BACKGROUND: Patients with ESKD on maintenance dialysis receive dialysis in common spaces with other patients and have a higher risk of severe SARS-CoV-2 infections. They may have persistently or intermittently positive SARS-CoV-2 RT-PCR tests after infection. We describe the clinical course of SARS-CoV-2 infection and the serologic response in a convenience sample of patients with ESKD to understand the duration of infectivity. METHODS: From August to November 2020, we enrolled patients on maintenance dialysis with SARS-CoV-2 infections from outpatient dialysis facilities in Atlanta, Georgia. We followed participants for approximately 42 days. We assessed COVID-19 symptoms and collected specimens. Oropharyngeal (OP), anterior nasal (AN), and saliva (SA) specimens were tested for the presence of SARS-CoV-2 RNA, using RT-PCR, and sent for viral culture. Serology, including neutralizing antibodies, was measured in blood specimens. RESULTS: Fifteen participants, with a median age of 58 (range, 37‒77) years, were enrolled. Median duration of RT-PCR positivity from diagnosis was 18 days (interquartile range [IQR], 8‒24 days). Ten participants had at least one, for a total of 41, positive RT-PCR specimens ≥10 days after symptoms onset. Of these 41 specimens, 21 underwent viral culture; one (5%) was positive 14 days after symptom onset. Thirteen participants developed SARS-CoV-2-specific antibodies, 11 of which included neutralizing antibodies. RT-PCRs remained positive after seroconversion in eight participants and after detection of neutralizing antibodies in four participants; however, all of these samples were culture negative. CONCLUSIONS: Patients with ESKD on maintenance dialysis remained persistently and intermittently SARS-CoV-2-RT-PCR positive. However, of the 15 participants, only one had infectious virus, on day 14 after symptom onset. Most participants mounted an antibody response, including neutralizing antibodies. Participants continued having RT-PCR-positive results in the presence of SARS-CoV-2-specific antibodies, but without replication-competent virus detected.

Establishing healthy dietary and physical activity patterns among youths is an important public health strategy for improving health and preventing chronic diseases; however, few adolescents meet U.S. government recommendations for dietary or physical activity behaviors, and disparities by sex and race/ethnicity exist. CDC analyzed data from the 2019 Youth Risk Behavior Survey to update estimates of dietary and physical activity behaviors among U.S. high school students overall and by sex and race/ethnicity. In addition, 2-year comparisons (2017 and 2019) and trends in prevalence of these behaviors during 2009-2019 were examined. In 2019, overall, during the 7 days before the survey, 41.8% of students had eaten fruit or drunk 100% fruit juices <1 time/day; 40.7% had eaten vegetables <1 time/day; and 16.7% had not eaten breakfast on all 7 days. Moreover, although 57.4% of students had played on ≥1 sports team during the 12 months before the survey, less than half of students had been physically active for ≥60 minutes/day on all 7 days (23.2%), had exercised to strengthen or tone their muscles on ≥3 days/week (49.5%), had met both aerobic and muscle-strengthening physical activity guidelines (16.5%), or had attended physical education classes on all 5 days in an average school week (25.9%). Trend data indicate limited progress in shifting dietary and physical activity behaviors. That is, with the exception of decreases in the percentage of students who had consumed soda ≥1 time/day (2009: 29.2%; 2019: 15.1%), sports drinks ≥1 time/day (2015: 13.8%; 2019: 10.6%), and <3 glasses/day of plain water (2015: 50.5%; 2019: 44.6%), high school students' dietary and physical activity behaviors have not improved and, in certain cases, have worsened. These findings support the need for multicomponent approaches, including policy and environmental changes, and opportunities for adolescents to learn about and practice making healthy choices.

Background Coronavirus disease 2019 (COVID-19), the respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China and has since become pandemic. As part of initial response activities in the United States, enhanced contact investigations were conducted to enable early identification and isolation of additional cases and to learn more about risk factors for transmission.Methods Close contacts of nine early travel-related cases in the United States were identified. Close contacts meeting criteria for active monitoring were followed, and selected individuals were targeted for collection of additional exposure details and respiratory samples. Respiratory samples were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction (RT-PCR) at the Centers for Disease Control and Prevention.Results There were 404 close contacts who underwent active monitoring in the response jurisdictions; 338 had at least basic exposure data, of whom 159 had ≥1 set of respiratory samples collected and tested. Across all known close contacts under monitoring, two additional cases were identified; both secondary cases were in spouses of travel-associated case patients. The secondary attack rate among household members, all of whom had ≥1 respiratory sample tested, was 13% (95% CI: 4 – 38%).Conclusions The enhanced contact tracing investigations undertaken around nine early travel-related cases of COVID-19 in the United States identified two cases of secondary transmission, both spouses. Rapid detection and isolation of the travel-associated case patients, enabled by public awareness of COVID-19 among travelers from China, may have mitigated transmission risk among close contacts of these cases.Competing Interest StatementThe authors have declared no competing interest.Funding StatementNo external funding was sought or received.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 may be available upon reasonable request.

BACKGROUND: Caffeine consumption is common during pregnancy, but published associations with birth defects are mixed. We updated estimates of associations between prepregnancy caffeine consumption and 48 specific birth defects from the National Birth Defects Prevention Study (NBDPS) for deliveries from 1997 to 2011. METHODS: NBDPS was a large population-based case-control study conducted in 10 U.S. states. We categorized self-reported total dietary caffeine consumption (mg/day) from coffee, tea, soda, and chocolate as: <10, 10 to <100, 100 to <200, 200 to <300, and ≥ 300. We used logistic regression to estimate adjusted odds ratios (aORs [95% confidence intervals]). Analyses for defects with ≥5 exposed case children were adjusted for maternal race/ethnicity, age at delivery, body mass index, early pregnancy cigarette smoking and alcohol use, and study site. RESULTS: Our analysis included 30,285 case and 11,502 control children, with mothers of 52% and 54%, respectively, reporting consuming <100 mg caffeine, and 11% of mothers of both cases and controls reported consuming ≥300 mg per day. Low (10 to <100 mg/day) levels of prepregnancy caffeine consumption were associated with statistically significant increases in aORs (1.2-1.7) for 10 defects. Associations with high (≥300 mg/day) levels of caffeine were generally weaker, except for craniosynostosis and aortic stenosis (aORs = 1.3 [1.1-1.6], 1.6 [1.1-2.3]). CONCLUSIONS: Given the large number of estimates generated, some of the statistically significant results may be due to chance and thus the weakly increased aORs should be interpreted cautiously. This study supports previous observations suggesting lack of evidence for meaningful associations between caffeine consumption and the studied birth defects.

Background: The COVID-19 pandemic has triggered stress, anxiety, and disruption to many individuals’ daily lives, which might impact eating habits. Objective: To examine changes in eating habits related to less healthy foods and beverages during the early phase of the COVID-19 pandemic among US adults. Design: Cross-sectional study. Participants/setting: Authors used SummerStyles data gathered in June 2020 among 3916 US adults (≥18 years). Main outcome measures: The outcome of interest was the reported frequency of consuming more (1) unhealthy snacks and desserts including chips, cookies, and ice cream and (2) sugar-sweetened beverages (SSBs) like regular soda, fruit drinks, sports/energy drinks, sweetened coffee/teas during the COVID-19 pandemic. Responses were categorized as Never/Rarely, Sometimes, or Often/Always. Explanatory variables were sociodemographics, weight status, and census regions. Statistical analyses performed: We used multinomial regressions to calculate adjusted odds ratios (AOR) for Sometimes or Often/Always consuming more unhealthy snacks/desserts (vs. Never/Rarely); and Sometimes or Often/Always more SSBs (vs. Never/Rarely). Results: Overall, 36% of adults reported sometimes consuming more unhealthy snacks/desserts; 16% did so often/always. Twenty-two percent of adults reported sometimes drinking more SSBs; 10% did so often/always. Factors significantly associated with higher odds of reporting often/always consuming more unhealthy snacks/desserts were younger adults (AOR range = 1.51–2.86 vs. adults ≥65 years), females (AOR = 1.58 vs. males), non-Hispanic Black (AOR = 1.89 vs. non-Hispanic White), lower household income (AOR = 2.01 for <USD 35,000 vs. ≥USD 100,000), and obesity (AOR = 1.56 vs. underweight/healthy weight). Factors significantly associated with odds of Often/Always drinking more SSBs were being younger (AOR range = 2.26–4.39 vs. adults ≥65 years), non-Hispanic Black (AOR = 3.25 vs. non-Hispanic White), Hispanic (AOR = 1.75 vs. non-Hispanic White), non-Hispanic Other race/ethnicity (AOR = 2.41 vs. non-Hispanic White), lower education (AOR = 2.03 for ≤high school; AOR = 1.80 for some college vs. college graduate), lower household income (AOR range = 1.64–3.15 vs. ≥USD 100,000), and obesity (AOR = 1.61 vs. underweight/healthy weight). Conclusions: Consuming more sugary foods and SSBs during the first phase of the pandemic was higher in younger adults, lower-income adults, people of racial/ethnic minority groups, and adults with obesity. Dietary shifts to less healthy foods and drinks may influence metabolic health if sustained long-term. Implementing strategies to support individual’s healthy eating habits during the ongoing pandemic and the pandemic recovery may benefit health and wellness. © 2022 by the authors. Licensee MDPI, Basel, Switzerland.

BACKGROUND: Carbapenem-resistant Enterobacterales (CRE) are highly antibiotic-resistant bacteria. Whether CRE resistant only to ertapenem among carbapenems (ertapenem "mono-resistant") represent a unique CRE subset with regards to risk factors, carbapenemase genes, and outcomes is unknown. METHODS: We analyzed surveillance data from 9 CDC Emerging Infections Program (EIP) sites. A case was the first isolation of a carbapenem-resistant Enterobacter cloacae complex, Escherichia coli, Klebsiella aerogenes, K. oxytoca, K. pneumoniae, or K. variicola from a normally sterile site or urine in an EIP catchment area resident in 2016-2017. We compared risk factors, carbapenemase genes, antibiotic susceptibility, and mortality of ertapenem "mono-resistant" cases to "other" CRE cases (resistant to1 carbapenem other than ertapenem) and analyzed risk factors for mortality. RESULTS: Of 2009 cases, 1249 (62.2%) were ertapenem-mono-resistant and 760 (37.8%) were other CRE. Ertapenem-mono-resistant CRE cases were more frequently80 years old (29.1% vs 19.5%; P<.0001) and female (67.9% vs 59.0%; P<.0001). Ertapenem-mono-resistant isolates were more likely to be Enterobacter cloacae complex (48.4% vs 15.4%; P<.0001) but less likely to be isolated from a normally sterile site (7.1% vs 11.7%; P<.01) or to have a carbapenemase gene (2.4% vs 47.4%; P<.0001). Ertapenem-mono-resistance was not associated with 90-day mortality in logistic regression models. Carbapenemase-positive isolates were associated with mortality (odds ratio, 1.93; 95% CI, 1.30-2.86). CONCLUSIONS: Ertapenem-mono-resistant CRE rarely have carbapenemase genes and have distinct clinical and microbiologic characteristics from other CRE. These findings may inform antibiotic choice and infection prevention practices, particularly when carbapenemase testing is not available.

BACKGROUND: In 2013, the Dominican Republic introduced 13-valent pneumococcal conjugate vaccine (PCV13) using a 3-dose schedule (at 2, 4 and 12 months of age). We evaluated the impact of PCV13 on serotypes causing pneumococcal pneumonia with pleural effusion. METHODS: Surveillance data after PCV13 introduction (July 2014 to June 2016) were compared with data before PCV13 introduction (July 2009 to June 2011). Cases were defined as radiologic evidence of pneumonia with pleural effusion in a child aged <15 years. Pneumococcus was detected in pleural fluid by either culture or polymerase chain reaction, and serotyping was performed. The Ministry of Health's PCV13 uptake data for 2014-2016 were obtained. RESULTS: The prevalence of pneumococcus among cases was similar before and after PCV13 introduction (56.4% and 52.8%, respectively). The proportion of pneumococcal cases caused by vaccine serotypes was 86% for children <2 years old both before and PCV13 introduction. Compared with before PCV13, serotype 14 accounted for a smaller (28% vs 13%, respectively; P = .02) and serotype 1 for a larger (23% vs 37%; P = .09) proportion of pneumococcal cases after PCV13 introduction. National uptake for the first, second, and third PCV13 doses was 94%, 81%, and 28%, respectively, in 2014 and 75%, 61%, and 26% in 2015. DISCUSSION: While the decrease in pneumococcal pneumonia with pleural effusion caused by serotype 14 may reflect an early effect of PCV13 implementation, other vaccine serotypes, including serotype 1, are not well controlled. Better PCV13 coverage for all 3 doses is needed.

Facility-wide testing performed at four outpatient hemodialysis facilities in the absence of an outbreak or escalating community incidence did not identify new SARS-CoV-2 infections and illustrated key logistical considerations essential to successful implementation of SARS-CoV-2 screening. Facilities could consider prioritizing facility-wide SARS-CoV-2 testing during suspicion of an outbreak in the facility or escalating community spread without robust infection control strategies in place. Being prepared to address operational considerations will enhance implementation of facility-wide testing in the outpatient dialysis setting.

Candida auris is an emerging, often multidrug-resistant yeast that is highly transmissible, resulting in health care–associated outbreaks, especially in long-term care facilities. Skin colonization with C. auris allows spread and leads to invasive infections, including bloodstream infections, in 5%–10% of colonized patients (1). Three major classes of antifungal medications exist for treating invasive infections: azoles (e.g., fluconazole), polyenes (e.g., amphotericin B), and echinocandins. Approximately 85% of C. auris isolates in the United States are resistant to azoles, 33% to amphotericin B, and 1% to echinocandins (2), based on tentative susceptibility breakpoints.* Echinocandins are thus critical for treatment of C. auris infections and are recommended as first-line therapy for most invasive Candida infections (3). Echinocandin resistance is a concerning clinical and public health threat, particularly when coupled with resistance to azole and amphotericin B (pan-resistance).

Liquid wastes (LW) disposed in hospital handwashing sinks may affect colonization of sink P-traps by carbapenemase-producing Klebsiella pneumoniae (CPKP), causing CPKP dispersal into the patient care environment. This study aimed to determine the effect of LW on biofilm formation and CPKP colonization in a P-Trap model (PTM). PTMs containing polymicrobial biofilms grown in autoclaved municipal tap water (ATW) supplemented with 5% dextrose in water (D5W), nutritional shake (Shake), sugar-based soft drink (Soda), or ATW were inoculated with K. pneumoniae ST258 KPC+ (ST258) or K. pneumoniae CAV1016 (CAV1016) and sampled after 7, 14, and 21 d. Biofilm bio-volume, mean thickness, and heterotrophic plate counts were significantly reduced and roughness coefficient significantly increased by Soda compared with D5W, Shake, or ATW. CPKP were significantly reduced by Soda but significantly amplified by D5W (ST258; CAV1016, 7 d) and Shake (ST258) suggesting that reducing LW disposal in sinks may reduce CPKP dispersal into patient care environments.

Residents of long-term care facilities (LTCFs), particularly those in skilled nursing facilities (SNFs), have experienced disproportionately high levels of COVID-19-associated morbidity and mortality and were prioritized for early COVID-19 vaccination (1,2). However, this group was not included in COVID-19 vaccine clinical trials, and limited postauthorization vaccine effectiveness (VE) data are available for this critical population (3). It is not known how well COVID-19 vaccines protect SNF residents, who typically are more medically frail, are older, and have more underlying medical conditions than the general population (1). In addition, immunogenicity of the Pfizer-BioNTech vaccine was found to be lower in adults aged 65-85 years than in younger adults (4). Through the CDC Pharmacy Partnership for Long-Term Care Program, SNF residents and staff members in Connecticut began receiving the Pfizer-BioNTech COVID-19 vaccine on December 18, 2020 (5). Administration of the vaccine was conducted during several on-site pharmacy clinics. In late January 2021, the Connecticut Department of Public Health (CT DPH) identified two SNFs experiencing COVID-19 outbreaks among residents and staff members that occurred after each facility's first vaccination clinic. CT DPH, in partnership with CDC, performed electronic chart review in these facilities to obtain information on resident vaccination status and infection with SARS-CoV-2, the virus that causes COVID-19. Partial vaccination, defined as the period from >14 days after the first dose through 7 days after the second dose, had an estimated effectiveness of 63% (95% confidence interval [CI] = 33%-79%) against SARS-CoV-2 infection (regardless of symptoms) among residents within these SNFs. This is similar to estimated effectiveness for a single dose of the Pfizer-BioNTech COVID-19 vaccine in adults across a range of age groups in noncongregate settings (6) and suggests that to optimize vaccine impact among this population, high coverage with the complete 2-dose series should be recommended for SNF residents and staff members.

BACKGROUND: Diet is thought to account for most adult human exposure to per- and polyfluoroalkyl substances (PFAS). Children are particularly vulnerable to adverse health effects of PFAS and may have different eating habits than adults. However, studies of dietary patterns and PFAS in children are limited. METHODS: We studied 548 Boston-area children with food frequency questionnaire data (89 food items) in early childhood (median age 3.3 years) and plasma concentrations of 6 PFAS quantified in mid-childhood (median age 7.7 years). We used univariate linear regression to examine associations between each food item and PFAS, accounting for multiple comparisons. We next used reduced rank regression (RRR) to estimate overall percent variation in PFAS explained by diet and identify dietary patterns most correlated with PFAS. All models were adjusted for race/ethnicity, maternal education, and household income. RESULTS: In univariate analyses, 2-(N-methyl-perfluorooctane sulfonamide) acetate (MeFOSAA) plasma concentrations were 17.8% (95% CI: 7.2, 29.5) and 17.0% (95% CI: 6.4, 28.7) higher per SD increment in intake of ice cream and soda, respectively. RRR identified 6 dietary patterns that together explained 18% variation in the plasma concentrations of the 6 PFAS, of which 50% was explained by a dietary pattern consisting of primarily packaged foods (including ice cream and soda) and fish. Children with higher intake of the packaged foods and fish dietary pattern had higher plasma concentrations of all PFAS, particularly MeFOSAA and PFOS. CONCLUSIONS: Our analysis examined food intake in association with several PFAS in children and identified dietary determinants that may be sources of PFAS exposure or reflect correlated lifestyle or toxicokinetic factors. Further investigation may help inform measures to modify childhood PFAS exposure.

BACKGROUND: Catheter associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI) represent a substantial portion of healthcare-associated infections (HAIs) reported in the United States. The Targeted Assessment for Prevention (TAP) Strategy is a quality improvement framework to reduce HAIs. Data from the TAP Facility Assessments were used to determine common infection prevention gaps for CAUTI and CLABSI. METHODS: Data from 2,044 CAUTI and 1,680 CLABSI Assessments were included in the analysis. Items were defined as potential gaps if ≥33% respondents answered Unknown, ≥33% No, or ≥50% No or Unknown or Never, Rarely, Sometimes, or Unknown to questions pertaining to those areas. Review of response frequencies and stratification by respondent role were performed to highlight opportunities for improvement. RESULTS: Across CAUTI and CLABSI Assessments, lack of physician champions (<35% Yes) and nurse champions (<55% Yes), along with lack of awareness of competency assessments, audits, and feedback were reported. Lack of practices to facilitate timely removal of urinary catheters were identified for CAUTI and issues with select device insertion practices, such as maintaining aseptic technique, were perceived as areas for improvement for CLABSI. CONCLUSIONS: These data suggest common gaps in critical components of infection prevention and control programs. The identification of these gaps has the potential to inform targeted CAUTI and CLABSI prevention efforts.

Coronavirus disease 2019 (COVID-19), the respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China and has since become pandemic. In response to the first cases identified in the United States, close contacts of confirmed COVID-19 cases were investigated to enable early identification and isolation of additional cases and to learn more about risk factors for transmission. Close contacts of nine early travel-related cases in the United States were identified and monitored daily for development of symptoms (active monitoring). Selected close contacts (including those with exposures categorized as higher risk) were targeted for collection of additional exposure information and respiratory samples. Respiratory samples were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction at the Centers for Disease Control and Prevention. Four hundred four close contacts were actively monitored in the jurisdictions that managed the travel-related cases. Three hundred thirty-eight of the 404 close contacts provided at least basic exposure information, of whom 159 close contacts had ≥1 set of respiratory samples collected and tested. Across all actively monitored close contacts, two additional symptomatic COVID-19 cases (i.e., secondary cases) were identified; both secondary cases were in spouses of travel-associated case patients. When considering only household members, all of whom had ≥1 respiratory sample tested for SARS-CoV-2, the secondary attack rate (i.e., the number of secondary cases as a proportion of total close contacts) was 13% (95% CI: 4-38%). The results from these contact tracing investigations suggest that household members, especially significant others, of COVID-19 cases are at highest risk of becoming infected. The importance of personal protective equipment for healthcare workers is also underlined. Isolation of persons with COVID-19, in combination with quarantine of exposed close contacts and practice of everyday preventive behaviors, is important to mitigate spread of COVID-19.

OBJECTIVES: To evaluate the impact of International Classification of Disease, 10th revision, Clinical Modification (ICD-10-CM) implementation on pneumonia hospitalizations rates, which had declined following pneumococcal conjugate vaccine introduction for infants in 2000. METHODS: We randomly selected records from a single hospital 1 year before (n = 500) and after (n = 500) October 2015 implementation of ICD-10-CM coding. We used a validated ICD-9-CM algorithm and translation of that algorithm to ICD-10-CM to identify pneumonia hospitalizations pre- and post-implementation, respectively. We recoded ICD-10-CM records to ICD-9-CM and vice versa. We calculated sensitivity and positive predictive value (PPV) of the ICD-10-CM algorithm using ICD-9-CM coding as the reference. We used sensitivity and PPV values to calculate an adjustment factor to apply to ICD-10 era rates to enable comparison with ICD-9-CM rates. We reviewed primary diagnoses of charts not meeting the pneumonia definition when recoded. RESULTS: Sensitivity and PPV of the ICD-10-CM algorithm were 94% and 92%, respectively, for young children and 74% and 79% for older adults. The estimated adjustment factor for ICD-10-CM period rates was -2.09% (95% credible region [CR], -7.71% to +3.0%) for children and +6.76% (95% CR, -3.06% to +16.7%) for older adults. We identified a change in coding adult charts that met the ICD-9-CM pneumonia definition that led to recoding in ICD-10-CM as chronic obstructive pulmonary disease (COPD) exacerbation. CONCLUSIONS: The ICD-10-CM algorithm derived from a validated ICD-9-CM algorithm should not introduce substantial bias for evaluating pneumonia trends in children. However, changes in coding of pneumonia associated with COPD in adults warrant further study.

We used data from the 2017 national Youth Risk Behavior Survey to examine associations between physical activity, sedentary, and healthy dietary behaviors and indicators of mental health, suicidal thoughts, and suicidal attempts among a representative sample of US high school students. Sex-stratified logistic regression was used to separately model each mental health-related outcome on the health-related behaviors, while controlling for race/ethnicity, grade, and body weight status. Significant associations were found between insufficient physical activity, sedentary, and less healthy dietary behaviors and the mental health-related outcomes. Feeling sad and hopeless was associated with not eating breakfast on all 7 days (past week), drinking soda or pop (female only), not meeting the aerobic physical activity guideline (male only), not playing on at least one sports team, and playing video/computer games or using a computer more than two hours (per day). Suicidal thoughts were associated with not eating breakfast on all 7 days, drinking soda or pop, not meeting the aerobic physical activity guideline, and playing video/computer games or using a computer more than two hours per day. Attempted suicide was associated with not eating breakfast on all 7 days, drinking soda or pop, drinking sports drinks, watching television more than two hours per day, and playing video or computer games or using a computer more than two hours per day (male only). While limiting sedentary behaviors and increasing physical activity and healthy dietary behaviors is not a sole solution for improving mental health among adolescents, it could be another possible strategy used in schools to benefit all students.

PURPOSE: Examine association of health literacy (HL) and menu-labeling (ML) usage with sugar-sweetened beverage (SSB) intake among adults in Mississippi. DESIGN: Quantitative, cross-sectional study. SETTING: 2016 Mississippi Behavioral Risk Factor Surveillance System data. PARTICIPANTS: Adults living in Mississippi (n = 4549). MEASURES: Outcome variable was SSB intake (regular soda, fruit drinks, sweet tea, and sports/energy drinks). Exposure variables were 3 HL questions (find information, understand oral information, and understand written information) and ML usage among adults who eat at fast-food/chain restaurants (user, nonuser, and do not notice ML). ANALYSIS: Multinomial logistic regressions were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for SSB intake >/=1 time/d (reference: 0 times/d) associated with HL and ML. RESULTS: In Mississippi, 46.8% of adults consumed SSB >/=1 time/d, and 26.9% consumed >/=2 times/d. The odds of consuming SSBs >/=1 time/d were higher among adults with lower HL (aOR = 1.7; 95% CI = 1.3-2.2) than those with higher HL. Among adults who ate at fast-food/chain restaurants, the odds of consuming SSBs >/=1 time/d were higher among nonusers of ML (aOR = 2.3; 95% CI = 1.7-3.1) and adults who did not notice ML (aOR = 1.8; 95% CI = 1.3-2.6) than ML users. CONCLUSION: Adults with lower HL and adults who do not use or notice ML consumed more SSBs in Mississippi. Understanding why lower HL and no ML usage are linked to SSB intake could guide the design of interventions to reduce SSB intake in this population.

BACKGROUND: Micronutrient powders (MNP) can reduce iron deficiency and anemia in children. OBJECTIVE: We evaluated the impact of an integrated infant and young child feeding (IYCF)-MNP intervention on anemia and micronutrient status among children aged 12-23 mo in Eastern Uganda. The intervention focused on MNP distribution, IYCF education, and caregiver behavior change. METHODS: Population-based cross-sectional surveys representative of children aged 12-23 mo in Amuria (intervention) and Soroti (nonintervention) districts were collected in June/July 2015 at baseline (n = 1260) and 12 mo after implementation at endline in 2016 (n = 1490). From pooled capillary blood, we assessed hemoglobin, malaria, ferritin, retinol binding protein (RBP), C-reactive protein, and ɑ1-acid glycoprotein. Ferritin and RBP were regression-adjusted to correct for inflammation. Caregivers reported sociodemographic characteristics and MNP knowledge and practices. Linear regression estimated the difference-in-difference (DiD) effect of MNP on hemoglobin, ferritin, and RBP, and logistic regression estimated DiD effect of MNP on anemia (hemoglobin <11.0 g/dL), iron deficiency (ferritin <12.0 µg/L), iron deficiency anemia (hemoglobin <11.0 g/dL and ferritin <12.0 µg/L), and vitamin A deficiency (VAD; RBP equivalent to <0.70 µmol/L retinol: <0.79 µmol/L at baseline and RBP <0.67 µmol/L at endline). RESULTS: In Amuria, 96% of children had ever consumed MNP versus <1% of children in Soroti. Fifty-four percent of caregivers reported organoleptic changes when MNP were added to foods cooked with soda ash. Adjusting for age, sex, malaria, recent morbidity, and household-level factors, the intervention was associated with -0.83 g/dL lower hemoglobin (95% CI, -1.36, -0.30 g/dL; P = 0.003) but not with anemia, ferritin, iron deficiency, iron deficiency anemia, RBP, or VAD. CONCLUSIONS: Despite high program fidelity, the intervention was associated with reduced hemoglobin concentrations but not with change in anemia or micronutrient status among children aged 12-23 mo in Eastern Uganda. Contextual factors, such as cooking with soda ash, might explain the lack of effectiveness.

OBJECTIVES: Frequent sugar-sweetened beverage (SSB) intake is associated with weight gain in women, and pre-pregnancy overweight and excessive gestational weight gain are linked to adverse pregnancy outcomes. SSB intake information for women of reproductive age (WRA) is limited. We described SSB intake among non-pregnant and pregnant WRA and identified correlates of daily intake. METHODS: Using 2017 Behavioral Risk Factor Surveillance System data, we analyzed SSB intake (regular soda, fruit drinks, sweet tea, sports/energy drinks) for 11,321 non-pregnant and 392 pregnant WRA (18-49 years) in 12 states and D.C. Adjusted odds ratios (aOR) for daily (>/= 1 time/day) SSB intake (reference: < 1 time/day) by characteristics were estimated using multivariable logistic regression. RESULTS: Overall, 27.3% of non-pregnant and 21.9% of pregnant women reported consuming SSBs >/= 1 time/day; 12.6% and 9.7%, respectively, consumed SSBs >/= 2 times/day. Among non-pregnant women, odds of daily SSB intake were higher for women who were non-Hispanic black (aOR 2.04, 95% CI 1.55-2.69) vs. non-Hispanic white; had </= high school education (aOR 2.79, CI 2.26-3.44) or some college (aOR 1.85, CI 1.50-2.27) vs. college graduates; lived in nonmetropolitan counties (aOR 1.35, CI 1.11-1.63) vs. metropolitan; had no physical activity (aOR 1.72, CI 1.43-2.07) vs. some; were former (aOR 1.51, CI 1.17-1.94) or current (aOR 3.48, CI 2.82-4.28) smokers vs. nonsmokers. Among pregnant women, those not married had higher odds (aOR 2.81, CI 1.05-7.51) for daily SSB intake than married women. CONCLUSIONS: One in five pregnant women and one in four non-pregnant women of reproductive age consumed SSBs at least once per day. Sociodemographic and behavioral correlates of daily SSB intake were identified.

BACKGROUND: Since the identification of the first two Candida auris cases in Chicago, Illinois, in 2016, ongoing spread has been documented in the Chicago area. We describe C. auris emergence in high-acuity long-term healthcare facilities and present a case-study of public health response to C. auris and carbapenemase-producing organisms (CPOs) at one ventilator-capable skilled nursing facility (vSNF A). METHODS: We performed point prevalence surveys (PPSs) to identify patients colonized with C. auris, infection control (IC) assessments, and provided ongoing support for IC improvements in Illinois acute and long-term care facilities during August 2016-December 2018. During 2018, we initiated a focused effort at vSNF A, and conducted seven C. auris PPSs; during four PPSs, we also performed CPO screening and environmental sampling. RESULTS: During August 2016-December 2018 in Illinois, 490 individuals were found to be colonized or infected with C. auris. PPSs identified highest prevalence of C. auris colonization in vSNF settings (prevalence 23-71%). IC assessments in multiple vSNFs identified common challenges in core IC practices. Repeat PPSs at vSNF A in 2018 identified increasing C. auris prevalence from 43% to 71%. Most residents screened during multiple PPSs remained persistently colonized with C. auris. Among 191 environmental samples collected, 39% were positive for C. auris, including samples from bedrails, windowsills, and shared patient-care items. CONCLUSIONS: High burden in vSNFs along with persistent colonization of residents and environmental contamination point to the need for prioritizing IC interventions to control spread of C. auris and CPOs.

PURPOSE: To examine factors associated with frequency of plain water (ie, tap, bottled, and unflavored sparkling water) intake among US high school students. DESIGN: Quantitative, cross-sectional study. SETTING: The 2017 national Youth Risk Behavior Survey data. SUBJECTS: US high school students with plain water intake data (N = 10 698). MEASURES: The outcome was plain water intake. Exposure variables were demographics, academic grades, and behavioral characteristics. ANALYSIS: We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for factors associated with infrequent plain water intake (<3 vs >/=3 times/day). RESULTS: Overall, 48.7% of high school students reported drinking plain water <3 times/day. Factors associated with infrequent plain water intake were younger age (</=15 years; aOR = 1.20, CI = 1.05-1.37); earning mostly D/F grades (aOR = 1.37, CI = 1.07-1.77); consuming regular soda 1 to 6 times/week (aOR = 1.92, CI = 1.67-2.20) or >/=1 time/day (aOR = 3.23, CI = 2.65-3.94), sports drinks 1 to 6 times/week (aOR = 1.30, CI = 1.14-1.49), milk <2 glasses/day (aOR = 1.51, CI = 1.31-1.73), fruits <2 times/day (aOR = 1.92, CI = 1.66-2.22), and vegetables <3 times/day (aOR = 2.42, CI = 2.04-2.89); and being physically active >/=60 minutes/day on <5 days/week (aOR = 1.83, CI = 1.60-2.08). Students with obesity were less likely to have infrequent water intake (aOR = 0.63, CI = 0.53-0.74). CONCLUSIONS: Infrequent plain water intake was associated with younger age, poor academic grades, poor dietary behaviors, and physical inactivity. These findings can inform intervention efforts to increase water intake to promote healthy lifestyles among adolescents.

We evaluated predictors of micronutrient powder (MNP) sachet coverage and recent intake using data from a cross-sectional survey representative of children aged 12-23 months in Amuria district, Uganda. In June/July 2016, caregivers were interviewed 12 months after implementation of an integrated MNP and infant and young child feeding pilot (N = 761). Logistic regression described predictors of (a) high-MNP sachet coverage (received at least 60 sachets/6 months) and (b) recent intake (consumed MNP during the 2 weeks preceding the survey) among children who had ever received MNP and had complete data (N = 683). Fifty-nine percent (95% Confidence Interval [CI] [53.8, 64.2]) of children had high-MNP sachet coverage, and 65.4% (95% CI [61.0, 69.9]) had recent intake. MNP ration cards (Adjusted Odds Ratio [AOR] 2.67, 95% CI [1.15, 6.23]), organoleptic changes to foods cooked with soda ash (AOR 1.52, 95% CI [1.08, 2.14]), having heard of anaemia (AOR 1.59, 95% CI [1.11, 2.26]), knowledge of correct MNP preparation (AOR 1.89, 95% CI [1.11, 3.19]), and current breastfeeding (AOR 2.04, 95% CI [1.36, 3.08]) were positively associated with MNP coverage whereas older child age (18-23 vs. 12-17 months) was inversely associated with coverage (AOR 0.32, 95% CI [0.23, 0.50]). MNP ration cards (AOR 2.86, 95% CI [1.34, 6.09]), having heard an MNP radio jingle (AOR 1.40, 95% CI [1.01, 1.94]), knowledge of correct MNP preparation (AOR 1.88, 95% CI [1.04, 3.39]), and the child not disliking MNP (AOR 1.90, 95% CI [1.13, 3.22]) were positively associated with recent intake. Interventions that increase caregiver knowledge and skills and focus on older children could improve MNP coverage and recent intake.

BACKGROUND: Pneumococcus is a leading cause of pneumonia and meningitis. Zambia introduced a 10-valent pneumococcal conjugate vaccine (PCV10) in July 2013 using a 3-dose primary series at ages 6, 10, and 14 weeks with no booster. We evaluated the impact of PCV10 on meningitis and pneumonia hospitalizations. METHODS: Using hospitalization data from first-level care hospitals, available at the Ministry of Health, and from the largest pediatric referral hospital in Lusaka, we identified children aged <5 years who were hospitalized with pneumonia or meningitis from January 2010-December 2016. We used time-series analyses to measure the effect of PCV10 on monthly case counts by outcome and age group (<1 year, 1-4 years), accounting for seasonality. We defined the pre- and post-PCV10 periods as January 2010-June 2013 and July 2014-December 2016, respectively. RESULTS: At first-level care hospitals, pneumonia and meningitis hospitalizations among children aged <5 years accounted for 108 884 and 1742 admissions in the 42 months pre-PCV10, respectively, and 44 715 and 646 admissions in the 30 months post-PCV10, respectively. Pneumonia hospitalizations declined by 37.8% (95% confidence interval [CI] 21.4-50.3%) and 28.8% (95% CI 17.7-38.7%) among children aged <1 year and 1-4 years, respectively, while meningitis hospitalizations declined by 72.1% (95% CI 63.2-79.0%) and 61.6% (95% CI 50.4-70.8%), respectively, in these age groups. In contrast, at the referral hospital, pneumonia hospitalizations remained stable and a smaller but significant decline in meningitis was observed among children aged 1-4 years (39.3%, 95% CI 16.2-57.5%). CONCLUSIONS: PCV10 introduction was associated with declines in meningitis and pneumonia hospitalizations in Zambia, especially in first-level care hospitals.

BACKGROUND: Bacterial meningitis is a major cause of morbidity and mortality in sub-Saharan Africa. We analyzed data from the World Health Organization's (WHO) Invasive Bacterial Vaccine-preventable Diseases Surveillance Network (2011-2016) to describe the epidemiology of laboratory-confirmed Streptococcus pneumoniae (Spn), Neisseria meningitidis, and Haemophilus influenzae meningitis within the WHO African Region. We also evaluated declines in vaccine-type pneumococcal meningitis following pneumococcal conjugate vaccine (PCV) introduction. METHODS: Reports of meningitis in children <5 years old from sentinel surveillance hospitals in 26 countries were classified as suspected, probable, or confirmed. Confirmed meningitis cases were analyzed by age group and subregion (South-East and West-Central). We described case fatality ratios (CFRs), pathogen distribution, and annual changes in serotype and serogroup, including changes in vaccine-type Spn meningitis following PCV introduction. RESULTS: Among 49 844 reported meningitis cases, 1670 (3.3%) were laboratory-confirmed. Spn (1007/1670 [60.3%]) was the most commonly detected pathogen; vaccine-type Spn meningitis cases declined over time. CFR was the highest for Spn meningitis: 12.9% (46/357) in the South-East subregion and 30.9% (89/288) in the West-Central subregion. Meningitis caused by N. meningitidis was more common in West-Central than South-East Africa (321/954 [33.6%] vs 110/716 [15.4%]; P < .0001). Haemophilus influenzae (232/1670 [13.9%]) was the least prevalent organism. CONCLUSIONS: Spn was the most common cause of pediatric bacterial meningitis in the African region even after reported cases declined following PCV introduction. Sustaining robust surveillance is essential to monitor changes in pathogen distribution and to inform and guide vaccination policies.

RATIONALE & OBJECTIVE: Contaminated water and other fluids are increasingly recognized to be associated with health care-associated infections. We investigated an outbreak of Gram-negative bloodstream infections at 3 outpatient hemodialysis facilities. STUDY DESIGN: Matched case-control investigations. SETTING & PARTICIPANTS: Patients who received hemodialysis at Facility A, B, or C from July 2015 to November 2016. EXPOSURES: Infection control practices, sources of water, dialyzer reuse, injection medication handling, dialysis circuit priming, water and dialysate test findings, environmental reservoirs such as wall boxes, vascular access care practices, pulsed-field gel electrophoresis, and whole-genome sequencing of bacterial isolates. OUTCOMES: Cases were defined by a positive blood culture for any Gram-negative bacteria drawn July 1, 2015 to November 30, 2016 from a patient who had received hemodialysis at Facility A, B, or C. ANALYTICAL APPROACH: Exposures in cases and controls were compared using matched univariate conditional logistic regression. RESULTS: 58 cases of Gram-negative bloodstream infection occurred; 48 (83%) required hospitalization. The predominant organisms were Serratia marcescens (n=21) and Pseudomonas aeruginosa (n=12). Compared with controls, cases had higher odds of using a central venous catheter for dialysis (matched odds ratio, 54.32; lower bound of the 95% CI, 12.19). Facility staff reported pooling and regurgitation of waste fluid at recessed wall boxes that house connections for dialysate components and the effluent drain within dialysis treatment stations. Environmental samples yielded S marcescens and P aeruginosa from wall boxes. S marcescens isolated from wall boxes and case-patients from the same facilities were closely related by pulsed-field gel electrophoresis and whole-genome sequencing. We identified opportunities for health care workers' hands to contaminate central venous catheters with contaminated fluid from the wall boxes. LIMITATIONS: Limited patient isolates for testing, on-site investigation occurred after peak of infections. CONCLUSIONS: This large outbreak was linked to wall boxes, a previously undescribed source of contaminated fluid and biofilms in the immediate patient care environment.

PURPOSE: To examine associations between knowledge of health conditions and sugar-sweetened beverage (SSB) intake among Hispanic adults. DESIGN: Quantitative, cross-sectional study. SETTING: The 2015 Estilos survey data. PARTICIPANTS: One thousand US Hispanic adults (>/=18 years). MEASURES: The outcome variable was frequency of SSB intake (regular soda, fruit drink, sports/energy drink, and sweetened coffee/tea drink). Exposure variables were knowledge of 6 SSB-related health conditions (weight gain, diabetes, dental caries, high cholesterol, heart disease, and hypertension). ANALYSIS: Six multinomial logistic regression models were used to estimate adjusted odds ratios for consuming SSBs >/=3 times/day (high intake), in relation to knowledge of SSB-related health conditions. RESULTS: Overall, 58% of Hispanic adults consumed SSBs >/=2 times/day and 36% consumed SSBs >/=3 times/day. Although most identified that weight gain (75%) and diabetes (76%) were related to drinking SSBs, only half identified this relation with dental caries (57%) and hypertension (41%). Even fewer identified high cholesterol (32%) and heart disease (32%) as related. In crude analyses, SSB intake was significantly associated with knowledge of the associations between SSBs and weight gain, dental caries, and heart disease; however, after adjusting for sociodemographics and acculturation, associations were no longer significant. CONCLUSIONS: Although SSB intake was very high, knowledge of SSB-related health conditions was low and was not related to high SSB intake among US Hispanic adults. Education efforts alone may not be adequate for Hispanic adults to change their behaviors.

PURPOSE: To examine associations of adolescent sugar-sweetened beverage (SSB) intake with parent SSB intake and parent and adolescent knowledge of SSB-related health risks. DESIGN: Quantitative, cross-sectional. SETTING: 2014 SummerStyles survey. SUBJECTS: Nine hundred and ninety parent and adolescent (12-17 years) pairs. MEASURES: The outcome was self-reported adolescent intake (0, >0 to <1, or >/=1 time/day) of SSBs (soda, fruit drinks, sports/energy drinks, other SSBs). The exposures were self-reported parent SSB intake (0, >0 to <1, >/=1 to <2, or >/=2 times/day) and parent and adolescent knowledge of SSB-related health risks (weight gain, diabetes, and dental caries). ANALYSIS: Separate multinomial logistic regression models were used to estimate adjusted odds ratios (aORs) for adolescent SSB intake >/=1 time/day (ref: 0 times/day), according to (1) parent SSB intake and (2) parent and (3) adolescent knowledge. RESULTS: About 31% of adolescents consumed SSBs >/=1 time/day, and 43.2% of parents consumed SSBs >/=2 times/day. Adolescent and parent knowledge that SSB intake is related to health conditions ranged from 60.7% to 80.4%: weight gain (75.0% and 80.4%, respectively), diabetes (60.7% and 71.4%, respectively), and dental caries (77.5% and 72.9%, respectively). In adjusted models, adolescent SSB intake >/=1 time/day was associated with parent intake >/=2 times/day (aOR = 3.30; 95% confidence interval = 1.62-6.74) but not with parent or adolescent knowledge of health risks. CONCLUSION: Parental SSB intake may be an important factor in understanding adolescent behavior; knowledge of SSB-related health conditions alone may not influence adolescent SSB behavior.

Three isolates of a previously reported novel catalase-negative, Gram-stain-positive, coccoid, alpha-haemolytic, Streptococcus species that were associated with meningoencephalitis in naive weanling mice were further evaluated to confirm their taxonomic status and to determine additional phenotypic and molecular characteristics. Comparative 16S rRNA gene sequence analysis showed nearly identical intra-species sequence similarity (>/=99.9 %), and revealed the closest phylogenetically related species, Streptococcus acidominimus and Streptococcus cuniculi, with 97.0 and 97.5 % sequence similarity, respectively. The rpoB, sodA and recN genes were identical for the three isolates and were 87.6, 85.7 and 82.5 % similar to S. acidominimus and 89.7, 86.2 and 80.7 % similar to S. cuniculi, respectively. In silico DNA-DNA hybridization analyses of mouse isolate 12-5202(T) against S. acidominimus CCUG 27296(T) and S. cuniculi CCUG 65085(T) produced estimated values of 26.4 and 25.7 % relatedness, and the calculated average nucleotide identity values were 81.9 and 81.7, respectively. These data confirm the taxonomic status of 12-5202(T) as a distinct Streptococcus species, and we formally propose the type strain, Streptococcusazizii 12-5202(T) (=CCUG 69378(T)=DSM 103678(T)). The genome of Streptococcus azizii sp. nov. 12-5202(T) contains 2062 total genes with a size of 2.34 Mbp, and an average G+C content of 42.76 mol%.

PURPOSE: To compare the performance of a 1-question survey screener measuring total sugar-sweetened beverage (SSB) intake to a screener measuring SSB types separately using 4 questions. DESIGN: Cross-sectional. SETTING: Web-based 2014 SummerStyles survey. PARTICIPANTS: A total of 4167 US adults (≥18 years). MEASURES: Frequency of SSB intake measured using a 1-question screener was compared to frequency using a 4-question screener (regular soda, fruit drinks, sports/energy drinks, sweetened coffee/tea). SSB intake (number of time/day) was categorized as 0, >0 to <1, and ≥1 time/day; difference in mean intake was calculated between 4 questions versus 1. ANALYSIS: Paired t tests were used, and agreement was evaluated using weighted kappa and Lin's concordance correlation coefficient (CCC). RESULTS: Mean SSB intake was 1.7 (95% confidence interval [CI]: 1.65-1.79) times/day using 4 questions and 0.6 (95% CI: 0.56-0.62) times/day using 1 question ( P < .001). Intake frequency based on 4 questions versus 1 was 16.0% versus 38.5% for 0 time/day, 15.6% versus 42.5% for >0 to <1 time/day, and 68.4% versus 18.9% for ≥1 time/day. There was fair agreement for the 3 SSB intake categories (kappa: .27) and poor absolute agreement between the 2 continuous measures (Lin's CCC: 0.31). CONCLUSION: Daily SSB intake was significantly lower using a 1-question screener versus a 4-question screener. Researchers should assess SSB types separately or consider that daily SSB intake is likely underestimated with 1 question.

It is known that the price of food influences the purchasing and consumption decisions of individuals; however, little work has examined if the price of healthier food relative to unhealthier food in an individual's neighborhood is associated with overall dietary quality while using data from multiple regions in the United States. Cross-sectional person-level data came from The Multi-Ethnic Study of Atherosclerosis (exam 5, 2010-2012 n = 2765); a food frequency questionnaire assessed diet. Supermarket food/beverage prices came from Information Resources Inc. (n = 794 supermarkets). For each individual, the average price of select indicators of healthier foods (vegetables, fruits, dairy) and unhealthier foods (soda, sweets, salty snacks), as well as their ratio, was computed for supermarkets within three miles of the person's residential address. Logistic regression estimated odds ratios of a high-quality diet (top quintile of Healthy Eating Index 2010) associated with healthy-to-unhealthy price ratio, adjusted for individual and neighborhood characteristics. Sensitivity analyses used an instrumental variable (IV) approach. Healthier foods cost nearly twice as much as unhealthier foods per serving on average (mean healthy-to-unhealthy ratio = 1.97 [SD 0.14]). A larger healthy-to-unhealthy price ratio was associated with lower odds of a high-quality diet (OR = 0.76 per SD increase in the ratio, 95% CI = [0.64-0.9]). IV analyses largely confirmed these findings although-as expected with IV adjustment-confidence intervals were wide (OR = 0.82 [0.57-1.19]). Policies to address the large price differences between healthier and unhealthy foods may help improve diet quality in the United States.