This study addresses the critical need for improved identification of suspected sex trafficking (SST) victims in emergency departments (ED). An analysis of data from the National Syndromic Surveillance Program identified 1,427 SST-related ED visits from January 2019 to December 2023: 1,267 females and 156 males. The highest rates of SST visits were observed in females aged 12–17 (0.37 per 10,000 visits). Rates varied by ethnicity, with American Indian or Alaska Native females at 0.18 per 10,000 visits. Results underscore the importance of diagnosis codes and chief complaint text in identifying SST cases. © 2025 Elsevier B.V., All rights reserved.

BACKGROUND: It is estimated that over 111,000 people in the U.S. died from a drug overdose in the twelve-month period ending in July 2023. More than three-quarters of those deaths were attributed to opioids. Naloxone has long been available in healthcare facilities to reverse opioid overdose rapidly and safely but is not universally accessible for use in community settings where overdoses occur. We conducted a systematic literature review and meta-analysis to assess the effectiveness of overdose education and naloxone distribution (OEND) programs in three types of community settings to reduce overdose deaths among people who use opioids nonmedically. METHODS: We systematically searched electronic databases, including Medline (OVID), Embase (OVID), Psycinfo (OVID), and Global Health (OVID), for peer-reviewed studies of OEND programs published during 2003-2018 (Group 1) that reported overdose outcomes individual level survivals or deaths immediately following naloxone administration. The PRISMA checklist guided screening, quality assessment, and data abstraction. We later identified studies published during 2018-2022 (Group 2), when drug usage and fentanyl-related overdose deaths notably increased, differed from earlier ones. We conducted meta-analyses on both Groups using random effects models to estimate summary survival proportions. RESULTS: Among the 44 Group 1 studies published during 2003-2018, survival did not differ by time (year), location, naloxone dose, or route of administration, but studies of OEND programs serving people who use drugs reported 98.3% (95% CI: 97.5-98.8) survival; those serving family of people who use drugs or other community members reported 95.0% (95% CI: 91.4-97.1) survival; and those for police reported 92.4% (95% CI: 88.9-94.8) survival (p < 0.01). Five Group 2 studies (2018-2022) yielded similar results. CONCLUSIONS: Community-based naloxone distribution programs can be effective in preventing opioid overdose deaths. The paper demonstrates that in the face of increasing overdose deaths over time, survival after naloxone administration has been sustained. The very high survival rates provide clear evidence for public health to continue efforts to expand channels for naloxone distribution in community settings.

OBJECTIVES: To evaluate how postmortem anthropometric malnutrition (PAM) measures align with expert panel attribution of malnutrition as a causal or significant condition in under-5 mortality (U5M). DESIGN: Cohort study using data from the Child Health and Mortality Prevention Surveillance network, incorporating clinical records, postmortem anthropometrics, minimally invasive tissue sampling, clinical abstraction and verbal autopsy to determine multiple causes of death. SETTING/PARTICIPANTS: 1405 deaths of children aged 1-59 months from six African countries between 2016 and 2023. PRIMARY AND SECONDARY OUTCOME MEASURES: PAM was determined using z-scores from the WHO Child Growth Standards: underweight (weight-for-age<(-2)), wasting (arm circumference-for-age or weight-for-length<(-2)) and stunting (length-for-age <(-2)). Performance metrics (sensitivity (SE), specificity (SP) and positive predictive values (PPV)) were calculated to determine the alignment between PAM and expert panel attribution of malnutrition as a causal or significant condition to death. RESULTS: Nearly 75% of cases demonstrated moderate-to-severe malnutrition by PAM, while expert panels attributed malnutrition in 41% of cases. Performance metrics varied across anthropometric indices: underweight exhibited the highest SE (89.7%), while wasting based on arm circumference had the highest SP (81.9%) and PPV (76.8%). Discrepancies between PAM classification and expert panel attribution differed significantly by site, age, location of death and preventability of death (p<0.05). Adjusted multivariate regression showed that expert panel attribution was more likely with increasing severity of PAM. CONCLUSIONS: The proportion of U5M attributable to malnutrition ranged between 41% (expert panel attribution) and 74% (PAM). Variability in classification underscores the need for monitoring and quality improvement measures to address discrepancies. Improved alignment between PAM and panel assessments is essential for accurately identifying malnutrition-related deaths and designing effective interventions to reduce U5M.

Thirty-four per cent of deaths among Americans aged 1-46 are due to injury, and many of these deaths could be prevented if all hospitals performed as well as the highest-performing hospitals. The Institute of Medicine and the National Academies of Science, Engineering and Medicine have called for learning health systems, with emphasis on clinical practice guidelines (CPGs) as a means of limiting preventable deaths. Reduction in mortality has been demonstrated when evidence-based trauma CPGs are adhered to; however, guidelines are variably updated, redundant, absent, inaccessible, or perceived as irrelevant. Ultimately, these barriers result in poor guideline implementation and preventable patient deaths. This multidisciplinary group of injury providers, clinical guidance developers and end users, public health and health policy experts and implementation scientists propose key areas for consideration in the definition of an ideal future state for clinical guidance development and dissemination. Suggestions include (1): professional societies collaborate rather than compete for guideline development.(2) Design primary clinical research for implementation, and where relevant, with guideline development in mind.(3) Select clinical topics for guideline development through systematic prioritization, with an emphasis on patient-centered outcomes.(4) Develop guideline authorship groups with a focus on transparency, equity of opportunity and diversity of representation.(5) Establish a plan for regular review and updating and provide the date the guideline was last updated for transparency.(6) Integrate options for adapting the guideline to local resources and needs at the time of development.(7) Make guidelines available on a platform that allows for open feedback and utilization tracking.(8) Improve discoverability of guidelines.(9) Optimize user-experience with a focus on inclusion of bedside-ready, mobile-friendly infographics, tables or algorithms when feasible.(10) Use open access and open licenses.(11) Disseminate clinical guidance via comprehensive and equitable communication channels. Guidelines are key to improve patient outcomes. The proposed focus to ensure trauma guidelines are equitably and effectively developed and disseminated globally.

INTRODUCTION: Food and nutrition security is crucial for health, but many U.S. households experience food insecurity. This systematic review conducted in support of the Community Preventive Services Task Force (CPSTF) examines the effectiveness of Fruit and Vegetable Incentive (FVI) programs in reducing food insecurity, increasing fruit and vegetable (FV) consumption, and improving health outcomes among households with lower incomes. METHODS: Community Guide systematic review methods were applied. Studies were identified through a literature search (inception of each database to February 2023). U.S. studies were included if they evaluated programs offering participants financial incentives to purchase FV; were designed for or implemented among populations with lower incomes; reported health-related outcomes; and were published in English as peer-reviewed articles or government reports. RESULTS: This review included 30 studies. Thirteen of 14 datapoints from 12 studies indicated FVI programs reduced household food insecurity. Twenty-one of 29 datapoints from 23 studies showed increased FV consumption. Programs providing incentives to participants at risk for or with diet-related health conditions improved blood glucose levels by a median of 0.64 percentage points. DISCUSSION: Based on the review findings, CPSTF recommends FVI programs for populations with lower incomes to reduce household food insecurity, increase household FV consumption, and improve blood glucose levels in participants at risk for or with diet-related health conditions. Although the review did not find direct evidence of reducing health disparities, the CPSTF expects that these programs will improve health equity across the US by improving the affordability and accessibility of healthier foods for households with lower incomes.

Rabies is a fatal encephalitic disease affecting all mammals. This report describes identification of raccoon rabies virus variant isolated from a stray kitten in an urban Midwestern city that is nonendemic for this virus variant. The kitten originally presented with nonspecific neurologic abnormalities. Astute veterinary, wildlife, and public health professionals played a critical role in the identification of this fatal zoonotic disease and the extensive public health and wildlife management response that ensued. This case serves as an important reminder of the risk of rabies in unvaccinated animals or those without known vaccination status, including stray animals.

On September 28, 2023, a kitten aged approximately 6 weeks found in Omaha, Nebraska, had test results positive for rabies at the Nebraska Veterinary Diagnostic Center (NVDC) after dying with neurologic signs and having bitten and scratched its caretakers. Preliminary investigation identified 10 exposed persons for whom postexposure prophylaxis (PEP)(†) was recommended. Subsequent variant-typing by NVDC yielded a presumptive positive result for the Eastern raccoon rabies virus variant (RRVV), which CDC confirmed on October 6.

Respiratory syncytial virus (RSV) is the second most common pathogen causing infant mortality. Additionally, RSV is a major cause of morbidity and mortality in older adults (age ≥60 years) similar to influenza. A protein-based maternal vaccine and monoclonal antibody (mAb) are now market-approved to protect infants, while an mRNA and two protein-based vaccines are approved for older adults. First-year experience protecting infants with nirsevimab in high-income countries shows a major public health benefit. It is expected that the RSV vaccine landscape will continue to develop in the coming years to protect all people globally. The vaccine and mAb landscape remain active with 30 candidates in clinical development using four approaches: protein-based, live-attenuated and chimeric vector, mRNA, and mAbs. Candidates in late-phase trials aim to protect young infants using mAbs, older infants and toddlers with live-attenuated vaccines, and children and adults using protein-based and mRNA vaccines. This Review provides an overview of RSV vaccines highlighting different target populations, antigens, and trial results. As RSV vaccines have not yet reached low-income and middle-income countries, we outline urgent next steps to minimise the vaccine delay.

The enduring spread of COVID-19 and other respiratory viruses highlights a need for greater focus on long-term public willingness to perform protective behaviors. Although COVID-19 is no longer considered a public health emergency of international concern, it is unknown whether people in the United States plan to continue protective behaviors to protect themselves and others against infection. To inform planning and communications, we used a nationally representative survey of 1,936 US adults to examine attitudes and intentions toward future vaccination and mask-wearing. A majority believed COVID-19 vaccines were safe (73%) and effective in protecting against serious illness (72%). One-third (33%) had strong intentions to get an updated COVID-19 vaccine most years in the future. Among those with weaker intentions (n=1,287), many cited concerns about safety (71%) and efficacy (64%), lack of trust in institutions (64%), or beliefs that prior vaccination or infection protected them (62%). Approximately two-thirds (69%) of respondents believed masks were effective in protecting the wearer from getting COVID-19, and a majority appeared moderately receptive to future public mask-wearing, particularly when there was proximate risk of infection from COVID-19 (67%) or other respiratory viruses (59%). Men, non-Hispanic White adults, younger adults, rural residents, and adults with higher incomes, without college degrees, and without serious medical conditions or physical limitations were more likely to indicate resistance toward future COVID-19 vaccination and/or mask-wearing. Findings support tailored messaging to address concerns and opportunities among different populations, as well as support for communications programs and community engagement to motivate future uptake.

Traffic-related pedestrian deaths in the United States reached a 40-year high in 2021. Each year, pedestrians also suffer nonfatal traffic-related injuries requiring medical treatment. Near real-time emergency department visit data from CDC's National Syndromic Surveillance Program during January 2021-December 2023 indicated that among approximately 301 million visits identified, 137,325 involved a pedestrian injury (overall visit proportion = 45.62 per 100,000 visits). The proportions of visits for pedestrian injury were 1.53-2.47 times as high among six racial and ethnic minority groups as that among non-Hispanic White persons. Compared with persons aged ≥65 years, proportions among those aged 15-24 and 25-34 years were 2.83 and 2.61 times as high, respectively. The visit proportion was 1.93 times as high among males as among females, and 1.21 times as high during September-November as during June-August. Timely pedestrian injury data can help collaborating federal, state, and local partners rapidly monitor trends, identify disparities, and implement strategies supporting the Safe System approach, a framework for preventing traffic injuries among all road users.

IMPORTANCE: Pregnant people and infants are at high risk of severe COVID-19 outcomes. Understanding changes in attitudes toward COVID-19 vaccines among pregnant and recently pregnant people is important for public health messaging. OBJECTIVE: To assess attitudinal trends regarding COVID-19 vaccines by (1) vaccination status and (2) race, ethnicity, and language among samples of pregnant and recently pregnant Vaccine Safety Datalink (VSD) members from 2021 to 2023. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional surveye study included pregnant or recently pregnant members of the VSD, a collaboration of 13 health care systems and the US Centers for Disease Control and Prevention. Unvaccinated, non-Hispanic Black, and Spanish-speaking members were oversampled. Wave 1 took place from October 2021 to February 2022, and wave 2 took place from November 2022 to February 2023. Data were analyzed from May 2022 to September 2023. EXPOSURES: Self-reported or electronic health record (EHR)-derived race, ethnicity, and preferred language. MAIN OUTCOMES AND MEASURES: Self-reported vaccination status and attitudes toward monovalent (wave 1) or bivalent Omicron booster (wave 2) COVID-19 vaccines. Sample- and response-weighted analyses assessed attitudes by vaccination status and 3 race, ethnicity, and language groupings of interest. RESULTS: There were 1227 respondents; all identified as female, the mean (SD) age was 31.7 (5.6) years, 356 (29.0%) identified as Black race, 555 (45.2%) identified as Hispanic ethnicity, and 445 (36.3%) preferred the Spanish language. Response rates were 43.5% for wave 1 (652 of 1500 individuals sampled) and 39.5% for wave 2 (575 of 1456 individuals sampled). Respondents were more likely than nonrespondents to be White, non-Hispanic, and vaccinated per EHR. Overall, 76.8% (95% CI, 71.5%-82.2%) reported 1 or more COVID-19 vaccinations; Spanish-speaking Hispanic respondents had the highest weighted proportion of respondents with 1 or more vaccination. Weighted estimates of somewhat or strongly agreeing that COVID-19 vaccines are safe decreased from wave 1 to 2 for respondents who reported 1 or more vaccinations (76% vs 50%; χ21 = 7.8; P < .001), non-Hispanic White respondents (72% vs 43%; χ21 = 5.4; P = .02), and Spanish-speaking Hispanic respondents (76% vs 53%; χ21 = 22.8; P = .002). CONCLUSIONS AND RELEVANCE: Decreasing confidence in COVID-19 vaccine safety in a large, diverse pregnant and recently pregnant insured population is a public health concern.

OBJECTIVES: To assess postmortem vitamin A (VA) concentrations in children under 5 years of age and evaluate the association between vitamin A deficiency (VAD) and infectious causes of death (CoD). STUDY DESIGN: In this cross-sectional study from the Child Health and Mortality Prevention Surveillance (CHAMPS) Network, liver biopsies collected within 72 hours of death were analyzed from 405 stillbirths and children under 5 years in Kenya and South Africa. Total liver vitamin A (VA) concentrations were quantified using ultra-performance liquid chromatography, and cutoffs of ≤0.1 μmol/g, >0.1 to <0.7 μmol/g, ≥0.7 to <1.0 μmol/g, and ≥1.0 μmol/g were used to define VAD, adequate VA status, high VA, and hypervitaminosis A, respectively. Causes of death (CoD) were determined by expert panel review. RESULTS: Among 366 liver samples with viable extraction, pooled prevalences of VAD, adequacy, high VA, and hypervitaminosis were 34.2%, 51.1%, 6.0%, and 8.7%, respectively. VAD was more common among neonates compared with stillbirths, infants, or children, and among those with low birthweight, underweight, or stunting (p<0.05). When adjusting for site, age, and sex, there was no significant association of VAD with increased infectious CoD (OR 1.9, 95%CI 0.9, 3.8, p=0.073). In stratified analyses, VA deficient boys, but not girls, had an increased risk of infectious CoD (OR 3.4, 95%CI 1.3, 10.3, p=0.013). CONCLUSIONS: Definitive post-mortem assessment of VA status identified both VAD and VA excess among children under 5 years of age in Kenya and South Africa. VAD in boys was associated with increased risk of infectious mortality. Our findings may inform a transition from universal VA supplementation to targeted strategies in certain countries.

The COVID-19 pandemic has highlighted the need for research about communicating with populations who have limited English proficiency in the United States during infectious disease outbreaks. These populations have experienced significantly worse health outcomes during emergencies, including the COVID-19 pandemic, and evidence-based risk communications are critical to protecting their health. To support improved development of emergency communications for these communities, we conducted a scoping review that examined the extent of research available, with an intent to identify which communications topics are covered in the literature and where research gaps exist. Following the JBI framework, with reporting guided by the PRISMA extension for scoping reviews, 6 electronic databases were systematically searched in October 2022. The inclusion criteria for articles selected were: data collected between 2009 and 2022, published in English, and focused on communications pertaining to emergency infectious disease outbreaks (eg, H1N1 influenza, Zika virus, COVID-19) for populations with limited English proficiency. Of 2,049 articles identified through the search, 31 met the inclusion criteria and were selected for review. We identified major limitations in the evidence base: a majority of studies were conducted only among Spanish speakers or during the COVID-19 pandemic, and most used qualitative or nonrandom samples. Most studies documented basic language barriers in communications, but there was little exploration of more nuanced barriers, such as cultural relevance or social context. Ahead of future outbreaks, more research is urgently needed to examine the information landscapes of populations with limited English proficiency, to inform the development of more effective communications strategies from public health institutions and others.

Vaccination equity is a national priority, but the extent to which participants in vaccine safety studies reflect the US population is unclear. The Vaccine Safety Datalink (VSD) is a collaboration between the CDC and thirteen healthcare organizations and databases, known as “sites”, with over 15 million members as of 2023. Sites contribute electronic health record data toward large studies of vaccine safety and coverage. 1 The aim of this study was to describe the reporting of race and ethnicity in Vaccine Safety Datalink (VSD) publications from 2011-2022.

During April 30-August 4, 2023, smoke originating from wildfires in Canada affected most of the contiguous United States. CDC used National Syndromic Surveillance Program data to assess numbers and percentages of asthma-associated emergency department (ED) visits on days with wildfire smoke, compared with days without wildfire smoke. Wildfire smoke days were defined as days when concentrations of particulate matter (particles generally ≤2.5 μm in aerodynamic diameter) (PM(2.5)) triggered an Air Quality Index ≥101, corresponding to the air quality categorization, "Unhealthy for Sensitive Groups." Changes in asthma-associated ED visits were assessed across U.S. Department of Health and Human Services regions and by age. Overall, asthma-associated ED visits were 17% higher than expected during the 19 days with wildfire smoke that occurred during the study period; larger increases were observed in regions that experienced higher numbers of continuous wildfire smoke days and among persons aged 5-17 and 18-64 years. These results can help guide emergency response planning and public health communication strategies, especially in U.S. regions where wildfire smoke exposure was previously uncommon.

PURPOSE: State and local public health departments (LHDs) are encouraged to collaborate with community-based organizations (CBOs) to enhance communication and promote protective practices with communities made vulnerable during emergencies, but there is little evidence-based understanding of practical approaches to fostering collaboration in this context. This research focuses on how collaboration enhances LHD capacity for effective communication for people with limited English proficiency (LEP) during infectious disease outbreaks specifically and strategies to facilitate productive LHD-CBO collaboration. DESIGN: Qualitative, telephone interviews, conducted March-October 2021. SETTING: Rural and urban jurisdictions with Chinese-speaking or Spanish-speaking populations across the United States. PARTICIPANTS: 36 LHD and 31 CBO staff working on outreach to Chinese and Spanish speakers during COVID-19. METHOD: Interviews were audio-recorded, transcribed verbatim, and analyzed using a team-based, codebook approach to thematic analysis. RESULTS: During COVID-19, CBOs extended LHD capacity to develop and disseminate effective communication, meaning communication that is rapidly in-language, culturally resonant, locally relevant, and trusted. Practical strategies to enable and sustain effective collaboration were needed to address operational dimensions (eg, material and administrative) and relational dimensions (eg, promoting trust and respect). CONCLUSION: Policies and financing to support LHD-CBO collaborations are critical to improving communication with people with LEP and addressing long-standing inequities in outcomes during outbreaks.

This article describes a significant decline in emergency department visits for acute life-threatening conditions during the COVID-19 pandemic, suggesting that patients may be delaying or avoiding care or unable to access care during the pandemic.

Beginning December 6, 2021, all international air passengers boarding flights to the United States were required to show either a negative result from a SARS-CoV-2 viral test taken ≤1 day before departure or proof of recovery from COVID-19 within the preceding 90 days (1). As of June 12, 2022, predeparture testing was no longer mandatory but remained recommended by CDC (2,3). Various modeling studies have estimated that predeparture testing the day before or the day of air travel reduces transmission or importation of SARS-CoV-2 by 31%-76% (4-7). Postarrival SARS-CoV-2 pooled testing data from CDC's Traveler-based Genomic Surveillance program were used to compare SARS-CoV-2 test results among volunteer travelers arriving at four U.S. airports during two 12-week periods: March 20-June 11, 2022, when predeparture testing was required, and June 12-September 3, 2022, when predeparture testing was not required. In a multivariable logistic regression model, pooled nasal swab specimens collected during March 20-June 11 were 52% less likely to be positive for SARS-CoV-2 than were those collected during June 12-September 3, after adjusting for COVID-19 incidence in the flight's country of origin, sample pool size, and collection airport (adjusted odds ratio [aOR] = 0.48, 95% CI = 0.39-0.58) (p<0.001). These findings support predeparture testing as a tool for reducing travel-associated SARS-CoV-2 transmission and provide important real-world evidence that can guide decisions for future outbreaks and pandemics.

INTRODUCTION: Adults with vision impairment may have unique needs when accessing health care to maintain good health. Our study examined the relationship between vision status and access to and use of health care. METHODS: We analyzed data on adults aged 18 years or older who participated in the 2018 Behavioral Risk Factor Surveillance System. Vision impairment was identified by a yes response to the question "Are you blind or do you have serious difficulty seeing, even when wearing glasses?" Survey questions assessed health care access over the past year (having health insurance coverage, a usual health care provider, or unmet health care needs because of cost) and use of health care during that period (routine checkup and dental visit). We estimated age-adjusted prevalence of our outcomes of interest and used bivariate analyses to compare estimates of the outcomes by vision impairment status. RESULTS: The prevalence of self-reported vision impairment was 5.3%. Compared with adults without impaired vision, adults with vision impairment had a lower prevalence of having health insurance coverage (80.6% vs 87.6%), a usual health care provider (71.9% vs 75.7%), or a dental visit in the past year (52.9% vs 67.2%) and a higher prevalence of having an unmet health care need in the past year because of cost (29.2% vs 12.6%). CONCLUSION: Adults with vision impairment reported lower access to and use of health care than those without. Further research can better identify and understand barriers to care to improve access to and use of health care among this population.

Increases in severe respiratory illness and acute flaccid myelitis (AFM) among children and adolescents resulting from enterovirus D68 (EV-D68) infections occurred biennially in the United States during 2014, 2016, and 2018, primarily in late summer and fall. Although EV-D68 annual trends are not fully understood, EV-D68 levels were lower than expected in 2020, potentially because of implementation of COVID-19 mitigation measures (e.g., wearing face masks, enhanced hand hygiene, and physical distancing) (1). In August 2022, clinicians in several geographic areas notified CDC of an increase in hospitalizations of pediatric patients with severe respiratory illness and positive rhinovirus/enterovirus (RV/EV) test results.* Surveillance data were analyzed from multiple national data sources to characterize reported trends in acute respiratory illness (ARI), asthma/reactive airway disease (RAD) exacerbations, and the percentage of positive RV/EV and EV-D68 test results during 2022 compared with previous years. These data demonstrated an increase in emergency department (ED) visits by children and adolescents with ARI and asthma/RAD in late summer 2022. The percentage of positive RV/EV test results in national laboratory-based surveillance and the percentage of positive EV-D68 test results in pediatric sentinel surveillance also increased during this time. Previous increases in EV-D68 respiratory illness have led to substantial resource demands in some hospitals and have also coincided with increases in cases of AFM (2), a rare but serious neurologic disease affecting the spinal cord. Therefore, clinicians should consider AFM in patients with acute flaccid limb weakness, especially after respiratory illness or fever, and ensure prompt hospitalization and referral to specialty care for such cases. Clinicians should also test for poliovirus infection in patients suspected of having AFM because of the clinical similarity to acute flaccid paralysis caused by poliovirus. Ongoing surveillance for EV-D68 is critical to ensuring preparedness for possible future increases in ARI and AFM.

In November 2021, CDC was notified of a cluster of previously healthy children with hepatitis of unknown etiology evaluated at a single U.S. hospital (1). On April 21, 2022, following an investigation of this cluster and reports of similar cases in Europe (2,3), a health advisory* was issued requesting U.S. providers to report pediatric cases(†) of hepatitis of unknown etiology to public health authorities. In the United States and Europe, many of these patients have also received positive adenovirus test results (1,3). Typed specimens have indicated adenovirus type 41, which typically causes gastroenteritis (1,3). Although adenovirus hepatitis has been reported in immunocompromised persons, adenovirus is not a recognized cause of hepatitis in healthy children (4). Because neither acute hepatitis of unknown etiology nor adenovirus type 41 is reportable in the United States, it is unclear whether either has recently increased above historical levels. Data from four sources were analyzed to assess trends in hepatitis-associated emergency department (ED) visits and hospitalizations, liver transplants, and adenovirus stool testing results among children in the United States. Because of potential changes in health care-seeking behavior during 2020-2021, data from October 2021-March 2022 were compared with a pre-COVID-19 pandemic baseline. These data do not suggest an increase in pediatric hepatitis or adenovirus types 40/41 above baseline levels. Pediatric hepatitis is rare, and the relatively low weekly and monthly counts of associated outcomes limit the ability to interpret small changes in incidence. Ongoing assessment of trends, in addition to enhanced epidemiologic investigations, will help contextualize reported cases of acute hepatitis of unknown etiology in U.S. children.

STUDY OBJECTIVE: We describe trends in emergency department (ED) visits for initial firearm injury encounters in the United States. METHODS: Using data from the Centers for Disease Control and Prevention's National Syndromic Surveillance Program, we analyzed monthly and yearly trends in ED visit rates involving a firearm injury (calculated as the number of firearm injury-related ED visits divided by the total number of ED visits for each month and multiplied by 100,000) by sex-specific age group and US region from 2018 to 2019 and conducted Joinpoint regression to detect trend significance. RESULTS: Among approximately 215 million ED visits captured in the National Syndromic Surveillance Program from January 2018 to December 2019, 132,767 involved a firearm injury (61.6 per 100,000 ED visits). Among males, rates of firearm injury-related ED visits significantly increased for all age groups between 15 and 64 years during the study period. Among females, rates of firearm injury-related ED visits significantly increased for all age groups between 15 and 54 years during the study period. By region, rates significantly changed in the northeast, southeast, and southwest for males and females during the study period. CONCLUSION: These analyses highlight a novel data source for monitoring trends in ED visits for firearm injuries. With increased and effective use of state and local syndromic surveillance data, in addition to improvements to firearm injury syndrome definitions by intent, public health professionals could better detect unusual patterns of firearm injuries across the United States for improved prevention and tailored response efforts.

Drzymalla Emily, Gladish Nicole, Koen Nastassja, Epstein Michael P, Kobor Michael S, Zar Heather J, Stein Dan J, Hüls Anke. Translational psychiatry 2021 11(1) 572

The Centers for Disease Control and Prevention explored use of emergency department (ED) visit data, during 2018-2020, from the National Syndromic Surveillance Program to monitor vaccine-associated adverse events (VAE) among all age groups. A combination of chief complaint terms and administrative diagnosis codes were used to detect VAE-related ED visits. Postvaccination fever was among the top 10 most frequently noted diagnoses. VAE annual trends demonstrated seasonality; visits trended upward starting in September of each year, coinciding with the administration of seasonal influenza vaccines. The 2020 VAE-related visit trend declined below the 2018 and 2019 baselines during March 22-September 5, 2020, before returning to the seasonal pattern. VAE-related visits declined in children aged 3-18 years in 2020 compared with 2018-2019, especially in the back-to-school months. These findings demonstrate that syndromic surveillance can complement traditional VAE reporting systems without an additional demand on data collection resources.

Beginning in March 2020, the COVID-19 pandemic and response, which included physical distancing and stay-at-home orders, disrupted daily life in the United States. Compared with the rate in 2019, a 31% increase in the proportion of mental health-related emergency department (ED) visits occurred among adolescents aged 12-17 years in 2020 (1). In June 2020, 25% of surveyed adults aged 18-24 years reported experiencing suicidal ideation related to the pandemic in the past 30 days (2). More recent patterns of ED visits for suspected suicide attempts among these age groups are unclear. Using data from the National Syndromic Surveillance Program (NSSP),* CDC examined trends in ED visits for suspected suicide attempts(†) during January 1, 2019-May 15, 2021, among persons aged 12-25 years, by sex, and at three distinct phases of the COVID-19 pandemic. Compared with the corresponding period in 2019, persons aged 12-25 years made fewer ED visits for suspected suicide attempts during March 29-April 25, 2020. However, by early May 2020, ED visit counts for suspected suicide attempts began increasing among adolescents aged 12-17 years, especially among girls. During July 26-August 22, 2020, the mean weekly number of ED visits for suspected suicide attempts among girls aged 12-17 years was 26.2% higher than during the same period a year earlier; during February 21-March 20, 2021, mean weekly ED visit counts for suspected suicide attempts were 50.6% higher among girls aged 12-17 years compared with the same period in 2019. Suicide prevention measures focused on young persons call for a comprehensive approach, that is adapted during times of infrastructure disruption, involving multisectoral partnerships (e.g., public health, mental health, schools, and families) and implementation of evidence-based strategies (3) that address the range of factors influencing suicide risk.

The incidence of tickborne diseases in the United States is increasing; reported cases more than doubled from >22,000 in 2004 to >48,000 in 2016 (1). Ticks are responsible for approximately 95% of all locally acquired vectorborne diseases reported by states and the District of Columbia, with Lyme disease accounting for >80% of those cases (2). After a tick bite, persons might seek care at an emergency department (ED) for tick removal and to receive postexposure prophylaxis, which has been shown to effectively prevent Lyme disease when taken within 72 hours of a high-risk bite (3). Using data from CDC's National Syndromic Surveillance Program (NSSP), investigators examined ED tick bite visits during January 2017-December 2019 by sex, age group, U.S. region, and seasonality. During this 36-month period, 149,364 ED tick bite visits were identified. Mean cumulative incidence was 49 ED tick bite visits per 100,000 ED visits overall; incidence was highest in the Northeast (110 per 100,000 ED visits). The seasonal distribution of ED tick bite visits was bimodal: the larger peak occurred during the spring and early summer, and the smaller peak occurred in the fall. This pattern aligns with the seasonality of a known and abundant human-biter, the blacklegged tick, Ixodes scapularis (4). Compared with other age groups, pediatric patients aged 0-9 years accounted for the highest number and incidence of ED tick bite visits; incidence was higher among male patients than among females. Tick bites are not monitored by current surveillance systems because a tick bite is an event that in and of itself is not a reportable condition to health departments. Syndromic surveillance of ED tick bite visits can provide timely information that might predict temporal and geographic risk for exposure to tickborne diseases and guide actionable public health messaging such as avoiding tick habitats, wearing repellent consistently when outdoors, and performing regular tick checks during times of increased tick bite risk.

Hispanic or Latino (Hispanic), non-Hispanic Black or African American (Black), and non-Hispanic American Indian or Alaska Native (AI/AN) persons have experienced disproportionately higher rates of hospitalization and death attributable to COVID-19 than have non-Hispanic White (White) persons (1-4). Emergency care data offer insight into COVID-19 incidence; however, differences in use of emergency department (ED) services for COVID-19 by racial and ethnic groups are not well understood. These data, most of which are recorded within 24 hours of the visit, might be an early indicator of changing patterns in disparities. Using ED visit data from 13 states obtained from the National Syndromic Surveillance Program (NSSP), CDC assessed the number of ED visits with a COVID-19 discharge diagnosis code per 100,000 population during October-December 2020 by age and race/ethnicity. Among 5,794,050 total ED visits during this period, 282,220 (4.9%) were for COVID-19. Racial/ethnic disparities in COVID-19 ED visit rates were observed across age groups. Compared with White persons, Hispanic, AI/AN, and Black persons had significantly more COVID-19-related ED visits overall (rate ratio [RR] range = 1.39-1.77) and in all age groups through age 74 years; compared with White persons aged ≥75 years, Hispanic and AI/AN persons also had more COVID-19-related ED visits (RR = 1.91 and 1.22, respectively). These differences in ED visit rates suggest ongoing racial/ethnic disparities in COVID-19 incidence and can be used to prioritize prevention resources, including COVID-19 vaccination, to reach disproportionately affected communities and reduce the need for emergency care for COVID-19.

IMPORTANCE: Risks for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among health care personnel (HCP) are unclear. OBJECTIVE: To evaluate the risk factors associated with SARS-CoV-2 seropositivity among HCP with the a priori hypothesis that community exposure but not health care exposure was associated with seropositivity. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted among volunteer HCP at 4 large health care systems in 3 US states. Sites shared deidentified data sets, including previously collected serology results, questionnaire results on community and workplace exposures at the time of serology, and 3-digit residential zip code prefix of HCP. Site-specific responses were mapped to a common metadata set. Residential weekly coronavirus disease 2019 (COVID-19) cumulative incidence was calculated from state-based COVID-19 case and census data. EXPOSURES: Model variables included demographic (age, race, sex, ethnicity), community (known COVID-19 contact, COVID-19 cumulative incidence by 3-digit zip code prefix), and health care (workplace, job role, COVID-19 patient contact) factors. MAIN OUTCOME AND MEASURES: The main outcome was SARS-CoV-2 seropositivity. Risk factors for seropositivity were estimated using a mixed-effects logistic regression model with a random intercept to account for clustering by site. RESULTS: Among 2 749 HCP, most were younger than 50 years (17 233 [69.6%]), were women (19 361 [78.2%]), were White individuals (15 157 [61.2%]), and reported workplace contact with patients with COVID-19 (12 413 [50.2%]). Many HCP worked in the inpatient setting (8893 [35.9%]) and were nurses (7830 [31.6%]). Cumulative incidence of COVID-19 per 10 000 in the community up to 1 week prior to serology testing ranged from 8.2 to 275.6; 20 072 HCP (81.1%) reported no COVID-19 contact in the community. Seropositivity was 4.4% (95% CI, 4.1%-4.6%; 1080 HCP) overall. In multivariable analysis, community COVID-19 contact and community COVID-19 cumulative incidence were associated with seropositivity (community contact: adjusted odds ratio [aOR], 3.5; 95% CI, 2.9-4.1; community cumulative incidence: aOR, 1.8; 95% CI, 1.3-2.6). No assessed workplace factors were associated with seropositivity, including nurse job role (aOR, 1.1; 95% CI, 0.9-1.3), working in the emergency department (aOR, 1.0; 95% CI, 0.8-1.3), or workplace contact with patients with COVID-19 (aOR, 1.1; 95% CI, 0.9-1.3). CONCLUSIONS AND RELEVANCE: In this cross-sectional study of US HCP in 3 states, community exposures were associated with seropositivity to SARS-CoV-2, but workplace factors, including workplace role, environment, or contact with patients with known COVID-19, were not. These findings provide reassurance that current infection prevention practices in diverse health care settings are effective in preventing transmission of SARS-CoV-2 from patients to HCP.

BACKGROUND: Prescribing naloxone to patients at increased opioid overdose risk is a key component of opioid overdose prevention efforts, but little is known about naloxone fills among patients receiving buprenorphine for opioid use disorder, one such high risk group. METHODS: This retrospective cross-sectional study used de-identified pharmacy claims representing 90% of all prescriptions filled at retail pharmacies in 50 states and the District of Columbia. We performed a multivariable logistic regression to examine filled naloxone prescriptions among patients receiving buprenorphine treatment and assessed how filled naloxone prescriptions vary by patient, prescriber, and community characteristics. RESULTS: Filled naloxone prescriptions occurred among 4.5% of buprenorphine treatment episodes. Episodes paid through Medicaid (aOR 2.40, 95%CI 2.33-2.47) and Medicare (aOR 1.53, 95%CI 1.46-1.60) had higher odds of filled naloxone prescriptions than commercial insurance episodes. Compared to episodes where the primary prescriber was an adult primary care physician, odds of filling a naloxone prescription were higher among episodes prescribed by addiction specialists (aOR 1.30, 95% CI 1.24-1.37) and physician assistants/nurse practitioners (aOR 1.57, 95% CI 1.53-1.61). CONCLUSIONS: Prescribing naloxone to patients receiving buprenorphine represents a tangible clinical action that can be taken to help prevent opioid overdose deaths. However, despite recommendations to co-prescribe naloxone to patients at increased risk for opioid overdose, rates of filling naloxone prescriptions remain low among patients dispensed buprenorphine. States, insurers, and health systems should consider implementing strategies to facilitate increased co-prescribing of naloxone to at-risk individuals.