Circulating vaccine-derived poliovirus (cVDPV) outbreaks can occur when oral poliovirus vaccine strains (most often, Sabin monovalent oral poliovirus vaccine type 2 [mOPV2]) undergo prolonged circulation in undervaccinated populations, resulting in genetic reversion to neurovirulence. A novel type 2 oral poliovirus vaccine (nOPV2) has been developed, which has been shown in clinical trials to be less likely than mOPV2 to revert to paralytic variants and to have limited genetic modifications in initial field use (1–4). Approximately 700 million doses of nOPV2 have been administered worldwide in response to outbreaks of cVDPV type 2 (cVDPV2). cVDPV2 detections originating from nOPV2 use from initial rollout during March 2021–September 7, 2023, are described in this report.

Objectives This study examines emergency preparedness behaviors among women with a recent live birth in Hawaii.Methods Using the 2016 Hawaii Pregnancy Risk Assessment Monitoring Survey we estimated weighted prevalence of eight preparedness behaviors.Results Among 1010 respondents (weighted response rate=56.3%), 79.3% reported at least one preparedness behavior and 11.2% performed all eight behaviors. The prevalence of women with a recent live birth in Hawaii reporting preparedness behaviors includes: 63.0% (95% CI: 58.7-67.1%) having enough supplies at home for at least seven days, 41.3% (95% CI: 37.1-45.6%) having an evacuation plan for their child(ren), 38.7% (95% CI: 34.5, 43.0) having methods to keep in touch, 37.8% (95% CI: 33.7, 42.1) having an emergency meeting place, 36.6% (95% CI: 32.6, 40.9) having an evacuation plan to leave home, 34.9% (95% CI: 30.9, 39.2) having emergencies supplies to take with if they have to leave quickly, 31.8% (95% CI: 27.9, 36.0) having copies of important documents, 31.6% (95% CI: 27.7, 35.8) having practiced what to do.Conclusion One in ten women practiced all eight behaviors indicating more awareness efforts are needed among this at-risk population in Hawaii. Hawaii can measure the effect of interventions to increase preparedness by tracking this question over time.“What is already known on this subject?”Preparedness is associated with reduced vulnerability, and postpartum women are considered an at-risk population in the post-disaster period with special clinical needs. One prior study has assessed disaster preparedness among postpartum women.“What this study adds?”This is the first study to describe a methodology to analyze the eight-part PRAMS emergency preparedness question. Among recently postpartum women in Hawaii, about 80% practiced at least one of eight emergency preparedness measures assessed and about 10% practiced all behaviors.Competing Interest StatementThe authors have declared no competing interest.Funding StatementCDC provides annual funding to participating PRAMS sites through a cooperative agreement.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:Ethics approval PRAMS protocol has been reviewed and approved by Centers for Disease Control and Preventions Institutional Review Board and approved as human subjects research (HSR #2233). Consent to participate All survey respondents provided verbal consent via phone or implied consent by returning a completed questionnaire. All 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).Yes I 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.Yes

OBJECTIVE: To assess the receipt of health care services among live-born infants of women with and without evidence of Zika virus (ZIKV) infection while pregnant during the 2016-2017 ZIKV outbreak in Puerto Rico. METHODS: We used data from the Pregnancy Risk Assessment Monitoring System-Zika Postpartum Emergency Response study telephone surveys to examine maternal reports of the receipt of health care services by infants born in Puerto Rico from August through December 2016 and November through December 2017. Evidence of ZIKV infection was ascertained from the infant's birth certificate or was self-reported in the survey. RESULTS: Fourteen percent of women in 2016 and 9% in 2017 had evidence of ZIKV infection during pregnancy. Most infants of women with evidence of ZIKV received the recommended health care services in 2016 and 2017, respectively, including a hearing test (91% vs. 92%), developmental assessment (90% vs. 92%), and an eye exam (74% vs. 70%); fewer received a head scan (45% vs. 36%) and evaluation for physical therapy (17% vs. 10%). From 2016 to 2017, the proportion of infants having a personal doctor increased for all infants; for infants of women without evidence of ZIKV infection, receiving hearing, developmental, and eye assessments increased. CONCLUSION: Most infants of women with evidence of ZIKV infection during pregnancy received the recommended hearing and developmental assessments during the ZIKV outbreak. Experiences with increasing service capacity during the ZIKV outbreak can be evaluated to inform the response to future emergencies that affect maternal and child health.

The emergence and international spread of neurovirulent circulating vaccine-derived polioviruses (cVDPVs) across multiple countries in Africa and Asia in recent years pose a major challenge to the goal of eradicating all forms of polioviruses. Approximately 90% of all cVDPV outbreaks are caused by the type 2 strain of the Sabin vaccine, an oral live, attenuated vaccine; cVDPV outbreaks typically occur in areas of persistently low immunization coverage (1). A novel type 2 oral poliovirus vaccine (nOPV2), produced by genetic modification of the type 2 Sabin vaccine virus genome (2), was developed and evaluated through phase I and phase II clinical trials during 2017-2019. nOPV2 was demonstrated to be safe and well-tolerated, have noninferior immunogenicity, and have superior genetic stability compared with Sabin monovalent type 2 (as measured by preservation of the primary attenuation site [domain V in the 5' noncoding region] and significantly lower neurovirulence of fecally shed vaccine virus in transgenic mice) (3-5). These findings indicate that nOPV2 could be an important tool in reducing the risk for generating vaccine-derived polioviruses (VDPVs) and the risk for vaccine-associated paralytic poliomyelitis cases. Based on the favorable preclinical and clinical data, and the public health emergency of international concern generated by ongoing endemic wild poliovirus transmission and cVDPV type 2 outbreaks, the World Health Organization authorized nOPV2 for use under the Emergency Use Listing (EUL) pathway in November 2020, allowing for its first use for outbreak response in March 2021 (6). As required by the EUL process, among other EUL obligations, an extensive plan was developed and deployed for obtaining and monitoring nOPV2 isolates detected during acute flaccid paralysis (AFP) surveillance, environmental surveillance, adverse events after immunization surveillance, and targeted surveillance for adverse events of special interest (i.e., prespecified events that have the potential to be causally associated with the vaccine product), during outbreak response, as well as through planned field studies. Under this monitoring framework, data generated from whole-genome sequencing of nOPV2 isolates, alongside other virologic data for isolates from AFP and environmental surveillance systems, are reviewed by the genetic characterization subgroup of an nOPV working group of the Global Polio Eradication Initiative. Global nOPV2 genomic surveillance during March-October 2021 confirmed genetic stability of the primary attenuating site. Sequence data generated through this unprecedented global effort confirm the genetic stability of nOPV2 relative to Sabin 2 and suggest that nOPV2 will be an important tool in the eradication of poliomyelitis. nOPV2 surveillance should continue for the duration of the EUL.

BACKGROUND: There is a critical need for maternal and child health data at the local level (for example, county), yet most counties lack sustainable resources or capabilities to collect local-level data. In such case, model-based small area estimation (SAE) could be a feasible approach. SAE for maternal or infant health-related behaviors at small areas has never been conducted or evaluated. METHODS: We applied multilevel regression with post-stratification approach to produce county-level estimates using Pregnancy Risk Assessment Monitoring System (PRAMS) data, 2016-2018 (n = 65,803 from 23 states) for 2 key outcomes, breastfeeding at 8 weeks and infant non-supine sleeping position. RESULTS: Among the 1,471 counties, the median model estimate of breastfeeding at 8 weeks was 59.8% (ranged from 34.9 to 87.4%), and the median of infant non-supine sleeping position was 16.6% (ranged from 10.3 to 39.0%). Strong correlations were found between model estimates and direct estimates for both indicators at the state level. Model estimates for both indicators were close to direct estimates in magnitude for Philadelphia County, Pennsylvania. CONCLUSION: Our findings support this approach being potentially applied to other maternal and infant health and behavioral indicators in PRAMS to facilitate public health decision-making at the local level.

BACKGROUND: Despite high infant mortality rates in the United States relative to other developed countries, little is known about survey participation among mothers of deceased infants. OBJECTIVE: To assess differences in survey response, contact and cooperation rates for mothers of deceased versus. living infants at the time of survey mailing (approximately 2-6 months postpartum), overall and by select maternal and infant characteristics. METHODS: We analysed 2016-2019 data for 50 sites from the Pregnancy Risk Assessment Monitoring System (PRAMS), a site-specific, population-based surveillance system of mothers with a recent live birth. We assessed differences in survey participation between mothers of deceased and living infants. Using American Association for Public Opinion Research (AAPOR) standard definitions and terminology, we calculated proportions of mothers who participated and were successfully contacted among sampled mothers (weighted response and contact rates, respectively), and who participated among contacted mothers (weighted cooperation rate). We then constructed multivariable survey-weighted logistic regression models to examine the adjusted association between infant vital status and weighted response, contact and cooperation rates, within strata of maternal and infant characteristics. RESULTS: Among sampled mothers, 0.3% (weighted percentage, n = 2795) of infants had records indicating they were deceased at the time of survey mailing and 99.7% (weighted percentage, n = 344,379) did not. Mothers of deceased infants had lower unadjusted weighted response (48.3% vs. 56.2%), contact (67.9% vs. 74.3%) and cooperation rates (71.1% vs. 75.6%). However, after adjusting for covariates, differences in survey participation by infant vital status were reduced. CONCLUSIONS: After covariate adjustment, differences in PRAMS participation rates were attenuated. However, participation rates among mothers of deceased infants remain two to four percentage points lower compared with mothers of living infants. Strategies to increase PRAMS participation could inform knowledge about experiences and behaviours before, during and shortly after pregnancy to help reduce infant mortality.

The Pregnancy Risk Assessment Monitoring System-Zika Postpartum Emergency Response study, implemented in Puerto Rico during the Zika virus outbreak (2016-2017) and after Hurricanes Irma and María (2017-2018), collected pregnancy-related data using postpartum hospital-based surveys and telephone follow-up surveys. Response rates of 75% or more were observed across five study surveys. The study informed programs, increased the Puerto Rico Department of Health's capacity to conduct maternal‒infant health surveillance, and demonstrated the effectiveness of this methodology for collecting data during public health emergencies. (Am J Public Health. 2022;112(4):574-578. https://doi.org/10.2105/AJPH.2021.306687).

Objectives. To examine associations of workplace leave length with breastfeeding initiation and continuation at 1, 2, and 3 months. Methods. We analyzed 2016 to 2018 data for 10 sites in the United States from the Pregnancy Risk Assessment Monitoring System, a site-specific, population-based surveillance system that samples women with a recent live birth 2 to 6 months after birth. Using multivariable logistic regression, we examined associations of leave length (< 3 vs ≥ 3 months) with breastfeeding outcomes. Results. Among 12 301 postpartum women who planned to or had returned to the job they had during pregnancy, 42.1% reported taking unpaid leave, 37.5% reported paid leave, 18.2% reported both unpaid and paid leave, and 2.2% reported no leave. Approximately two thirds (66.2%) of women reported taking less than 3 months of leave. Although 91.2% of women initiated breastfeeding, 81.2%, 72.1%, and 65.3% of women continued breastfeeding at 1, 2, and 3 months, respectively. Shorter leave length (< 3 months), whether paid or unpaid, was associated with lower prevalence of breastfeeding at 2 and 3 months compared with 3 or more months of leave. Conclusions. Women with less than 3 months of leave reported shorter breastfeeding duration than did women with 3 or more months of leave. (Am J Public Health. Published online ahead of print October 21, 2021:e1-e10. https://doi.org/10.2105/AJPH.2021.306484).

OBJECTIVE: The aim of this study was to examine emergency preparedness behaviors among women with a recent live birth in Hawaii. METHODS: Using the 2016 Hawaii Pregnancy Risk Assessment Monitoring System, we estimated weighted prevalence of 8 preparedness behaviors. RESULTS: Among 1010 respondents (weighted response rate, 56.3%), 79.3% reported at least 1 preparedness behavior, and 11.2% performed all 8 behaviors. The prevalence of women with a recent live birth in Hawaii reporting preparedness behaviors includes: 63.0% (95% CI: 58.7-67.1%) having enough supplies at home for at least 7 days, 41.3% (95% CI: 37.1-45.6%) having an evacuation plan for their child(ren), 38.7% (95% CI: 34.5-43.0%) having methods to keep in touch, 37.8% (95% CI: 33.7-42.1%) having an emergency meeting place, 36.6% (95% CI: 32.6-40.9%) having an evacuation plan to leave home, 34.9% (95% CI: 30.9-39.2%) having emergency supplies to take with them if they have to leave quickly, 31.8% (95% CI: 27.9-36.0%) having copies of important documents, and 31.6% (95% CI: 27.7-35.8%) having practiced what to do during a disaster. CONCLUSIONS: One in 10 women practiced all 8 behaviors, indicating more awareness efforts are needed among this population in Hawaii. The impact of preparedness interventions implemented in Hawaii can be tracked with this question over time.

Illicit benzodiazepines are emerging drugs of abuse that are unlawfully manufactured in laboratories and have clinical side effects and toxicity that are not well understood. Although prescription and illicit benzodiazepines are structurally similar (1), illicit benzodiazepines can have different pharmacological properties; this contributes to concerns about their potential potency and clinical implications (1,2). Simultaneous exposure to both illicit benzodiazepines and opioids increases overdose risk (3). Although naloxone will reverse opioid overdose symptoms, it does not reverse overdoses resulting from nonopioid drugs. Therefore, in cases of co-exposure to opioids and benzodiazepines, including illicit benzodiazepines, symptoms of benzodiazepine intoxication (e.g., profound sedation) are unaffected by naloxone, leading to risk for respiratory failure or death (1). Rapid increases in the forensic and clinical detection of illicit benzodiazepines during 2020 have raised concerns about the drug’s role in overdoses, but clinical descriptions of overdoses caused by illicit benzodiazepine co-exposure are limited (4–6). This report describes the detection of illicit benzodiazepine co-exposures among patients treated in emergency departments (EDs) with suspected opioid overdoses in selected states.

OBJECTIVES: The Utah Study of Associated Risks of Stillbirth (SOARS) collects data about stillbirths that are not included in medical records or on fetal death certificates. We describe the design, methods, and survey response rate from the first year of SOARS. METHODS: The Utah Department of Health identified all Utah women who experienced a stillbirth from June 1, 2018, through May 31, 2019, via fetal death certificates and invited them to participate in SOARS. The research team based the study protocol on the Pregnancy Risk Assessment Monitoring System surveillance of women with live births and modified it to be sensitive to women's recent experience of a stillbirth. We used fetal death certificates to examine survey response rates overall and by maternal characteristics, gestational age of the fetus, and month in which the loss occurred. RESULTS: Of 288 women invited to participate in the study, 167 (58.0%) completed the survey; 149 (89.2%) responded by mail and 18 (10.8%) by telephone. A higher proportion of women who were non-Hispanic White (vs other races/ethnicities), were married (vs unmarried), and had ≥high school education (vs <high school education) responded to the survey. Differences between responders and nonresponders by maternal age, gestational age of the fetus, or month of delivery were not significant. Among responders, item nonresponse rates were low (range, 0.6%-5.4%). The question about income (4.8%) and the questions about tests offered and performed during the hospital stay had the highest item nonresponse rates. CONCLUSIONS: The response rate suggests that a mail- and telephone-based survey can be successful in collecting self-reported information about risk factors for stillbirths not currently included in medical records or fetal death certificates.

Residents and staff members of long-term care facilities (LTCFs), because they live and work in congregate settings, are at increased risk for infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1,2). In particular, skilled nursing facilities (SNFs), LTCFs that provide skilled nursing care and rehabilitation services for persons with complex medical needs, have been documented settings of COVID-19 outbreaks (3). In addition, residents of LTCFs might be at increased risk for severe outcomes because of their advanced age or the presence of underlying chronic medical conditions (4). As a result, the Advisory Committee on Immunization Practices has recommended that residents and staff members of LTCFs be offered vaccination in the initial COVID-19 vaccine allocation phase (Phase 1a) in the United States (5). In December 2020, CDC launched the Pharmacy Partnership for Long-Term Care Program* to facilitate on-site vaccination of residents and staff members at enrolled LTCFs. To evaluate early receipt of vaccine during the first month of the program, the number of eligible residents and staff members in enrolled SNFs was estimated using resident census data from the National Healthcare Safety Network (NHSN(†)) and staffing data from the Centers for Medicare & Medicaid Services (CMS) Payroll-Based Journal.(§) Among 11,460 SNFs with at least one vaccination clinic during the first month of the program (December 18, 2020-January 17, 2021), an estimated median of 77.8% of residents (interquartile range [IQR] = 61.3%- 93.1%) and a median of 37.5% (IQR = 23.2%- 56.8%) of staff members per facility received ≥1 dose of COVID-19 vaccine through the Pharmacy Partnership for Long-Term Care Program. The program achieved moderately high coverage among residents; however, continued development and implementation of focused communication and outreach strategies are needed to improve vaccination coverage among staff members in SNFs and other long-term care settings.

During the beginning of the coronavirus disease 2019 (COVID-19) pandemic, nursing homes were identified as congregate settings at high risk for outbreaks of COVID-19 (1,2). Their residents also are at higher risk than the general population for morbidity and mortality associated with infection with SARS-CoV-2, the virus that causes COVID-19, in light of the association of severe outcomes with older age and certain underlying medical conditions (1,3). CDC's National Healthcare Safety Network (NHSN) launched nationwide, facility-level COVID-19 nursing home surveillance on April 26, 2020. A federal mandate issued by the Centers for Medicare & Medicaid Services (CMS), required nursing homes to commence enrollment and routine reporting of COVID-19 cases among residents and staff members by May 25, 2020. This report uses the NHSN nursing home COVID-19 data reported during May 25-November 22, 2020, to describe COVID-19 rates among nursing home residents and staff members and compares these with rates in surrounding communities by corresponding U.S. Department of Health and Human Services (HHS) region.* COVID-19 cases among nursing home residents increased during June and July 2020, reaching 11.5 cases per 1,000 resident-weeks (calculated as the total number of occupied beds on the day that weekly data were reported) (week of July 26). By mid-September, rates had declined to 6.3 per 1,000 resident-weeks (week of September 13) before increasing again, reaching 23.2 cases per 1,000 resident-weeks by late November (week of November 22). COVID-19 cases among nursing home staff members also increased during June and July (week of July 26 = 10.9 cases per 1,000 resident-weeks) before declining during August-September (week of September 13 = 6.3 per 1,000 resident-weeks); rates increased by late November (week of November 22 = 21.3 cases per 1,000 resident-weeks). Rates of COVID-19 in the surrounding communities followed similar trends. Increases in community rates might be associated with increases in nursing home COVID-19 incidence, and nursing home mitigation strategies need to include a comprehensive plan to monitor local SARS-CoV-2 transmission and minimize high-risk exposures within facilities.

We examined pregnant women's use of personal protective measures to prevent mosquito bites during the 2016-2017 Zika outbreak in Puerto Rico. Healthcare provider counseling on recommended measures was associated with increased use of insect repellent among pregnant women but not with wearing protective clothing.

We surveyed women with a recent live birth who resided in 16 US states and 1 city during the 2016 Zika outbreak. We found high awareness about the risk of Zika virus infection during pregnancy and about advisories to avoid travel to affected areas but moderate levels of discussions with healthcare providers.

We examined condom use throughout pregnancy during the Zika outbreak in Puerto Rico during 2016. Overall, <25% of women reported consistent condom use during pregnancy. However, healthcare provider counseling was associated with a 3-fold increase in consistent use, reinforcing the value of provider counseling in Zika prevention efforts.

PURPOSE: Patient navigation (PN) is an increasingly recognized element of high-quality, patient-centered cancer care, yet PN in many cancer programs is absent or limited, often because of concerns of extra cost without tangible financial benefits. METHODS: Five real-world examples of PN programs are used to demonstrate that in the pure fee-for-service and the alternative payment model worlds of reimbursement, strong cases can be made to support the benefits of PN. RESULTS: In three large programs, PN resulted in increased patient retention and increased physician loyalty within the cancer programs, leading to increased revenue. In addition, in two programs, PN was associated with a reduction in unnecessary resource utilization, such as emergency department visits and hospitalizations. PN also reduces burdens on oncology providers, potentially reducing burnout, errors, and costly staff turnover. CONCLUSION: PN has resulted in improved patient outcomes and patient satisfaction and has important financial benefits for cancer programs in the fee-for-service and the alternative payment model worlds, lending support for more robust staffing of PN programs.

PURPOSE: Recent advances in cancer treatment have resulted in greatly improved survival, and yet many patients in the USA have not benefited due to poor access to healthcare and difficulty accessing timely care across the cancer care continuum. Recognizing these issues and the need to facilitate discussions on how to improve navigation services for patients with cancer, the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine (NASEM) held a workshop entitled, "Establishing Effective Patient Navigation Programs in Oncology. The purpose of this manuscript is to disseminate the conclusions of this workshop while providing a clinically relevant review of patient navigation in oncology. DESIGN: Narrative literature review and summary of workshop discussions RESULTS: Patient navigation has been shown to be effective at improving outcomes throughout the spectrum of cancer care. Work remains to develop consensus on scope of practice and evaluation criteria and to align payment incentives and policy. CONCLUSION: Patient navigation plays an essential role in overcoming patient- and system-level barriers to improve access to cancer care and outcomes for those most in need.

Data System. The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state-based surveillance system of maternal behaviors, attitudes, and experiences before, during, and shortly after pregnancy. PRAMS is conducted by the Centers for Disease Control and Prevention's Division of Reproductive Health in collaboration with state health departments. Data Collection/Processing. Birth certificate records are used in each participating jurisdiction to select a sample representative of all women who delivered a live-born infant. PRAMS is a mixed-mode mail and telephone survey. Annual state sample sizes range from approximately 1000 to 3000 women. States stratify their sample by characteristics of public health interest such as maternal age, race/ethnicity, geographic area of residence, and infant birth weight. Data Analysis/Dissemination. States meeting established response rate thresholds are included in multistate analytic data sets available to researchers through a proposal submission process. In addition, estimates from selected indicators are available online. Public Health Implications. PRAMS provides state-based data for key maternal and child health indicators that can be tracked over time. Stratification by maternal characteristics allows for examinations of disparities over a wide range of health indicators. (Am J Public Health. Published online ahead of print August 23, 2018: e1-e9. doi:10.2105/AJPH.2018.304563).

INTRODUCTION: There have been dramatic improvements in reducing infant sleep-related deaths since the 1990s, when recommendations were introduced to place infants on their backs for sleep. However, there are still approximately 3,500 sleep-related deaths among infants each year in the United States, including those from sudden infant death syndrome, accidental suffocation and strangulation in bed, and unknown causes. Unsafe sleep practices, including placing infants in a nonsupine (on side or on stomach) sleep position, bed sharing, and using soft bedding in the sleep environment (e.g., blankets, pillows, and soft objects) are modifiable risk factors for sleep-related infant deaths.

Zika virus infection during pregnancy remains a serious health threat in Puerto Rico. Infection during pregnancy can cause microcephaly, brain abnormalities, and other severe birth defects (1). From January 1, 2016 through March 29, 2017, Puerto Rico reported approximately 3,300 pregnant women with laboratory evidence of possible Zika virus infection (2). There is currently no vaccine or intervention to prevent the adverse effects of Zika virus infection during pregnancy; therefore, prevention has been the focus of public health activities, especially for pregnant women (3). CDC and the Puerto Rico Department of Health analyzed data from the Pregnancy Risk Assessment Monitoring System Zika Postpartum Emergency Response (PRAMS-ZPER) survey conducted from August through December 2016 among Puerto Rico residents with a live birth. Most women (98.1%) reported using at least one measure to avoid mosquitos in their home environment. However, only 45.8% of women reported wearing mosquito repellent daily, and 11.5% reported wearing pants and shirts with long sleeves daily. Approximately one third (38.5%) reported abstaining from sex or using condoms consistently throughout pregnancy. Overall, 76.9% of women reported having been tested for Zika virus by their health care provider during the first or second trimester of pregnancy. These results can be used to assess and refine Zika virus infection prevention messaging and interventions for pregnant women and to reinforce measures to promote prenatal testing for Zika.

Asphalt pavement milling machines use a rotating cutter drum to remove the deteriorated road surface for recycling. The removal of the road surface has the potential to release respirable crystalline silica, to which workers can be exposed. This paper describes an evaluation of respirable crystalline silica exposures to the operator and ground worker from two different half-lane and larger asphalt pavement milling machines that had ventilation dust controls and water-sprays designed and installed by the manufacturers. Manufacturer A completed milling for eleven days at four highway construction sites in Wisconsin, and Manufacturer B completed milling for ten days at seven highway construction sites in Indiana. To evaluate the dust controls, full-shift personal breathing zone air samples were collected from an operator and ground worker during the course of normal employee work activities of asphalt pavement milling at eleven different sites. Forty-two personal breathing zone air samples were collected over 21 days (sampling on an operator and ground worker each day). All samples were below 50 mug/m3 for respirable crystalline silica, the National Institute for Occupational Safety and Health recommended exposure limit. The geometric mean personal breathing zone air sample was 6.2 mug/m3 for the operator and 6.1 mug/m3 for the ground worker for the Manufacturer A milling machine. The geometric mean personal breathing zone air sample was 4.2 mug/m3 for the operator and 9.0 mug/m3 for the ground worker for the Manufacturer B milling machine. In addition, upper 95% confidence limits for the mean exposure for each occupation were well below 50 mug/m3 for both studies. The silica content in the bulk asphalt material being milled ranged from 7% to 23% silica for roads milled by Manufacturer A and from 5% to 12% silica for roads milled by Manufacturer B. The results indicate that engineering controls consisting of ventilation controls in combination with water-sprays are capable of controlling occupational exposures to respirable crystalline silica generated by asphalt pavement milling machines on highway construction sites.

Group A Streptococcus (GAS) is the most common bacterial cause of pharyngitis, implicated in 20%-30% of pediatric and 5%-15% of adult health care visits for sore throat. Along with the sudden onset of throat pain, GAS pharyngitis symptoms include fever, headache, and bilateral tender cervical lymphadenopathy. Accurate diagnosis and management of GAS pharyngitis is critical for limiting antibiotic overuse and preventing rheumatic fever, but distinguishing between GAS and viral pharyngitis clinically is challenging. Guidelines for diagnosis and management of GAS pharyngitis have been published by the Infectious Diseases Society of America (IDSA). IDSA recommends that patients with sore throat be tested for GAS to distinguish between GAS and viral pharyngitis; however, IDSA emphasizes the use of selective testing based on clinical symptoms and signs to avoid identifying GAS carriers rather than acute GAS infections. Therefore, testing for GAS usually is not recommended for the following: patients with sore throat and accompanying symptoms (e.g., cough, rhinorrhea) that strongly suggest a viral etiology; children aged <3 years, because acute rheumatic fever is extremely rare in this age group; and asymptomatic household contacts of patients with GAS pharyngitis. IDSA recommends penicillin or amoxicillin as the treatment of choice based on effectiveness and narrow spectrum of activity. To date, penicillin-resistant GAS has never been documented.

BACKGROUND: From December 2013 through May 2014, physicians, dermatopathologists, and public health authorities collaborated to characterize an outbreak of Mycobacterium marinum and other nontuberculous mycobacterial skin and soft tissue infections (SSTIs) associated with handling fish in New York City's Chinatown. Clinicopathologic and laboratory investigations were performed on a series of patients. METHODS: Medical records were reviewed for 29 patients. Culture results were available for 27 patients and 24 biopsy specimens were evaluated by histopathology, immunohistochemistry (IHC) staining for acid-fast bacilli (AFB), and mycobacterial polymerase chain reaction (PCR) assays. RESULTS: All patients received antibiotics. The most commonly prescribed antibiotic regimen was clarithromycin and ethambutol. Of the 29 patients in this case series, 16 (55%) received surgical treatment involving incision and drainage, mass excision, and synovectomy. Of these, 7 (44%) had deep tissue involvement. All patients showed improvement. For those with culture results, 11 of 27 (41%) were positive for M. marinum; the remainder showed no growth. Poorly formed granulomas (96%), neutrophils (75%), and necrosis (79%) were found in 24 biopsies. Of 15 cases that were culture-negative and analyzed by other methods, 9 were PCR positive for M. marinum group species, 8 were IHC positive, and 3 were positive by AFB stains. CONCLUSIONS: A multidisciplinary approach was used to identify cases in an outbreak of M. marinum infections. The use of histopathology, culture, and IHC plus PCR from full thickness skin biopsy can lead to improved diagnosis of M. marinum SSTIs compared to relying solely on mycobacterial culture, the current gold standard.

BACKGROUND: Israel has used an inactivated polio vaccine (IPV)-only schedule since 2005 (95% coverage). Silent reintroduction of wild type poliovirus 1 (WPV1) into Israel in early 2013 was detected in Southern Israel via routine environmental surveillance without clinical cases. OBJECTIVES: To estimate the rate of WPV1 excretion by age and residence and inform decision-making regarding supplemental immunization with OPV. STUDY DESIGN: A convenience sample of Bedouin and Jewish residential areas in the epicenter of the incident, focusing on under 8 year-olds who not previously given OPV. Fecal samples were directly tested for WPV1 RNA using a novel qRT-PCR assay. Positive samples were confirmed by gold standard cell culture and subject to genotyping. RESULTS: Overall, 2196 non-duplicate fecal samples were collected and analyzed. WPV1 was detected in 61 samples (2.8%), 55 of which (90.2%) were from Bedouins. WPV1 excretion rates were 5.4% among Bedouins and 0.6% among Jewish individuals. Respective age-specific rates among Bedouin and Jewish children were 4.9% and 0.2% for 0-2 years and 7.2% and 1.7% for 2-8 years. Molecular testing had 89.5% sensitivity (higher than culture) and 100% specificity. CONCLUSION: The rapid performance of a field study to evaluate WPV1 excretion unequivocally demonstrated substantial WPV1 infection rates among children under 8 years in Southern Israel, thus informing the decision to vaccinate this age group with bOPV and risk communication to both healthcare personnel and the public. Rapid development and implementation of molecular screening can thus underpin risk assessment and management in complex epidemiological situations.

BACKGROUND: Israel has >95% polio vaccine coverage with the last nine birth cohorts immunized exclusively with IPV. Using acute flaccid paralysis (AFP) and routine, monthly countrywide environmental surveillance, no wild poliovirus circulation was detected between 1989 and Feb 2013, after which wild type 1 polioviruses (WPV1-SOAS) have persistently circulated in southern Israel and intermittently in other areas without any paralytic cases as determined by intensified surveillance of environmental and human samples. AIM: To characterize antigenic and neurovirulence properties of WPV1-SOAS silently circulating in a highly vaccinated population. METHODS: WPV1-SOAS capsid genes from environmental and stool surveillance isolates were sequenced, their neurovirulence was determined using Tg21-PVR-transgenic mice and their antigenicity was characterized by in vitro neutralization using human sera, epitope-specific monoclonal murine anti-OPV antibodies, and sera from IPV immunized rats and mice. RESULTS: WPV1 amino acid sequences in neutralizing epitopes varied from Sabin 1 and Mahoney, with little variation among WPV1 isolates. Neutralization by MoAbs against three of four OPV epitopes was lost. Three-fold lower GMTs (Z=-4.018; P<0.001; Wilcoxon Signed Ranks Test) against WPV1 than against Mahoney in human serum correlated with 4 to 6-fold lower neutralization titers in serum from IPV immunized rats and mice. WPV1-SOAS isolates were neurovirulent (50% i.m. paralytic dose in Tg21-PVR-mice: log107.0). IPV immunized mice were protected against WPV1-induced paralysis. CONCLUSIONS: Phenotypic and antigenic profile changes of WPV1-SOAS may have contributed to the intense silent transmission, while the reduced neurovirulence to the absence of paralytic cases in the background of high population immunity.

BACKGROUND: After 25 years without poliomyelitis cases caused by wild poliovirus (WPV) circulation in Israel, sewage sampling detected WPV type 1 (WPV1) in April 2013, despite high vaccination coverage using only inactivated poliovirus vaccine (IPV) since 2005. METHODS: We used a differential equation-based model to simulate the dynamics of poliovirus transmission and population immunity in Israel due to past exposure to WPV and use of oral poliovirus vaccine (OPV) in addition to IPV. We explored the impacts of various immunization options to stop imported WPV1 circulation in Israel. RESULTS: We successfully modeled the potential for WPVs to circulate without detected cases in Israel. Maintaining a sequential IPV/OPV schedule instead of switching to IPV-only in 2005 would have kept population immunity high enough in Israel to prevent WPV1 circulation. The Israeli response to WPV1 detection prevented paralytic cases; a more rapid response might have interrupted transmission more quickly. CONCLUSIONS: IPV protection alone might not provide sufficient population immunity to prevent poliovirus transmission after an importation. As countries transition to IPV in immunization schedules, they may need to actively manage population immunity and consider continued OPV use to avoid the potential circulation of imported live polioviruses until globally-coordinated OPV cessation.

This paper describes the restructuring of the Pregnancy Risk Assessment Monitoring System (PRAMS), a surveillance system of the Centers for Disease Control and Prevention (CDC)'s Division of Reproductive Health conducted for 25 years in collaboration with state and city health departments. With the ultimate goal to better inform health care providers, public health programs, and policy, changes were made to various aspects of PRAMS to enhance its capacity on assessing and monitoring public health interventions and clinical practices in addition to risk behaviors, disease prevalence, comorbidities, and service utilization. Specifically, the three key PRAMS changes identified as necessary and described in this paper are questionnaire revision, launching the web-based centralized PRAMS Integrated Data Collection System, and enhancing the access to PRAMS data through the web query system known as Centers for Disease Control and Prevention's PRAMS Online Data for Epidemiologic Research/PRAMStat. The seven action steps of Knowledge To Action cycle, an illustration of the implementation science process, that reflect the milestones necessary in bridging the knowledge-to-action gap were used as framework for each of these key changes.

Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder and affects approximately 1 in 15,000 births in the United States. CAH is one of the disorders included on the Newborn Screening (NBS) Recommended Uniform Screening Panel. The commonly used immunological NBS test is associated with a high false positive rate and there is interest in developing second-tier assays to increase screening specificity. Approximately 90% of the classic forms of CAH, salt-wasting and simple virilizing, are due to mutations in the CYP21A2 gene. These include single nucleotide changes, insertions, deletions, as well as chimeric genes involving CYP21A2 and its highly homologous pseudogene CYP21A1P. A novel loci-specific PCR approach was developed to individually amplify the CYP21A2 gene, the nearby CYP21A1P pseudogene, as well as any 30 kb deletion and gene conversion mutations, if present, as single separate amplicons. Using commercially available CAH positive specimens and 14 families with an affected CAH proband, the single long-range amplicon approach demonstrated higher specificity as compared to previously published methods.

Exposures to diacetyl, a primary ingredient of butter flavoring, have been shown to cause respiratory disease among workers who mix flavorings. This study focused on evaluating ventilation controls designed to reduce emissions from the flavor mixing tanks, the major source of diacetyl in the plants. Five exhaust hood configurations were evaluated in the laboratory: standard hinged lid-opened, standard hinged lid-closed, hinged lid-slotted, dome with 38-mm gap, and dome with 114-mm gap. Tracer gas tests were performed to evaluate quantitative capture efficiency for each hood. A perforated copper coil was used to simulate an area source within the 1.2-meter diameter mixing tank. Capture efficiencies were measured at four hood exhaust flow rates (2.83, 5.66, 11.3, and 17.0 cubic meters per minute) and three cross draft velocities (0, 30, and 60 meters per minute). All hoods evaluated performed well with capture efficiencies above 90% for most combinations of exhaust volume and cross drafts. The standard hinged lid was the least expensive to manufacture and had the best average capture efficiency (over 99%) in the closed configuration for all exhaust flow rates and cross drafts. The hinged lid-slotted hood had some of the lowest capture efficiencies at the low exhaust flow rates compared to the other hood designs. The standard hinged lid performed well, even in the open position, and it provided a flexible approach to controlling emissions from mixing tanks. The dome hood gave results comparable to the standard hinged lid but it is more expensive to manufacture. The results of the study indicate that emissions from mixing tanks used in the production of flavorings can be controlled using simple inexpensive exhaust hoods.