diabetes in people with prediabetes. These recommendations aim to improve current federal diabetes prevention activities by 1) increasing awareness of and diagnosis of prediabetes on a population basis; 2) increasing the availability of, referral to, and insurance coverage for the National Diabetes Prevention Program and the Medicare Diabetes Prevention Program; 3) facilitating Food and Drug Administration review and approval of metformin for diabetes prevention; and 4) supporting research to enhance the effectiveness of diabetes prevention. Cognizant of the burden of type 1 diabetes, the recommendations also highlight the importance of research to advance our understanding of the etiology of and opportunities for prevention of type 1 diabetes.

BACKGROUND: CDC recommendation for treatment of uncomplicated gonorrhea (NG) were revised in December 2020 and include ceftriaxone monotherapy when chlamydial infection was excluded. We evaluated the impact of these revised treatment recommendations using data from a network of STD clinics prior to the change in guidelines. METHODS: We performed a cross-sectional analysis from 8 STD clinics participating in the STD Surveillance Network from Jan 2015-June 2018 assessing gonorrhea/chlamydia (CT) testing episodes, NAAT results, CT only and NG/CT treatment records, and timing of treatment. We describe the frequency of NG and CT treatment practices and what proportion of patients treated would not have had to receive an anti-chlamydial agent. RESULTS: Of 190,589 episodes that occurred during the study period, 67,895 (35.6%) episodes were associated with a treatment record consistent with gonorrhea and/or chlamydia (CT only (n = 37,530) or NG/CT (n = 30,365)), most (~86%) were prescribed on the same-day as initial testing. Of the 67,895 episodes with corresponding treatment record(s), 42.1% were positive for either NG or CT compared to 3.7% were positive for NG or CT for those not associated with treatment records (n = 122,694 episodes). Among 30,365 episodes associated with NG/CT treatment records, monotherapy would only have been indicated for 10.1% (3,081/30,365) of the episodes as they were treated on follow-up and were NG positive and CT negative. CONCLUSIONS: Treatment was prescribed in one third of NG/CT testing episodes, with the majority provided same day. Despite changes in NG treatment guidelines to ceftriaxone monotherapy, majority of patients would continue to receive an anti-chlamydia agent when treated for gonorrhea in these settings.

Schumacher Amy C, Elbadawi Lina I, DeSalvo Traci, Straily Anne, Ajzenberg Daniel, Letzer David, Moldenhauer Ellen, Handly Tammy L, Hill Dolores, Dardé Marie-Laure, Pomares Christelle, Passebosc-Faure Karine, Bisgard Kristine, Gomez Carlos A, Press Cindy, Smiley Stephanie, Montoya José G, Kazmierczak James J. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2022

INTRODUCTION: Alcohol-impaired driving (AID) crashes accounted for 10 511 deaths in the USA in 2018, or 29% of all motor vehicle-related crash deaths. This study describes self-reported AID in the USA during 2014, 2016 and 2018 and determines AID-related demographic and behavioural characteristics. METHODS: Data were from the nationally representative Behavioral Risk Factor Surveillance System. Adults were asked 'During the past 30 days, how many times have you driven when you have had perhaps too much to drink?' AID prevalence, episode counts and rates per 1000 population were estimated using annualised individual AID episodes and weighted survey population estimates. Results were stratified by characteristics including gender, binge drinking, seatbelt use and healthcare engagement. RESULTS: Nationally, 1.7% of adults engaged in AID during the preceding 30 days in 2014, 2.1% in 2016 and 1.7% in 2018. Estimated annual number of AID episodes varied across year (2014: 111 million, 2016: 186 million, 2018: 147 million) and represented 3.7 million, 4.9 million and 4.0 million adults, respectively. Corresponding yearly episode rates (95% CIs) were 452 (412-492) in 2014, 741 (676-806) in 2016 and 574 (491-657) in 2018 per 1000 population. Among those reporting AID in 2018, 80% were men, 86% reported binge drinking, 47% did not always use seatbelts and 60% saw physicians for routine check-ups within the past year. CONCLUSIONS: Although AID episodes declined from 2016 to 2018, AID was still prevalent and more common among men and those who binge drink. Most reporting AID received routine healthcare. Proven AID-reducing strategies exist.

Steps per day were measured by accelerometer for 7 days among 5,545 women aged 63-97 years between 2012 and 2014. Incident falls were ascertained from daily fall calendars for 13 months. Median steps per day were 3,216. There were 5,473 falls recorded over 61,564 fall calendar-months. The adjusted incidence rate ratio comparing women in the highest versus lowest step quartiles was 0.71 (95% confidence interval [0.54, 0.95]; ptrend across quartiles = .01). After further adjustment for physical function using the Short Physical Performance Battery, the incidence rate ratio was 0.86 ([0.64, 1.16]; ptrend = .27). Mediation analysis estimated that 63.7% of the association may be mediated by physical function (p = .03). In conclusion, higher steps per day were related to lower incident falls primarily through their beneficial association with physical functioning. Interventions that improve physical function, including those that involve stepping, could reduce falls in older adults.

BACKGROUND: HIV co-infection among persons diagnosed with gonorrhea is not well characterized. Trends in HIV prevalence among persons diagnosed with gonorrhea may have significant implications for HIV prevention interventions, especially for MSM. MSM are increasing and disproportionately represented among incident gonorrhea cases reported in a multi-state sentinel surveillance network. Using data from this network, we estimated HIV prevalence among MSM by self-report and explored trends in co-infection by key demographics. DESIGN: Observational study using enhanced surveillance data. METHODS: Six geographically diverse jurisdictions in the STD Surveillance Network (SSuN) 2010 - 2019 randomly sampled laboratory-confirmed gonorrhea cases. Enhanced investigations on sampled cases included patient interviews eliciting demographic, behavioral and HIV testing history. These data were weighted to adjust for study design and non-response to estimate trends in HIV prevalence. RESULTS: Of 653,522 reported cases, 28,979 were sampled and investigated. The proportion of cases reporting living with diagnosed HIV at the time of their gonorrhea diagnosis increased 61% across the study period from 6.6% in 2010 to 10.8% in 2019. The observed increase in HIV prevalence is concurrent with an increase in the proportion of gonorrhea cases attributable to MSM. HIV prevalence among MSM decreased in two jurisdictions and increasing trends were observed among Non-Hispanic Black and Hispanic MSM. HIV prevalence decreased among non-Hispanic White MSM, MSM under 20 and those 40 years of age or older. CONCLUSIONS: Diagnosis with gonorrhea, especially among MSM, should be a sentinel event triggering screening for HIV, referral to high-impact HIV prevention interventions or to HIV primary care.

Despite evidence of the effectiveness of behavioral change interventions for type 2 diabetes prevention, health care provider referrals to organizations offering the National Diabetes Prevention Program (National DPP) lifestyle change program (LCP) remain suboptimal. This study examined facilitators of LCP referrals among primary care providers and pharmacists (providers). We analyzed data on 1956 providers from 2016 to 2017 DocStyles web-based surveys. Pearson chi-square or Fisher's exact tests were used for bivariate associations between facilitators, provider characteristics, and their self-reported referral and bi-directional referral (where they received patient status updates back from the LCPs) to an LCP. Multiple logistic regressions were used to estimate the effects of facilitators to referral practices, controlling for providers' characteristics. Geocoding was done at the street level for in-person, public LCP class locations and at the zip code level for survey respondents to create a density measure for LCP availability within 10 miles. Overall, 21% of providers referred their patients with prediabetes to LCPs, and 6.4% engaged in bi-directional referral. Provider practices that established clinical-community linkages (CCLs) with LCPs (AOR = 4.88), used electronic health records (EHRs) to manage patients (AOR = 2.94), or practiced within 10 miles of an in-person, public LCP class location (AOR = 1.49) were more likely to refer. Establishing CCLs with LCPs (AOR = 8.59) and using EHRs (AOR = 1.86) were also facilitators of bi-directional referral. This study highlights the importance of establishing CCLs between provider settings and organizations offering the National DPP LCP, increasing use of EHRs to manage patients, and increasing availability of in-person LCP class locations near provider practices.

BACKGROUND: New York City (NYC) was the U.S. epicenter of the Spring 2020 COVID-19 pandemic. We present seroprevalence of SARS-CoV-2 infection and correlates of seropositivity immediately after the first wave. METHODS: From a serosurvey of adult NYC residents (May 13-July 21, 2020), we calculated the prevalence of SARS-CoV-2 antibodies stratified by participant demographics, symptom history, health status, and employment industry. We used multivariable regression models to assess associations between participant characteristics and seropositivity. RESULTS: Seroprevalence among 45,367 participants was 23.6% (95% CI, 23.2%-24.0%). High seroprevalence (>30%) was observed among Black and Hispanic individuals, people from high poverty neighborhoods, and people in health care or essential worker industry sectors. COVID-19 symptom history was associated with seropositivity (adjusted relative risk=2.76; 95% CI, 2.65-2.88). Other risk factors included sex, age, race/ethnicity, residential area, employment sector, working outside the home, contact with a COVID-19 case, obesity, and increasing numbers of household members. CONCLUSIONS: Based on a large serosurvey in a single U.S. jurisdiction, we estimate that just under one-quarter of NYC adults were infected in the first few months of the COVID-19 epidemic. Given disparities in infection risk, effective interventions for at-risk groups are needed during ongoing transmission.

BACKGROUND: Although many viral respiratory illnesses are transmitted within households, the evidence base for SARS-CoV-2 is nascent. We sought to characterize SARS-CoV-2 transmission within US households and estimate the household secondary infection rate (SIR) to inform strategies to reduce transmission. METHODS: We recruited laboratory-confirmed COVID-19 patients and their household contacts in Utah and Wisconsin during March 22-April 25, 2020. We interviewed patients and all household contacts to obtain demographics and medical histories. At the initial household visit, 14 days later, and when a household contact became newly symptomatic, we collected respiratory swabs from patients and household contacts for testing by SARS-CoV-2 rRT-PCR and sera for SARS-CoV-2 antibodies testing by enzyme-linked immunosorbent assay (ELISA). We estimated SIR and odds ratios (OR) to assess risk factors for secondary infection, defined by a positive rRT-PCR or ELISA test. RESULTS: Thirty-two (55%) of 58 households had evidence of secondary infection among household contacts. The SIR was 29% (n = 55/188; 95% confidence interval [CI]: 23-36%) overall, 42% among children (<18 years) of the COVID-19 patient and 33% among spouses/partners. Household contacts to COVID-19 patients with immunocompromised conditions had increased odds of infection (OR: 15.9, 95% CI: 2.4-106.9). Household contacts who themselves had diabetes mellitus had increased odds of infection (OR: 7.1, 95% CI: 1.2-42.5). CONCLUSIONS: We found substantial evidence of secondary infections among household contacts. People with COVID-19, particularly those with immunocompromising conditions or those with household contacts with diabetes, should take care to promptly self-isolate to prevent household transmission.

BACKGROUND: Public health research uses decedents' usual industry and occupation (I&O) from US death certificates to assess mortality incidence and risk factors. Of necessity, such research may exclude decedents with insufficient I&O information, and assume death certificates reflect current (at time of death) I&O. This study explored the demographic implications of such research conditions by describing usual occupation and current employment status among decedents by demographic characteristics in a large multistate data set. METHODS: Death certificate occupations classified by Standard Occupational Classification (SOC) (ie, compensated occupation) and other categories (eg, student) for 36 507 decedents (suicide, homicide, other, undetermined intent) age 22+ years from the 2016 National Violent Death Reporting System's (NVDRS) 32 US states were analyzed. Decedents not employed at the time of death (eg, laid off) were identified through nondeath certificate NVDRS data sources (eg, law enforcement reports). RESULTS: Female decedents, younger (age < 30 years) male decedents, some non-White racial group decedents, less educated decedents, and undetermined intent death decedents were statistically less likely to be classified by SOC based on death certificates-primarily due to insufficient information. Decedents classified by SOC from death certificates but whose non-death certificate data indicated no employment at the time of death were more often 30+ years old, White, less educated, died by suicide, or had nonmanagement occupations. CONCLUSIONS: Whether decedents have classifiable occupations from death certificates may vary by demographic characteristics. Research studies that assess decedents by usual I&O can identify and describe how any such demographic trends may affect research results on particular public health topics.

BACKGROUND: During 2017, in response to a physician's report, the Wisconsin Department of Health Services, Division of Public Health, began investigating an outbreak of febrile illness among attendees of a retreat where never frozen, intentionally undercooked, locally harvested venison was served. Preliminary testing tentatively identified the illness as toxoplasmosis. METHODS: Confirmatory human serology panels and testing of the venison to confirm and categorize the presence and type of Toxoplasma gondii were completed by French and American national reference laboratories. All 12 retreat attendees were interviewed; medical records were reviewed. RESULTS: All attendees were male; median age was 51 years (range: 22-75). After a median incubation period of 7 days, 9 (82%) of 11 exposed persons experienced illness lasting a median of 12 days. All 9 sought outpatient healthcare for symptoms including fever, chills, sweats, and headache (100%) and ocular disturbances (33%). Testing confirmed the illness as toxoplasmosis and venison as the infection source. Multiple laboratory results were atypical for toxoplasmosis, including transaminitis (86%), lymphocytopenia (88%), thrombocytopenia (38%), and leukopenia (63%). One exposed but asymptomatic person was seronegative; the other had immunity from prior infection. The T. gondii strain was identified as closely related to an atypical genotype (haplogroup 12, polymerase chain reaction restriction fragment length polymorphism genotype 5) common in North American wildlife but with previously uncharacterized human clinical manifestations. CONCLUSIONS: The T. gondii strain contaminating the venison might explain the unusual clinical presentations. In North America, clinicians and venison consumers should be aware of risk for severe or unusual presentations of acute toxoplasmosis after consuming undercooked game meat.

BACKGROUND: Extragenital gonorrhea (GC) and chlamydia (CT) are usually asymptomatic and only detected through screening. Ceftriaxone plus azithromycin is the recommended GC treatment; monotherapy (azithromycin or doxycycline) is recommended for CT. In urethral CT-positive/urethral GC-negative persons who are not screened extragenitally, CT monotherapy can lead to GC undertreatment and may foster the development of gonococcal antimicrobial resistance. We assessed urethral and extragenital GC and CT positivity among men who have sex with men (MSM) attending sexually transmitted disease (STD) clinics. METHODS: We included visit data for MSM tested for GC and CT at 30 STD clinics in 10 jurisdictions during 1/1/2015-6/30/2019. Using an inverse-variance random effects model to account for heterogeneity between jurisdictions, we calculated weighted test visit positivity estimates and 95% confidence intervals (CI) for GC and CT at urethral and extragenital sites, and extragenital GC among urethral CT-positive/GC-negative test visits. RESULTS: Of 139,718 GC and CT test visits, we calculated overall positivity (GC=16.7% [95% CI=14.4-19.1]; CT=13.3% [95% CI=12.7-13.9]); urethral positivity (GC=7.5% [95% CI=5.7-9.3]; CT=5.2% [95% CI=4.6-5.8]); rectal positivity (GC=11.8% [95% CI=10.4-13.2]; CT=12.6% [95% CI=11.8-13.4]); and pharyngeal positivity (GC=9.1% [95% CI=7.9-10.3]; CT=1.8% [95% CI=1.6-2.0]). Of 4,566 urethral CT-positive/GC-negative test visits with extragenital testing, extragenital GC positivity was 12.5% (95% CI=10.9-14.1). CONCLUSION: Extragenital GC and CT were common among MSM. Without extragenital screening of MSM with urethral CT, extragenital GC would have been undetected and undertreated in ~13% of these men. Undertreatment could potentially select for antimicrobial resistance. These findings underscore the importance of extragenital screening in MSM.

BACKGROUND: Extragenital gonorrhea (GC) and chlamydia (CT) are usually asymptomatic and only detected through screening. Ceftriaxone plus azithromycin is the recommended GC treatment; monotherapy (azithromycin or doxycycline) is recommended for CT. In urethral CT-positive/urethral GC-negative persons who are not screened extragenitally, CT monotherapy can lead to GC undertreatment and may foster the development of gonococcal antimicrobial resistance. We assessed urethral and extragenital GC and CT positivity among men who have sex with men (MSM) attending sexually transmitted disease (STD) clinics. METHODS: We included visit data for MSM tested for GC and CT at 30 STD clinics in 10 jurisdictions during 1/1/2015-6/30/2019. Using an inverse-variance random effects model to account for heterogeneity between jurisdictions, we calculated weighted test visit positivity estimates and 95% confidence intervals (CI) for GC and CT at urethral and extragenital sites, and extragenital GC among urethral CT-positive/GC-negative test visits. RESULTS: Of 139,718 GC and CT test visits, we calculated overall positivity (GC=16.7% [95% CI=14.4-19.1]; CT=13.3% [95% CI=12.7-13.9]); urethral positivity (GC=7.5% [95% CI=5.7-9.3]; CT=5.2% [95% CI=4.6-5.8]); rectal positivity (GC=11.8% [95% CI=10.4-13.2]; CT=12.6% [95% CI=11.8-13.4]); and pharyngeal positivity (GC=9.1% [95% CI=7.9-10.3]; CT=1.8% [95% CI=1.6-2.0]). Of 4,566 urethral CT-positive/GC-negative test visits with extragenital testing, extragenital GC positivity was 12.5% (95% CI=10.9-14.1). CONCLUSION: Extragenital GC and CT were common among MSM. Without extragenital screening of MSM with urethral CT, extragenital GC would have been undetected and undertreated in ~13% of these men. Undertreatment could potentially select for antimicrobial resistance. These findings underscore the importance of extragenital screening in MSM.

In January 2018, the Wisconsin Department of Health Services, Division of Public Health (DPH), received a report of a culture-confirmed case of Legionnaires' disease. The patient, who was immunocompromised, had died at a local hospital 10 days after being admitted. DPH and an infection preventionist from the hospital investigated to determine the source of the infection and prevent additional cases. Because the case was suspected to be nosocomial, health care facility water samples were tested for Legionella. When these samples were negative, water sources in the patient's home were tested. These tested positive for Legionella pneumophila, and the bacteria remained after an attempt to remediate. The patient and home isolates were identified as L. pneumophila serogroup 3, sequence type 93, by whole-genome multilocus sequence typing. A second resident of the home did not become ill. This case highlights the potential for immunocompromised persons and others at risk for Legionnaires' disease to be exposed to Legionella through home water systems containing the bacteria and demonstrates the difficulty of home remediation. This case also illustrates the role of lower respiratory tract specimens in the identification of less common Legionella infections (e.g., L. pneumophila serogroup 3) and confirmation of the infection source.

Policy Points Although preventable chronic conditions such as type 2 diabetes carry a significant cost and health burden, few lifestyle interventions have been scaled at a national policy level. The translation of the National Diabetes Prevention Program lifestyle intervention from research to a Medicare-covered service can serve as a model for national adoption of other interventions that have the potential to improve population health. The successful translation of the National Diabetes Prevention Program has depended on the collaboration of government agencies, academic researchers, community-based healthcare providers, payers, and other parties. CONTEXT: Many evidence-based health interventions never achieve national implementation. This article analyzes factors that supported the translation and national implementation of a lifestyle change intervention to prevent or delay type 2 diabetes in individuals with prediabetes. METHODS: We used the Knowledge to Action framework, which was developed to map how science is translated into effective health programs, to examine how the evidence-based intervention from the 2002 Diabetes Prevention Program trial was translated into the Centers for Disease Control and Prevention's large-scale National Diabetes Prevention Program, eventually resulting in payment for the lifestyle intervention as a Medicare-covered service. FINDINGS: Key findings of our analysis include the importance of a collaboration among researchers, policymakers, and payers to encourage early adopters; development of evidence-based, national standards to support widespread adoption of the intervention; and use of public input from community organizations to scale the intervention to a national level. CONCLUSIONS: This analysis offers timely lessons for other high-value, scalable interventions attempting to move beyond the evidence-gathering phase and into translation and institutionalization.