Workers in electronics waste and lamp recycling facilities are at risk of exposure to elemental mercury through inhalation of mercury vapor and mercury-containing dust. Employers at an electronics waste and lamp recycling facility in Ohio that crushes mercury-containing lamps expressed concerns about mercury exposure from work processes and requested a health hazard evaluation by CDC's National Institute for Occupational Safety and Health (NIOSH). In April 2023, NIOSH conducted a multidisciplinary investigation to assess elemental and inorganic mercury exposures, including epidemiologic, environmental, and ventilation assessments. Results indicated that mercury vapor was detected throughout the facility, with six of 14 workers having elevated urine mercury levels. These workers had a median job tenure of 8 months; four did not speak English, and five reported symptoms consistent with mercury toxicity, such as metallic or bitter taste, difficulty thinking, and changes in personality. Recommendations included improving the ventilation system, changing work practices to reduce mercury exposure, and providing training and communication tailored to the worker. As the electronic waste recycling industry continues to grow, it is important for employers to evaluate mercury exposure and safeguard employees using a hierarchy of controls. Health departments should consider monitoring occupational mercury exposure in recycling facilities, and clinicians should be aware of the potential for mercury toxicity among workers in these settings.

During responses to outbreaks, the collection and analysis of data on employed case patients' industry and occupation are necessary to better understand the relationship between work and health outcomes. The occurrence of mpox by occupation and industry has not previously been assessed in the context of the 2022 outbreak. We analyzed employment data from 2548 mpox cases reported to the U.S. Centers for Disease Control and Prevention from surveillance systems in seven U.S. jurisdictions and population-based reference data on employment patterns from the U.S. Bureau of Labor Statistics to describe the differential proportionate distribution of cases across occupation and industry groups using the proportionate morbidity ratio. In gender-specific analyses, we found that men employed in certain occupations and industries had a higher relative risk of mpox than others. While occupational transmission cannot be ruled out, it is more likely that individuals with personal and behavioral risk factors for mpox were more likely to work in these occupations and industries. This analysis provides an example of collecting and analyzing occupation and industry data in case reports to understand possible differences in risk by occupation and industry in infectious disease outbreak investigation and help inform resource allocation, messaging, and response.

OBJECTIVES: The risk for mpox virus (MPXV) transmission in most workplaces has not been thoroughly assessed in the context of the 2022 global mpox outbreak. Our objectives were to describe mpox case patients who worked while infectious and the subsequent workplace contact tracing efforts, risk assessments, and outcomes. METHODS: The Centers for Disease Control and Prevention requested information from health departments in the United States in September 2022 to identify people with confirmed or probable mpox who worked outside the home while infectious, either before or after diagnosis, from June 1 through August 31, 2022. We collected and summarized data on demographic, clinical, and workplace characteristics of case patients and workplace contact investigations. We stratified data by industry and occupation categories. RESULTS: In total, 102 case patients were reported by 6 jurisdictions. The most common industries were accommodation and food services (19.8%) and professional business, management, and technical services (17.0%). Contact investigations identified 178 total contacts; 54 cases (52.9%) had no contacts identified. Of 178 contacts, 54 (30.3%) were recommended to receive postexposure prophylaxis (PEP) and 18 (10.1%) received PEP. None of the contacts developed a rash or were tested for orthopox or mpox, and none were reported to have confirmed or probable mpox. CONCLUSION: Data from 6 jurisdictions suggest that the risk of MPXV transmission from workers to others in workplace settings in many industries is low. These findings might support future updates to exposure risk classifications and work activity recommendations for patients. These findings also demonstrate the importance of collecting and analyzing occupation and industry data in case reports to better understand risks in workplaces.

BACKGROUND: Inhalational anthrax is rare and clinical experience limited. Expert guidelines recommend treatment with combination antibiotics including protein synthesis-inhibitors to decrease toxin production and increase survival, although evidence is lacking. METHODS: Rhesus macaques exposed to an aerosol of Bacillus anthracis spores were treated with ciprofloxacin, clindamycin, or ciprofloxacin + clindamycin after becoming bacteremic. Circulating anthrax lethal factor and protective antigen were quantitated pretreatment and 1.5 and 12 hours after beginning antibiotics. RESULTS: In the clindamycin group, 8 of 11 (73%) survived demonstrating its efficacy for the first time in inhalational anthrax, compared to 9 of 9 (100%) with ciprofloxacin, and 8 of 11 (73%) with ciprofloxacin + clindamycin. These differences were not statistically significant. There were no significant differences between groups in lethal factor or protective antigen levels from pretreatment to 12 hours after starting antibiotics. Animals that died after clindamycin had a greater incidence of meningitis compared to those given ciprofloxacin or ciprofloxacin + clindamycin, but numbers of animals were very low and no definitive conclusion could be reached. CONCLUSION: Treatment of inhalational anthrax with clindamycin was as effective as ciprofloxacin in the nonhuman primate. Addition of clindamycin to ciprofloxacin did not enhance reduction of circulating toxin levels.

Community-based interventions may reduce and prevent childhood obesity by transforming the environments in which children live, learn, and play through a series of interventions implemented throughout the community that encourage healthy behaviors. While empirical support is building for the effectiveness of such interventions, little is known about the economic costs and benefits of community-wide childhood obesity interventions. This study examined whether the benefits of a community-wide, child-focused, obesity prevention intervention, Shape Up Somerville: Eat Smart Play Hard (SUS), exceeded its costs by estimating its return on investment. The SUS intervention study occurred in Somerville, Massachusetts (and in two additional geographic areas, which were the study's control group) during the 2003/04 and 2004/05 school years. We estimated SUS's costs using SUS data over the two-year intervention. We estimated benefits (i.e., healthcare costs and productivity losses averted for children and their parents) over a ten-year time horizon using SUS effectiveness results and other sources. SUS generated an estimated $1.51 in savings for every $1.00 invested in the program (return on investment of $0.51). Over ten years, the estimated costs averted were over $500,000 with net benefits of $197,120 (2014 dollars). SUS was estimated to be a cost-saving intervention when examined over a ten-year time horizon. The excess benefits generated by SUS likely arose from the community-wide nature of the intervention which extended exposure (and estimated benefits) beyond children to parents as well. These results illustrate that allocating resources to community-wide, child-focused obesity prevention interventions may be a beneficial investment.

OBJECTIVES: The rate of severe maternal morbidity in the United States increased approximately 200% during 1993-2014. Few studies have reported on the health of the entire pregnant population, including women at low risk for maternal morbidity. This information might be useful for interventions aimed at primary prevention of pregnancy complications. To better understand this, we sought to describe the distribution of comorbid risk among all delivery hospitalizations in Massachusetts and its association with the distribution of severe maternal morbidity. METHODS: Using an existing algorithm, we assigned an obstetric comorbidity index (OCI) score to delivery hospitalizations contained in the Massachusetts pregnancy to early life longitudinal (PELL) data system during 1998-2013. We identified which hospitalizations included severe maternal morbidity and calculated the rate and frequency of these hospitalizations by OCI score. RESULTS: During 1998-2013, PELL contained 1,185,182 delivery hospitalizations; of these 5325 included severe maternal morbidity. Fifty-eight percent of delivery hospitalizations had an OCI score of zero. The mean OCI score increased from 0.60 in 1998 to 0.82 in 2013. Hospitalizations with an OCI score of zero comprised approximately one-third of all deliveries complicated by severe maternal morbidity, but had the lowest rate of severe maternal morbidity (22.8/10,000 delivery hospitalizations). CONCLUSIONS: The mean OCI score increased during the study period, suggesting that an overall increase in risk factors has occurred in the pregnant population in Massachusetts. Interventions that can make small decreases to the mean OCI score could have a substantial impact on the number of deliveries complicated by severe maternal morbidity. Additionally, all delivery facilities should be prepared for severe complications during low-risk deliveries.

Purpose Describe how Ohio and Massachusetts explored severe maternal morbidity (SMM) data, and used these data for increasing awareness and driving practice changes to reduce maternal morbidity and mortality. Description For 2008-2013, Ohio used de-identified hospital discharge records and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify delivery hospitalizations. Massachusetts used existing linked data system infrastructure to identify delivery hospitalizations from birth certificates linked to hospital discharge records. To identify delivery hospitalizations complicated by one or more of 25 SMMs, both states applied an algorithm of ICD-9-CM diagnosis and procedure codes. Ohio calculated a 2013 SMM rate of 144 per 10,000 delivery hospitalizations; Massachusetts calculated a rate of 162. Ohio observed no increase in the SMM rate from 2008 to 2013; Massachusetts observed a 33% increase. Both identified disparities in SMM rates by maternal race, age, and insurance type. Assessment Ohio and Massachusetts engaged stakeholders, including perinatal quality collaboratives and maternal mortality review committees, to share results and raise awareness about the SMM rates and identified high-risk populations. Both states are applying findings to inform strategies for improving perinatal outcomes, such as simulation training for obstetrical emergencies, licensure rules for maternity units, and a focus on health equity. Conclusion Despite data access differences, examination of SMM data informed public health practice in both states. Ohio and Massachusetts maximized available state data for SMM investigation, which other states might similarly use to understand trends, identify high risk populations, and suggest clinical or population level interventions to improve maternal morbidity and mortality.

Racial/ethnic minority groups, particularly African American and Hispanic people, have a disproportionate burden of HIV infection and poor health outcomes despite substantial federal investment to address HIV-related health disparities.1,2 In spring 2011, the US Department of Health and Human Services (HHS) Office of HIV/AIDS and Infectious Disease Policy (OHAIDP) initiated the first of several cross-agency brainstorming discussions on a demonstration project to be funded through the Secretary’s Minority AIDS Initiative Fund (SMAIF) that would address racial/ethnic disparities in HIV/AIDS morbidity and mortality. These discussions, which involved federal staff members from several HHS operating and staff divisions, were the foundation for a new initiative—the Care and Prevention in the United States (CAPUS) Demonstration Project (hereinafter, CAPUS).

BACKGROUND: Zika virus has recently emerged as a novel cause of microcephaly. CDC has asked states to rapidly ascertain and report cases of Zika-linked birth defects, including microcephaly. Massachusetts added head circumference to its birth certificate (BC) in 2011. The accuracy of head circumference measurements from state vital records data has not been reported. METHODS: We sought to assess the accuracy of Massachusetts BC head circumference measurements by comparing them to measurements for 2,217 infants born during 2012-2013 captured in the Massachusetts Birth Defects Monitoring Program (BDMP) data system. BDMP contains information abstracted directly from infant medical records and served as the true head circumference value (i.e., gold standard) for analysis. We calculated the proportion of head circumference measurements in agreement between the BC and BDMP data. We assigned growth chart head circumference percentile categories to each BC and BDMP measurement, and calculated the sensitivity and specificity of BC-based categories to predict BDMP-based categories. RESULTS: No difference was found in head circumference measurements between the two sources in 77.9% (n = 1,727) of study infants. The sensitivity of BC-based head circumference percentile categories ranged from 85.6% (<3rd percentile) to 92.7% (≥90th percentile) and the specificity ranged from 97.6% (≥90th percentile) to 99.3% (<3rd percentile). CONCLUSIONS: BC head circumference measurements agreed with those abstracted from the medical chart the majority of the time. Head circumference measurements on the BC were more specific than sensitive across all standardized growth chart percentile categories.

As the lipidomics field continues to advance, self-evaluation within the community is critical. Here, we performed an interlaboratory comparison exercise for lipidomics using Standard Reference Material (SRM) 1950 Metabolites in Frozen Human Plasma, a commercially available reference material. The interlaboratory study comprised 31 diverse laboratories, with each lab using a different lipidomics workflow. A total of 1527 unique lipids were measured across all laboratories, and consensus location estimates and associated uncertainties were determined for 339 of these lipids measured at the sum composition level by five or more participating laboratories. These evaluated lipids detected in SRM 1950 serve as community-wide benchmarks for intra- and inter-laboratory quality control and method validation. These analyses were performed using non-standardized laboratory-independent workflows. The consensus locations were also compared to a previous examination of SRM 1950 by the LIPID MAPS consortium. While the central theme of the interlaboratory study was to provide values to help harmonize lipids, lipid mediators, and precursor measurements across the community, it was also initiated to stimulate a discussion regarding areas in need of improvement.

Opioid overdose deaths in Massachusetts increased 150% from 2012 to 2015 (1). The proportion of opioid overdose deaths in the state involving fentanyl, a synthetic, short-acting opioid with 50-100 times the potency of morphine, increased from 32% during 2013-2014 to 74% in the first half of 2016 (1-3). In April 2015, the Drug Enforcement Agency (DEA) and CDC reported an increase in law enforcement fentanyl seizures in Massachusetts, much of which was believed to be illicitly manufactured fentanyl (IMF) (4). To guide overdose prevention and response activities, in April 2016, the Massachusetts Department of Public Health and the Office of the Chief Medical Examiner collaborated with CDC to investigate the characteristics of fentanyl overdose in three Massachusetts counties with high opioid overdose death rates. In these counties, medical examiner charts of opioid overdose decedents who died during October 1, 2014-March 31, 2015 were reviewed, and during April 2016, interviews were conducted with persons who used illicit opioids and witnessed or experienced an opioid overdose. Approximately two thirds of opioid overdose decedents tested positive for fentanyl on postmortem toxicology. Evidence for rapid progression of fentanyl overdose was common among both fatal and nonfatal overdoses. A majority of interview respondents reported successfully using multiple doses of naloxone, the antidote to opioid overdose, to reverse suspected fentanyl overdoses. Expanding and enhancing existing opioid overdose education and prevention programs to include fentanyl-specific messaging and practices could help public health authorities mitigate adverse effects associated with overdoses, especially in communities affected by IMF.

In November 2015, a neurologist in the Boston, Massachusetts, area reported four cases of an uncommon amnestic syndrome involving acute and complete ischemia of both hippocampi, as identified by magnetic resonance imaging (MRI), to the Massachusetts Department of Public Health (MDPH) (1). A subsequent e-mail alert, generated by the Massachusetts Board of Registration in Medicine and sent to relevant medical specialists (including neurologists, neuroradiologists, and emergency physicians), resulted in the identification of 10 additional cases that had occurred during 2012-2016. All 14 patients (mean and median age = 35 years) had been evaluated at hospitals in eastern Massachusetts. Thirteen of the 14 patients underwent routine clinical toxicology screening at the time of initial evaluation; eight tested positive for opioids, two for cocaine, and two for benzodiazepines. Apart from sporadic cases (2-6), this combination of clinical and imaging findings has been reported rarely. The apparent temporospatial clustering, relatively young age at onset (19-52 years), and associated substance use among these patients should stimulate further case identification to determine whether these observations represent an emerging syndrome related to substance use or other causes (e.g., a toxic exposure).

OBJECTIVE: Multilevel interventions to prevent underage drinking are more effective than individual-level strategies, and messaging campaigns are key to such approaches. Recognizing the benefits of translating best practices across public health domains, this paper details the communications campaign from Shape Up Somerville (SUS), an exemplar for multilevel community-based approaches to address pediatric obesity, highlighting lessons learned for alcohol educators. METHODS: All elements of SUS, including the communications strategy, were developed collaboratively with local partners. Communication initiatives included community-engaged brand development to unify diverse intervention components; school-based communications to promote new opportunities for healthy eating and physical activity; and media partnerships to promote healthy behaviors community-wide. RESULTS: The overall SUS intervention was effective in reducing prevalence of overweight/obesity among first- to third-graders in Somerville relative to control communities. Process evaluation showed that communications successfully reached diverse community segments and raised awareness of and receptivity to changes. CONCLUSIONS AND PRACTICE IMPLICATIONS: Communications campaigns are essential components of multilevel interventions addressing public health challenges including obesity and underage drinking. Such communications should be developed collaboratively with the target audience and stakeholders, designed to engage community members at multiple levels through multiple channels within a systems framework, and sustained through local partnerships.

This article explores how the ACA's community health needs assessment requirement and the Community Reinvestment Act can encourage collaboration among tax-exempt hospitals, public health agencies, financial institutions, and communities to improve population health through aligned health improvement planning and initiatives to address social, economic, and environmental factors that affect health.

Childhood obesity is a serious national health problem with 17% of American youth living with obesity.1 In 2010, the Patient Protection and Affordable Care Act (ACA) appropriated $25 million for a 4-year community-based study to determine whether an integrated model of primary care and public health services can improve underserved children's risk factors for obesity. In response, the CDC established the Childhood Obesity Research Demonstration (CORD) to meet the requirements of the ACA and address the call by expert groups for comprehensive, multilevel, multisetting approaches to prevent and reduce childhood obesity.2 This commentary introduces the nine articles in this issue that describe the research collaboration funded by the CDC. | Obesity-related health behaviors, such as nutrition and physical activity, are shaped by multiple sources of influence and environments, including the home, early care and education, school, healthcare, and other community settings. Therefore, a host of setting stakeholders who influence these settings, including government, education, the private setting, nonprofit organizations, and families, have a role to play in creating healthier communities. CORD will add to the limited research available on comprehensive, community-wide models for childhood obesity prevention. A recent comparative effectiveness review of the peer-reviewed childhood obesity prevention literature in developed countries found there is a need for more studies that include results from interventions occurring in multiple settings.3 The systematic review found a very limited number of articles with multiple settings and only one community-based, multiple-setting, early childhood obesity prevention study that measured weight and had at least 1 year of follow-up.4 In school-aged youth in the United States, Shape Up Somerville has been novel in its results of reducing BMI over 2 years through a community-based participatory research approach that met the community's interests and strengths and interventions that could be included into existing “platforms” (schools, afterschool, and community).5

OBJECTIVES: We investigated the body mass index (BMI; weight in pounds/[height in inches]2 x 703) of parents whose children participated in Shape Up Somerville (SUS), a community-based participatory research study that altered household, school, and community environments to prevent and reduce childhood obesity. METHODS: SUS was a nonrandomized controlled trial with 30 participating elementary schools in 3 Massachusetts communities that occurred from 2002 to 2005. It included first-, second-, and third-grade children. We used an inverse probability weighting estimator adjusted for clustering effects to isolate the influence of SUS on parent (n = 478) BMI. The model's dependent variable was the change in pre- and postintervention parent BMI. RESULTS: SUS was significantly associated with decreases in parent BMIs. SUS decreased treatment parents' BMIs by 0.411 points (95% confidence interval = -0.725, -0.097) relative to control parents. CONCLUSIONS: The benefits of a community-based environmental change childhood obesity intervention can spill over to parents, resulting in decreased parental BMI. Further research is warranted to examine the effects of this type of intervention on parental health behaviors and health outcomes.