BACKGROUND: Indoor residual spraying (IRS) is a malaria control strategy implemented before the rainy season. Nchelenge District, Zambia is a holoendemic setting where IRS has been conducted since 2008 with little impact on malaria incidence or parasite prevalence. Pre-rainy season IRS may not reduce the post-rainy season peak abundance of the major vector, Anopheles funestus. METHODS: A controlled, pre-post, prospective cohort study assessed the impact of late-rainy season IRS on malaria prevalence, incidence, hazard, and vector abundance. Three hundred eighty-two individuals were enrolled across four household clusters, of which two were sprayed in April 2022 toward the end of the rainy season. Monthly household and individual surveys and indoor overnight vector collections were conducted through August 2022. Multivariate regression and time-to-event analyses estimated the impact of IRS on outcomes measured by rapid diagnostic tests, microscopy, and quantitative polymerase chain reaction. RESULTS: Seventy two percent of participants tested positive by rapid diagnostic test at least once and incidence by microscopy was 3.4 infections per person-year. Residing in a household in a sprayed area was associated with a 52% reduction in infection hazard (hazards ratio: 0.48, 95% confidence interval [0.29, 0.78]) but not with changes in incidence, prevalence, or vector abundance. The study-wide entomological inoculation rate was 34 infectious bites per person per year. CONCLUSION: Monthly tracking of incidence and prevalence did not demonstrate meaningful changes in holoendemic transmission intensity. However, hazard of infection, which provides greater power for detecting changes in transmission, demonstrated that late rainy season IRS reduced malaria risk.

Objective: The National Association of Chronic Disease Directors (NACDD) is a nonprofit organization that supports state and territorial chronic disease prevention and health promotion efforts through capacity building and technical assistance. Each year, NACDD surveys health department leaders who oversee chronic disease prevention and health promotion (hereafter, Chronic Disease Directors). We have previously used the annual survey results to inform strategic planning and resource allocation but have not historically published key findings in the peer-reviewed literature. In this paper, we report on NACDD’s 2023 survey outcomes and place those findings into the broader public health policy context. Design: State Chronic Disease Directors completed a survey about their organizational capacity and development needs. Responses were summarized in aggregate and by jurisdiction size. Results: State chronic disease units have varied staffing and responsibilities, but most address diabetes, cardiovascular diseases, and cancer screening and prevention. Chronic Disease Directors generally reported strong or improving capacity in most practice areas but ranked workforce development lower. Staffing increased slightly during 2023 compared with the 2020 baseline (median of 1.3 and 1.1 employees per 100 000 jurisdiction population, respectively). However, Chronic Disease Directors expressed ongoing concerns about turnover, hiring, and training of inexperienced staff, as well as about funding limitations and uncertainty. Looking forward to 2024, many Chronic Disease Directors expressed intentions to focus on supporting their workforce with training and development opportunities and addressing health equity. Conclusions: During this period of pandemic recovery, turnover, hiring, and training—particularly of the many new public health staff—remain key areas of concern for many chronic disease units. Continued stabilization of public health funding and increased prioritization of organizational capacity development—particularly workforce development, chronic disease data systems, and tools for addressing health equity—could help ensure chronic disease units can better address current and emerging challenges in chronic disease prevention and health promotion. © 2024 Lippincott Williams and Wilkins. All rights reserved.

BACKGROUND: Unintentional injuries disproportionately impact American Indian and Alaska Native (AI/AN) populations. Developing effective and culturally tailored data collection and intervention programs requires an understanding of past prevention efforts in AI/AN communities, but limited peer-reviewed literature on the topic is available. This scoping review aims to summarize efforts that have been published in the Primary Care Provider newsletter, a source of gray literature available through the Indian Health Service. METHODS: The research team obtained all injury related articles in the Provider newsletter and excluded those that did not describe an unintentional injury prevention effort. Included articles were organized chronologically and by topic, and outcomes were described in a data abstraction form. RESULTS: A total of 247 articles from the Provider newsletter were screened, and 68 were included in this review. The most number of articles were published in 2007 (n = 15). Many focused not specifically on one tribal community but on the AI/AN community as a whole (n = 27), while others reported that certain tribes were the focus of study but did not identify tribes by name (n = 24). The following is a list of 14 tribal communities explicitly mentioned: Omaha, Cherokee, Ute, Yakama, Chippewa, Apache, Ho-Chunk, The Crow Tribe, Tohono O'odham Nation, Fort Mojave Tribe, Chemehuevi Tribe, The Rosebud Tribe, Navajo, and The Pueblo of Jemez. Published unintentional injury prevention efforts have covered the following 7 topics in AI/AN communities: falls, motor vehicle crashes, poisonings, improving data, burns, children, and other. CONCLUSION: This scoping review makes available and searchable information on injury prevention work conducted in and for AI/AN communities that is not currently found in the peer-reviewed literature.

Uncertainty about the importance of influenza transmission by airborne droplet nuclei generates controversy for infection control. Human challenge-transmission studies have been supported as the most promising approach to fill this knowledge gap. Healthy, seronegative volunteer ‘Donors’ (n=52) were randomly selected for intranasal challenge with influenza A/Wisconsin/67/2005 (H3N2). ‘Recipients’ randomized to Intervention (IR, n=40) or Control (CR, n=35) groups were exposed to Donors for four days. IRs wore face shields and hand sanitized frequently to limit large droplet and contact transmission. One transmitted infection was confirmed by serology in a CR, yielding a secondary attack rate of 2.9% among CR, 0% in IR (p=0.47 for group difference), and 1.3% overall, significantly less than 16% (p<0.001) expected based on a proof-of-concept study secondary attack rate and considering that there were twice as many Donors and days of exposure. The main difference between these studies was mechanical building ventilation in the follow-on study, suggesting a possible role for aerosols.Author summary Understanding the relative importance of influenza modes of transmission informs strategic use of preventive measures to reduce influenza risk in high-risk settings such as hospitals and is important for pandemic preparedness. Given the increasing evidence from epidemiological modelling, exhaled viral aerosol, and aerobiological survival studies supporting a role for airborne transmission and the potential benefit of respirators (and other precautions designed to prevent inhalation of aerosols) versus surgical masks (mainly effective for reducing exposure to large droplets) to protect healthcare workers, more studies are needed to evaluate the extent of risk posed airborne versus contact and large droplet spray transmission modes. New human challenge-transmission studies should be carefully designed to overcome limitations encountered in the current study. The low secondary attack rate reported herein also suggests that the current challenge-transmission model may no longer be a more promising approach to resolving questions about transmission modes than community-based studies employing environmental monitoring and newer, state-of-the-art deep sequencing-based molecular epidemiological methods.Competing Interest StatementJSN-V-T and BK declare previous consultancy fees from H-Vivo plc, unrelated to the current work. JSN-V-T is currently seconded to the Department of Health and Social Care (DHSC), England; the views expressed in this paper are not necessarily those of DHSC. RLW, AG and AM are employees of H-Vivo plc each of whom hold shares and /or share options in the company.Clinical TrialNCT01710111Funding StatementThis work was supported by U.S. CDC, Cooperative Agreement: Grant Number 1U01P000497-01. The views expressed in this paper are those of the authors and do not necessarily represent the official position of the funding agency.Author DeclarationsAll relevant ethical guidelines have been followed; any necessary IRB and/or ethics committee approvals have been obtained and details of the IRB/oversight body are included in the manuscript.YesAll necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesData required for reproduction of analyses is available upon request. Scripts and other documentati n to reproduce analyses are available at Digital Repositories at the University of Maryland (13) and https://gitlab.com/jacobbueno/emit_quarantine_main. http://drum.lib.umd.edu/handle/1903/25315

Face masks are recommended to reduce community transmission of SARS-CoV-2. One of the primary benefits of face masks and other coverings is as source control devices to reduce the expulsion of respiratory aerosols during coughing, breathing, and speaking. Face shields and neck gaiters have been proposed as an alternative to face masks, but information about face shields and neck gaiters as source control devices is limited. We used a cough aerosol simulator with a pliable skin headform to propel small aerosol particles (0 to 7 µm) into different face coverings. An N95 respirator blocked 99% of the cough aerosol, a medical grade procedure mask blocked 59%, a 3-ply cotton cloth face mask blocked 51%, and a polyester neck gaiter blocked 47% as a single layer and 60% when folded into a double layer. In contrast, the face shield blocked 2% of the cough aerosol. Our results suggest that face masks and neck gaiters are preferable to face shields as source control devices for cough aerosols.Competing Interest StatementThe authors have declared no competing interest.Funding StatementThis research was funded by the National Institute for Occupational Safety and Health (NIOSH), US Centers for Disease Control and Prevention (CDC).Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:No IRB approval requiredAll necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesExperimental data is available upon request.

Since the initial identification of vaccine-derived rubella virus (RuV) in the cutaneous granulomas of pediatric patients with inborn errors of immunity (IEI) in 2014, more than 80 cases of RuV granulomas have been reported implicating both vaccine-derived and wild type RuV. Previously thought to arise exclusively in patients with significant immunocompromise, the identification of RuV granulomas in clinically immunocompetent patients adds nuance to our understanding of the interplay between host environment, immune dysregulation, and RuV granuloma formation. This review summarizes the literature on RuV granulomas including clinical and histopathologic features, proposed pathomechanisms supporting granuloma development, and potential therapeutic options. There is no standardized algorithm to guide the workup and diagnosis of suspected RuV granulomas. We highlight the importance of contributing RuV granuloma cases to ongoing CDC surveillance efforts to monitor wild type and vaccine-derived RuV transmission. Studies advancing our understanding of RuV granulomas may provide insights into the role of viral infectious agents in granulomatous disease pathogenesis and guide the development of improved therapeutic options.

BACKGROUND: Data on medium-term outcomes in indivduals with myocarditis after mRNA COVID-19 vaccination are scarce. We aimed to assess clinical outcomes and quality of life at least 90 days since onset of myocarditis after mRNA COVID-19 vaccination in adolescents and young adults. METHODS: In this follow-up surveillance study, we conducted surveys in US individuals aged 12-29 years with myocarditis after mRNA COVID-19 vaccination, for whom a report had been filed to the Vaccine Adverse Event Reporting System between Jan 12 and Nov 5, 2021. A two-component survey was administered, one component to patients (or parents or guardians) and one component to health-care providers, to assess patient outcomes at least 90 days since myocarditis onset. Data collected were recovery status, cardiac testing, and functional status, and EuroQol health-related quality-of-life measures (dichotomised as no problems or any problems), and a weighted quality-of-life measure, ranging from 0 to 1 (full health). The EuroQol results were compared with published results in US populations (aged 18-24 years) from before and early on in the COVID-19 pandemic. FINDINGS: Between Aug 24, 2021, and Jan 12, 2022, we collected data for 519 (62%) of 836 eligible patients who were at least 90 days post-myocarditis onset: 126 patients via patient survey only, 162 patients via health-care provider survey only, and 231 patients via both surveys. Median patient age was 17 years (IQR 15-22); 457 (88%) patients were male and 61 (12%) were female. 320 (81%) of 393 patients with a health-care provider assessment were considered recovered from myocarditis by their health-care provider, although at the last health-care provider follow-up, 104 (26%) of 393 patients were prescribed daily medication related to myocarditis. Of 249 individuals who completed the quality-of-life portion of the patient survey, four (2%) reported problems with self-care, 13 (5%) with mobility, 49 (20%) with performing usual activities, 74 (30%) with pain, and 114 (46%) with depression. Mean weighted quality-of-life measure (0·91 [SD 0·13]) was similar to a pre-pandemic US population value (0·92 [0·13]) and significantly higher than an early pandemic US population value (0·75 [0·28]; p<0·0001). Most patients had improvements in cardiac diagnostic marker and testing data at follow-up, including normal or back-to-baseline troponin concentrations (181 [91%] of 200 patients with available data), echocardiograms (262 [94%] of 279 patients), electrocardiograms (240 [77%] of 311 patients), exercise stress testing (94 [90%] of 104 patients), and ambulatory rhythm monitoring (86 [90%] of 96 patients). An abnormality was noted among 81 (54%) of 151 patients with follow-up cardiac MRI; however, evidence of myocarditis suggested by the presence of both late gadolinium enhancement and oedema on cardiac MRI was uncommon (20 [13%] of 151 patients). At follow-up, most patients were cleared for all physical activity (268 [68%] of 393 patients). INTERPRETATION: After at least 90 days since onset of myocarditis after mRNA COVID-19 vaccination, most individuals in our cohort were considered recovered by health-care providers, and quality of life measures were comparable to those in pre-pandemic and early pandemic populations of a similar age. These findings might not be generalisable given the small sample size and further follow-up is needed for the subset of patients with atypical test results or not considered recovered. FUNDING: US Centers for Disease Control and Prevention.

OBJECTIVE: Globally, COVID-19 has affected how children learn. We evaluated the impact of Test to Stay (TTS) on secondary and tertiary transmission of SARS-CoV-2 and potential impact on in-person learning in four school districts in the United States from September 13-November 19, 2021. METHODS: Implementation of TTS varied across school districts. Data on index cases, school-based close contacts, TTS participation, and testing results were obtained from four school districts in diverse geographic regions. Descriptive statistics, secondary and tertiary attack risk, and a theoretical estimate of impact on in-person learning were calculated. RESULTS: Fifty-one schools in four school districts reported 374 COVID-19 index cases and 2,520 school-based close contacts eligible for TTS. The proportion participating in TTS ranged from 22%-79%. By district, the secondary attack risk (SAR) and tertiary attack risk (TAR) among TTS participants ranged between 2.2%-11.1% and 0%-17.6%, respectively. Nine clusters were identified among secondary cases and two among tertiary cases. The theoretical maximum number of days of in-person learning saved by using TTS was 976-4,650 days across jurisdictions. CONCLUSIONS: TTS preserves in-person learning days. Decisions to participate in TTS may have been influenced by ease of access to testing, communication between schools and families, testing logistics, and school resources. TAR determination became more complicated when numbers of close contacts increased. Minimizing exposure through continued implementation of layered prevention strategies is imperative. To ensure adequate resources for implementation of TTS, community transmission levels should be considered.

IMPORTANCE: Vaccine-derived and wild-type rubella virus (RuV) has been identified within granulomas in patients with inborn errors of immunity, but has not been described in granulomas of healthy adults. OBJECTIVE: To determine the association between RuV and atypical granulomatous inflammation in immune-competent adults. DESIGN, SETTING, AND PARTICIPANTS: This case series, conducted in US academic dermatology clinics from January 2019 to January 2021, investigated the presence of RuV in skin specimens using RuV immunofluorescent staining of paraffin-embedded tissue sections, real-time reverse-transcription polymerase chain reaction, whole-genome sequencing with phylogenetic analyses, and cell culture by the US Centers for Disease Control and Prevention. Rubella immunoglobulin G, immunoglobulin M enzyme-linked immunoassay, and viral neutralization assays were performed for the sera of immunocompetent individuals with treatment refractory cutaneous granulomas and histopathology demonstrating atypical palisaded and necrotizing granulomas. Clinical immune evaluation was performed. MAIN OUTCOMES AND MEASURES: Identification, genotyping, and culture of vaccine-derived and wild-type RuV within granulomatous dermatitis of otherwise clinically immune competent adults. RESULTS: Of the 4 total immunocompetent participants, 3 (75%) were women, and the mean (range) age was 61.5 (49.0-73.0) years. The RuV capsid protein was detected by immunohistochemistry in cutaneous granulomas. The presence of RuV RNA was confirmed by real-time reverse-transcription polymerase chain reaction in fresh-frozen skin biopsies and whole-genome sequencing. Phylogenetic analysis of the RuV sequences showed vaccine-derived RuV in 3 cases and wild-type RuV in 1. Live RuV was recovered from the affected skin in 2 participants. Immunology workup results demonstrated no primary immune deficiencies. CONCLUSIONS AND RELEVANCE: The case series study results suggest that RuV (vaccine derived and wild type) can persist for years in cutaneous granulomas in clinically immunocompetent adults and is associated with atypical (palisaded and necrotizing type) chronic cutaneous granulomas. These findings represent a potential paradigm shift in the evaluation, workup, and management of atypical granulomatous dermatitis and raises questions regarding the potential transmissibility of persistent live RuV.

An international system should be established to support personal protective equipment (PPE) inventory monitoring, particularly within the healthcare industry. In this article, the authors discuss the development and 15-week deployment of a proof-of-concept prototype that included the use of a Healthcare Trust Data Platform to secure and transmit PPE-related data. Seventy-eight hospitals participated, including 66 large hospital systems, 11 medium-sized hospital systems, and a single hospital. Hospitals reported near-daily inventory information for N95 respirators, surgical masks, and face shields, ultimately providing 159 different PPE model numbers. Researchers cross-checked the data to ensure the PPE could be accurately identified. In cases where the model number was inaccurately reported, researchers corrected the numbers whenever possible. Of the PPE model numbers reported, 74.2% were verified-60.5% of N95 respirators, 40.0% of face shields, and 84.0% of surgical masks. The authors discuss the need to standardize how PPE is reported, possible aspects of a PPE data standard, and standards groups who may assist with this effort. Having such PPE data standards would enable better communication across hospital systems and assist in emergency preparedness efforts during pandemics or natural disasters.

IMPORTANCE: Immunodeficiency-related, vaccine-derived rubella virus (RuV) as an antigenic trigger of cutaneous and visceral granulomas is a rare, recently described phenomenon in children and young adults treated with immunosuppressant agents. OBJECTIVE: To perform a comprehensive clinical, histologic, immunologic, molecular, and genomic evaluation to elucidate the potential cause of an adult patient's atypical cutaneous granulomas. DESIGN, SETTING, AND PARTICIPANTS: A prospective evaluation of skin biopsies, nasopharyngeal swabs, and serum samples submitted to the Centers for Disease Control and Prevention was conducted to assess for RuV using real-time reverse-transcriptase polymerase chain reaction (RT-PCR) and viral genomic sequencing. The samples were obtained from a man in his 70s with extensive cutaneous granulomas mimicking both cutaneous sarcoidosis (clinically) and CD8+ granulomatous cutaneous T-cell lymphoma (histopathologically). The study was conducted from September 2019 to February 2021. MAIN OUTCOMES AND MEASURES: Identification and genotyping of a novel immunodeficiency-related RuV-associated granulomatous dermatitis. RESULTS: Immunohistochemistry for RuV capsid protein and RT-PCR testing for RuV RNA revealed RuV in 4 discrete skin biopsies from different body sites. In addition, RuV RNA was detected in the patient's nasopharyngeal swabs by RT-PCR. The full viral genome was sequenced from the patient's skin biopsy (RVs/Philadelphia.PA.USA/46.19/GR, GenBank Accession #MT249313). The patient was ultimately diagnosed with a novel RuV-associated granulomatous dermatitis. CONCLUSIONS AND RELEVANCE: The findings of this study suggest that clinicians and pathologists may consider RuV-associated granulomatous dermatitis during evaluation of a patient because it might have implications for the diagnosis of cutaneous sarcoidosis, with RuV serving as a potential antigenic trigger, and for the diagnosis of granulomatous cutaneous T-cell lymphoma, with histopathologic features that may prompt an evaluation for immunodeficiency and/or RuV.

There were 37 longwall faces operating in mines in the United States in 2019. The average panel width for these longwalls was approximately 368.5 m (1209 ft). This translates to a range of approximately 170–240 shields per longwall, depending upon the width of shield. The movement of longwall shields is a significant contributor to respirable dust overexposures to longwall operators. Foam is expected to have the potential to reduce this shield dust generation. The foam is applied to the area on the roof between the coal face and the shield tip after the shearer passes. In this study, the longwall shield dust simulator was used to test three foam agents for their ability to control dust from longwall shield movements. Results showed that at low-velocity ventilation (≈ 3.0 m/s (600 fpm)) all foam agents were able to produce dust reduction levels of at least 45%. At high-velocity ventilation (≈ 5.1 m/s (1000 fpm)), the reductions were lower and more variable, ranging from being undeterminable for one foam agent to having 46%–63% reductions for the other two foam agents, with one instance of an increase in dust concentration. Overall, the use of foam agents can provide longwall shield dust control. Important factors are roof coverage and the ability of foam to remain on the roof for extended time periods.

Face masks are recommended to reduce community transmission of SARS-CoV-2. One of the primary benefits of face masks and other coverings is as source control devices to reduce the expulsion of respiratory aerosols during coughing, breathing, and speaking. Face shields and neck gaiters have been proposed as an alternative to face masks, but information about face shields and neck gaiters as source control devices is limited. We used a cough aerosol simulator with a pliable skin headform to propel small aerosol particles (0 to 7 &#236;m) into different face coverings. An N95 respirator blocked 99% (standard deviation (SD) 0.3%) of the cough aerosol, a medical grade procedure mask blocked 59% (SD 6.9%), a 3-ply cotton cloth face mask blocked 51% (SD 7.7%), and a polyester neck gaiter blocked 47% (SD 7.5%) as a single layer and 60% (SD 7.2%) when folded into a double layer. In contrast, the face shield blocked 2% (SD 15.3%) of the cough aerosol. Our results suggest that face masks and neck gaiters are preferable to face shields as source control devices for cough aerosols.

Uncertainty about the importance of influenza transmission by airborne droplet nuclei generates controversy for infection control. Human challenge-transmission studies have been supported as the most promising approach to fill this knowledge gap. Healthy, seronegative volunteer 'Donors' (n = 52) were randomly selected for intranasal challenge with influenza A/Wisconsin/67/2005 (H3N2). 'Recipients' randomized to Intervention (IR, n = 40) or Control (CR, n = 35) groups were exposed to Donors for four days. IRs wore face shields and hand sanitized frequently to limit large droplet and contact transmission. One transmitted infection was confirmed by serology in a CR, yielding a secondary attack rate of 2.9% among CR, 0% in IR (p = 0.47 for group difference), and 1.3% overall, significantly less than 16% (p<0.001) expected based on a proof-of-concept study secondary attack rate and considering that there were twice as many Donors and days of exposure. The main difference between these studies was mechanical building ventilation in the follow-on study, suggesting a possible role for aerosols.

BACKGROUND: Almost one-quarter of all new HIV diagnoses in the United States occur among persons aged 13-24 years. These youths have the poorest HIV care continuum (HCC) outcomes, yet few empirical youth-specific data are available. METHODS: The Strategic Multisite Initiative for the Identification, Linkage, and Engagement in Care of HIV-infected youth (SMILE) helped HIV-infected (mostly newly diagnosed) youth, aged 12-24 years, link to youth-friendly care, and evaluated each milestone of the HCC (October 2012-September 2014). Numbers of HIV-infected youth referred, linked, engaged, and retained in care were recorded, along with sociodemographics. Viral suppression (VS) was defined as >/=1 HIV viral load (VL) below the level of detection on study. Correlates of VS were examined using Cox proportional hazards models. RESULTS: Among 1411 HIV-infected youth, 1053 (75%) were linked, 839 (59%) engaged, and 473 (34%) retained in care at adolescent health care sites. Antiretroviral therapy was initiated among 474 (34%), and 166 (12%) achieved VS. Predictors of VS included lower VL at baseline [aHR 1.56 (95% CI: 1.32-1.89), P < 0.0001], recent antiretroviral therapy receipt [aHR 3.10 (95% CI: 1.86-5.18), P < 0.0001], and shorter time from HIV testing until referral to linkage coordinator [aHR 2.52 (95% CI: 1.50-4.23), P = 0.0005 for 7 days to 6 weeks and aHR 2.08 (95% CI: 1.08-4.04), P = 0.0294 for 6 weeks to 3 months compared with >3 months]. CONCLUSIONS: Although this large national sample of predominately newly diagnosed youths linked to care at similar rates as adults, they achieved disproportionately lower rates of VS. Prompt referral to youth-friendly linkage services was an independent predictor of VS. Youth-focused interventions are urgently needed to improve their HCC outcomes.

BACKGROUND: The causative agents for the current national outbreak of electronic-cigarette, or vaping, product use-associated lung injury (EVALI) have not been established. Detection of toxicants in bronchoalveolar-lavage (BAL) fluid from patients with EVALI can provide direct information on exposure within the lung. METHODS: BAL fluids were collected from 51 patients with EVALI in 16 states and from 99 healthy participants who were part of an ongoing study of smoking involving nonsmokers, exclusive users of e-cigarettes or vaping products, and exclusive cigarette smokers that was initiated in 2015. Using the BAL fluid, we performed isotope dilution mass spectrometry to measure several priority toxicants: vitamin E acetate, plant oils, medium-chain triglyceride oil, coconut oil, petroleum distillates, and diluent terpenes. RESULTS: State and local health departments assigned EVALI case status as confirmed for 25 patients and as probable for 26 patients. Vitamin E acetate was identified in BAL fluid obtained from 48 of 51 case patients (94%) in 16 states but not in such fluid obtained from the healthy comparator group. No other priority toxicants were found in BAL fluid from the case patients or the comparator group, except for coconut oil and limonene, which were found in 1 patient each. Among the case patients for whom laboratory or epidemiologic data were available, 47 of 50 (94%) had detectable tetrahydrocannabinol (THC) or its metabolites in BAL fluid or had reported vaping THC products in the 90 days before the onset of illness. Nicotine or its metabolites were detected in 30 of 47 of the case patients (64%). CONCLUSIONS: Vitamin E acetate was associated with EVALI in a convenience sample of 51 patients in 16 states across the United States. (Funded by the National Cancer Institute and others.).

Obesity and type 2 diabetes disproportionately impact U.S. racial and ethnic minority communities and low-income populations. Improvements in implementing efficacious interventions to reduce the incidence of type 2 diabetes are underway (i.e., the National Diabetes Prevention Program), but challenges in effectively scaling-up successful interventions and reaching at-risk populations remain. In October 2017, the National Institutes of Health convened a workshop to understand how to (1) address socioeconomic and other environmental conditions that perpetuate disparities in the burden of obesity and type 2 diabetes; (2) design effective prevention and treatment strategies that are accessible, feasible, culturally relevant, and acceptable to diverse population groups; and (3) achieve sustainable health improvement approaches in communities with the greatest burden of these diseases. Common features of guiding frameworks to understand and address disparities and promote health equity were described. Promising research directions were identified in numerous areas, including study design, methodology, and core metrics; program implementation and scalability; the integration of medical care and social services; strategies to enhance patient empowerment; and understanding and addressing the impact of psychosocial stress on disease onset and progression in addition to factors that support resiliency and health.

A laboratory apparatus (shield dust simulator) was designed and constructed to simulate the dust generated during the advance of longwall hydraulic roof supports, or shields. The objective of the study was to develop a tool that could be used to test the hypothesis that foam applied to a mine roof prior to a shield advance could be used to reduce the respirable dust generated during shield advances. This paper will outline the design parameters for the development of the system, as well as describe baseline testing of coal and limestone dust. Results show that the average instantaneous respirable dust concentrated during simulated shield advance. Confidence intervals were calculated from the instantaneous respirable dust data to determine the repeatability of the data produced by the device.

A ventilation research study was conducted by the National Institute for Occupational Safety and Health and a cooperating trona mine in the Green River basin of Wyoming, USA. The mine operation uses the longwall mining method in trona bed 17, a commonly mined unit in the region. The longwall face length is 228 m (750 ft), and caving on the face occurred up to the back of the longwall shields. The mine is ventilated using a main blowing fan and a bleeder shaft. For this study, sulfur hexafluoride (SF6) tracer gas was released in two separate monitoring experiments. For the first experiment, tracer gas was released on the face, this test focused on airflow along the longwall face of the active panel. Face test showed the airflow patterns to be more complex than just head-to-tail flow in the main ventilation air stream on the active panel. For the second experiment, tracer gas was released 2 crosscuts inby the face on the headgate side, this test focused on gas transport in the mined-out portion of the same active panel. Gob test showed a pathway of movement through the front of the active panel gob that moved outby from the tailgate corner. The primary pathway of tracer gas movement in the active panel gob was towards the headgate and tailgate bleeders and out of a bleeder shaft. The rate of movement towards the back of the gob was measured to be 0.19 m/s (37 fpm).

Veterinarians play a crucial role in zoonotic disease detection in animals and prevention of disease transmission; reporting these zoonoses to public health officials is an important first step to protect human and animal health. Evidence suggests veterinarians and their staff are at higher risk for exposure to zoonoses because of possible interactions with infected animals. We examined the knowledge, attitudes, and practices of veterinarians regarding zoonotic disease reporting to public health agencies and associated infection prevention (IP) practices such as personal protective equipment (PPE) use, and the need for targeted education and outreach for veterinarians in Arizona. An online questionnaire was developed and distributed by email in September 2015 and was available through November 2015 to all 1,100 members of the Arizona Veterinary Medical Association. Chi-square and logistic regression analyses were performed. In total, 298 (27%) veterinarians from all 15 Arizona counties completed the survey; the majority (70%) were female, practiced small animal medicine (84%), and reported practicing veterinary medicine for >=10 years (75%). Only 57% reported they knew when to report a suspected zoonotic disease and 60% reported they knew how to make that type of report. The majority said they would report rabies (97%), plague (96%), and highly pathogenic avian influenza (91%) to a state agency. Most respondents reported using PPE (e.g., masks, face shields, and gloves) when performing a surgical procedure (96%) or necropsy (94%), although fewer reported using PPE for handling clinically ill animals (37%) or healthy animals (17%). Approximately 70% reported always using PPE when in contact with animal birthing fluids, urine, or feces, and 47% for contact with animal blood, saliva, or other body fluids. Veterinarians who agreed that they knew the appropriate actions to protect themselves from zoonotic disease exposures were more likely to report always washing their hands before eating or drinking at work (OR = 3.81, 95% confidence interval (CI) [1.97-7.35], P < 0.01). Responses for when to make a report and how to report were not significantly different by gender, years of practice, or holding additional degrees, but did differ by practice type, age, and number of veterinarians in the practice. Small animal veterinarians were less likely to report knowing when to make a report compared to other veterinarians (P < 0.01). Respondents demonstrated suboptimal zoonotic disease reporting and IP practices, including PPE use. Public health agencies should improve outreach and education to veterinarians to facilitate better zoonotic disease prevention practices and reporting.

In longwall mining, ventilation is considered one of the more effective means for controlling gases and dust. In order to study longwall ventilation in a controlled environment, researchers built a unique physical model called the Longwall Instrumented Aerodynamic Model (LIAM) in a laboratory at the National Institute for Occupational Safety and Health (NIOSH) Pittsburgh Mining Research Division (PMRD) campus. LIAM is a 1:30 scale physical model geometrically designed to simulate a single longwall panel with a three-entry headgate and tailgate configuration, along with three back bleeder entries. It consists of a twopart heterogeneous gob that simulates a less compacted unconsolidated zone and more compacted consolidated zone. It has a footprint of 8.94 m (29 ft.) by 4.88 m (16 ft.), with a simulated face length of 220 m (720 ft.) in full scale. LIAM is built with critical details of the face, gob, and mining machinery. It is instrumented with pressure gauges, flow anemometers, temperature probes, a fan, and a data acquisition system. Scaling relationships are derived on the basis of Reynolds and Richardson numbers to preserve the physical and dynamic similitude. This paper discusses the findings from a study conducted in the LIAM to investigate the gob-face interaction, airflow patterns within the gob, and airflow dynamics on the face for varying roof caving characteristics. Results are discussed to show the impact of caving behind the shields on longwall ventilation.

In October 2016, the Harare City Health Department (HCHD) surveillance system recorded the beginning of an upward trend in typhoid cases. On December 27, 2016, after the typhoid fever–associated death of a student, the Ministry of Health and Child Care (MOHCC) in Zimbabwe declared an outbreak of typhoid fever. HCHD defined a suspected case in a resident of Harare City as an illness that began on or after October 6, 2016, with fever ≥100.4°F (38°C), body pains, headache, and abdominal pain. Patients with confirmed cases had blood or stool specimens positive for Salmonella Typhi. | | HCHD reported 860 cases with illness onset from October 6, 2016, through March 8, 2017, including 780 suspected cases, 80 confirmed cases, and four deaths (case fatality rate = 0.5%) (Figure). A spike in suspected cases on January 1 followed widespread media reports of the death of the student, but none of these cases were confirmed by lab testing. A total of 665 (77%) cases occurred in the high-density suburbs of Budiriro, Glen View, and Mbare; 24 (3%) patients were from outside Harare. Patients ranged in age from 1 month to 78 years (median age = 18 years); 48% were female.

A comprehensive monitoring program was conducted to measure the rock mass displacements, support response, and stress changes at a longwall tailgate entry in West Virginia. Monitoring was initiated a few days after development of the gateroad entries and continued during passage of the longwall panels on both sides of the entry. Monitoring included overcore stress measurements of the initial stress within the rock mass, changes in cable bolt loading, standing support pressure, roof deformation, rib deformation, stress changes in the coal pillar, and changes in the full three-dimensional stress tensor within the rock mass at six locations around the monitoring site. During the passage of the first longwall, stress measurements in the rock and coal detected minor changes in loading while minor changes were detected in roof deformation. As a result of the relatively favorable stress and geological conditions, the support systems did not experience severe loading or rock deformation until the second panel approached within 10-15 m of the instrumented locations. After reaching the peak loading at about 50-75 mm of roof sag, the cable bolts started to unload, and load was transferred to the standing supports. The standing support system was able to maintain an adequate opening inby the shields to provide ventilation to the first crosscut inby the face, as designed. The results were used to calibrate modeled cable bolt response to field data, and to validate numerical modeling procedures that have been developed to evaluate entry support systems. It is concluded that the support system was more than adequate to control the roof of the tailgate up to the longwall face location. The monitoring results have provided valuable data for the development and validation of support design strategies for longwall tailgate entries.

Longwall face ventilation is an important component of the overall coal mine ventilation system. Increased production rates due to higher-capacity mining equipment tend to also increase methane emission rates from the coal face, which must be diluted by the face ventilation. Increases in panel length, with some mines exceeding 6,100 m (20,000 ft), and panel width provide additional challenges to face ventilation designs. To assess the effectiveness of current face ventilation practices at a study site, a face monitoring study with continuous monitoring of methane concentrations and automated recording of longwall shearer activity was combined with a tracer gas test on a longwall face. The study was conducted at a U.S. longwall mine operating in a thick, bituminous coal seam and using a U-type, bleederless ventilation system. Multiple gob gas ventholes were located near the longwall face. These boreholes had some unusual design concepts, including a system of manifolds to modify borehole vacuum and flow and completion depths close to the horizon of the mined coalbed that enabled direct communication with the mine atmosphere. The mine operator also had the capacity to inject nitrogen into the longwall gob, which occurred during the monitoring study. The results show that emission rates on the longwall face showed a very limited increase in methane concentrations from headgate to tailgate despite the occurrence of methane delays during monitoring. Average face air velocities were 3.03 m/s (596 fpm) at shield 57 and 2.20 m/s (433 fpm) at shield 165. The time required for the sulfur hexafluoride (SF(6)) peak to occur at each monitoring location has been interpreted as being representative of the movement of the tracer slug. The rate of movement of the slug was much slower in reaching the first monitoring location at shield 57 compared with the other face locations. This lower rate of movement, compared with the main face ventilation, is thought to be the product of a flow path within and behind the shields that is moving in the general direction of the headgate to the tailgate. Barometric pressure variations were pronounced over the course of the study and varied on a diurnal basis.

BACKGROUND: In 2014, the U.S. Public Health Service (USPHS) Commissioned Corps deployed to Monrovia, Liberia, to operate a 25-bed Ebola treatment unit (ETU) constructed by the U.S. Military. The ETU was named the Monrovia Medical Unit (MMU) and was constructed from an U.S. Air Force Expeditionary Medical Support (EMEDS) unit with modifications on the basis of consultation from Medecins Sans Frontieres, the World Health Organization, and expert panels from the U.S. Department of Defense and Department of Health and Human Services. From November 12, 2014, to April 30, 2015, 42 patients (18 confirmed Ebola virus disease [EVD] and 24 suspected EVD) from nine countries were treated by USPHS providers at the MMU. The medications used in the MMU were primarily procured from the EMEDS 25-bed pharmacy cache. However, specific formulary additions were made for treatment of EVD. METHODS: Using the MMU pharmacy dispensing data, we compared and contrasted the medications used in the MMU with recommendations in published EVD treatment guidelines for austere settings. FINDINGS: After comparing and contrasting the MMU pharmacy dispensing data with publications with EVD medication recommendations applicable to resource-limited settings, 101 medications were included in the USPHS Essential Medications for the Management of EVD List (EML) for an austere, isolated clinical environment. DISCUSSION/IMPACT/RECOMMENDATIONS: Because Ebola outbreaks often occur in remote areas, proactive planning, improved preparedness, and optimal patient care for EVD are needed, especially in the context of austere environments with a scarcity of resources. We developed the EML to assist in the planning for future Ebola outbreaks in a remote clinical environment and to provide a list of medications that have been used in an ETU. The EML is a comprehensive medication list that builds on the existing publications with EVD treatment recommendations applicable to supply-constrained clinical environments. As well, it is a resource for the provision of medications when evaluating donations, procurement, and may help inform estimates for product inventory requirements for an ETU. We hope the EML will improve readiness and enhance the capabilities of local and regional international responders.

There is a clear, persistent association between poverty and HIV risk and HIV infection. Low educational attainment, neighborhood disadvantage, and residential instability are ways in which poverty is instrumentally experienced in urban America. We investigated the role of lived poverty at both the individual and neighborhood levels in transactional sex behavior among African American men who have sex with men (MSM) residing in urban neighborhoods. Using population-averaged models estimated by generalized estimating equation (GEE) models, we identified individual-level and neighborhood-level factors that are associated with exchanging sex for drugs and/or money. We tested the association between neighborhood and individual-level socioeconomic status and HIV risk behavior by combining area-based measures of neighborhood quality from the US Census with individual survey data from 542 low-income African American MSM. The primary outcome measure was self-reported transactional sex defined as exchanging sex for drugs or money. Individual-level covariates included high school non-completion, income, and problem drug use. Neighborhood-level covariates were high school non-completion and poverty rates. The findings suggested that educational attainment is associated with both the individual level and neighborhood level. Participants were more likely to engage in transactional sex if they did not complete high school (OR = 1.78), and similarly if their neighbors did not complete high school (OR = 7.70). These findings suggest potential leverage points for both community-level interventions and advocacy for this population, particularly related to transactional sex and education, and will aid HIV prevention efforts that seek to address the contextual constraints on individual risk behavior.

BACKGROUND: In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or SARS, healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCWs use PPE as instructed. OBJECTIVES: To evaluate which type or component of full-body PPE and which method of donning or removing (doffing) PPE have the least risk of self-contamination or infection for HCWs, and which training methods most increase compliance with PPE protocols. SEARCH METHODS: We searched MEDLINE (PubMed up to 8 January 2016), Cochrane Central Register of Trials (CENTRAL up to 20 January 2016), EMBASE (embase.com up to 8 January 2016), CINAHL (EBSCOhost up to 20 January 2016), and OSH-Update up to 8 January 2016. We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE. SELECTION CRITERIA: We included all eligible controlled studies that compared the effect of types or components of PPE in HCWs exposed to highly infectious diseases with serious consequences, such as EVD and SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or removing PPE, and the effects of various types of training in PPE use on the same outcomes. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We intended to perform meta-analyses but we did not find sufficiently similar studies to combine their results. MAIN RESULTS: We included nine studies with 1200 participants evaluating ten interventions. Of these, eight trials simulated the exposure with a fluorescent marker or virus or bacteria containing fluids. Five studies evaluated different types of PPE against each other but two did not report sufficient data. Another two studies compared different types of donning and doffing and three studies evaluated the effect of different types of training.None of the included studies reported a standardised classification of the protective properties against viral penetration of the PPE, and only one reported the brand of PPE used. None of the studies were conducted with HCWs exposed to EVD but in one study participants were exposed to SARS. Different types of PPE versus each otherIn simulation studies, contamination rates varied from 25% to 100% of participants for all types of PPE. In one study, PPE made of more breathable material did not lead to a statistically significantly different number of spots with contamination but did have greater user satisfaction (Mean Difference (MD) -0.46 (95% Confidence Interval (CI) -0.84 to -0.08, range 1 to 5, very low quality evidence). In another study, gowns protected better than aprons. In yet another study, the use of a powered air-purifying respirator protected better than a now outdated form of PPE. There were no studies on goggles versus face shields, on long- versus short-sleeved gloves, or on the use of taping PPE parts together. Different methods of donning and doffing procedures versus each otherTwo cross-over simulation studies (one RCT, one CCT) compared different methods for donning and doffing against each other. Double gloving led to less contamination compared to single gloving (Relative Risk (RR) 0.36; 95% CI 0.16 to 0.78, very low quality evidence) in one simulation study, but not to more noncompliance with guidance (RR 1.08; 95% CI 0.70 to 1.67, very low quality evidence). Following CDC recommendations for doffing led to less contamination in another study (very low quality evidence). There were no studies on the use of disinfectants while doffing. Different types of training versus each otherIn one study, the use of additional computer simulation led to less errors in doffing (MD -1.2, 95% CI -1.6 to -0.7) and in another study additional spoken instruction led to less errors (MD -0.9, 95% CI -1.4 to -0.4). One retrospective cohort study assessed the effect of active training - defined as face-to-face instruction - versus passive training - defined as folders or videos - on noncompliance with PPE use and on noncompliance with doffing guidance. Active training did not considerably reduce noncompliance in PPE use (Odds Ratio (OR) 0.63; 95% CI 0.31 to 1.30) but reduced noncompliance with doffing procedures (OR 0.45; 95% CI 0.21 to 0.98, very low quality evidence). There were no studies on how to retain the results of training in the long term or on resource use.The quality of the evidence was very low for all comparisons because of high risk of bias in studies, indirectness of evidence, and small numbers of participants. This means that it is likely that the true effect can be substantially different from the one reported here. AUTHORS' CONCLUSIONS: We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. We also found very low quality evidence that double gloving and CDC doffing guidance appear to decrease the risk of contamination and that more active training in PPE use may reduce PPE and doffing errors more than passive training. However, the data all come from single studies with high risk of bias and we are uncertain about the estimates of effects.We need simulation studies conducted with several dozens of participants, preferably using a non-pathogenic virus, to find out which type and combination of PPE protects best, and what is the best way to remove PPE. We also need randomised controlled studies of the effects of one type of training versus another to find out which training works best in the long term. HCWs exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection.

Choi et al. [2015] recently evaluated Korean workers exposed to indium compounds to assess health outcomes indicative of interstitial lung disease. They found meaningful associations between serum indium concentration and the biomarkers Krebs von den Lungen-6 (KL-6) and surfactant protein-D (SP-D), as well as interstitial changes on high-resolution computed tomography (HRCT). Work sites assessed in their study included indium-tin oxide (ITO) target manufacturing facilities, indium reclaim factories, and display panel manufacturing plants. | We reported similar relationships between health outcomes and indium exposure in workers at an ITO production facility that also reclaimed indium in the United States [Cummings et al., 2014]. Absent from our study, but included in the Korean assessment, were data from workers downstream to the manufacturing of ITO targets, such as display panel manufacturing plants that utilize the ITO targets to apply a thin film of ITO by sputtering. The extent of occupational exposure to ITO and other indium-containing compounds in these downstream industries in the United States remains largely unknown. Hines et al. [2013] found that workers at ITO thin film deposition companies were exposed to indium between sputtering runs when ITO targets were resurfaced or during cleaning of chamber interiors and shields. In fact, personal indium air concentration reached 5.4 mg/m3 for cleaning sputter or evaporation chambers [Hines et al., 2013], which is orders of magnitude above the Japanese respirable exposure limit of 0.3 mg/m3 [MHLW, 2010].

Background In January 2015, a total of 11 new diagnoses of human immunodeficiency virus (HIV) infection were reported in a small community in Indiana. We investigated the extent and cause of the outbreak and implemented control measures. Methods We identified an outbreak-related case as laboratory-confirmed HIV infection newly diagnosed after October 1, 2014, in a person who either resided in Scott County, Indiana, or was named by another case patient as a syringe-sharing or sexual partner. HIV polymerase (pol) sequences from case patients were phylogenetically analyzed, and potential risk factors associated with HIV infection were ascertained. Results From November 18, 2014, to November 1, 2015, HIV infection was diagnosed in 181 case patients. Most of these patients (87.8%) reported having injected the extended-release formulation of the prescription opioid oxymorphone, and 92.3% were coinfected with hepatitis C virus. Among 159 case patients who had an HIV type 1 pol gene sequence, 157 (98.7%) had sequences that were highly related, as determined by phylogenetic analyses. Contact tracing investigations led to the identification of 536 persons who were named as contacts of case patients; 468 of these contacts (87.3%) were located, assessed for risk, tested for HIV, and, if infected, linked to care. The number of times a contact was named as a syringe-sharing partner by a case patient was significantly associated with the risk of HIV infection (adjusted risk ratio for each time named, 1.9; P<0.001). In response to this outbreak, a public health emergency was declared on March 26, 2015, and a syringe-service program in Indiana was established for the first time. Conclusions Injection-drug use of extended-release oxymorphone within a network of persons who inject drugs in Indiana led to the introduction and rapid transmission of HIV. (Funded by the state government of Indiana and others.).

Unintentional injuries are a persistent public health problem in the United States. A new health care landscape has the potential to create a clinical environment that fosters greater involvement by health care providers in injury prevention. The aim of this article is to provide evidence supporting the need for engagement by primary care providers in unintentional home injury prevention along with examples of how this could be accomplished. We know a great deal about what population groups are at risk for certain types of injuries. We also know that many injuries can be prevented through policies, programs, and resources that ensure safe environments and promote safe behaviors. For example, the Centers for Disease Control and Prevention's STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative comprises clinical decision support tools and educational materials for health care providers. Two effective interventions that have demonstrated a reduction in falls among children are the redesign of baby walkers (engineering) and the mandated use of window guards (enforcement). Primary care clinicians can play a key role in promoting their patient's safety. Taken collectively, a focused attention on preventing unintentional home injuries by primary care providers can contribute to the reduction of injuries and result in optimal health for all.