Monkeypox virus (MPXV) is a re-emerging virus of global concern. An outbreak of Clade I MPXV affected 20 captive chimpanzees in Cameroon in 2016. We describe the epidemiology, virology, phylogenetics, and clinical progression of this outbreak. Clinical signs included exanthema, facial swelling, peri-laryngeal swelling, and eschar. Mpox can be lethal in captive chimpanzees with death likely resulting from respiratory complications. We advise avoiding anesthesia in animals with respiratory signs to reduce the likelihood of death. This outbreak presented a risk to animal care staff. There is a need for increased awareness and a One Health approach to preparation for outbreaks in wildlife rescue centers in primate range states where MPXV occurs. Control measures should include quarantining affected animals, limiting human contacts, surveillance of humans and animals, use of personal protective equipment, and regular decontamination of enclosures.

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.

ABSTRACTDespite the human immunodeficiency virus (HIV) pandemic continuing worldwide for 40 years, no vaccine to combat the disease has been licensed for use in at risk populations. Here, we describe a novel recombinant vesicular stomatitis virus (rVSV) vector vaccine expressing modified HIV envelope glycoproteins and Ebola virus glycoprotein. Three heterologous immunizations successfully prevented infection by a different clade SHIV in 60% of nonhuman primates (NHPs). No trend was observed between resistance and antibody interactions. Resistance to infection was associated with high proportions of central memory T cell CD69 and CD154 marker upregulation, increased IL-2 production, and a reduced IFN-γ response, offering insight into correlates of protection.

In urban areas, exposure to greenspace has been found to be beneficial to human health. The biodiversity hypothesis proposed that exposure to diverse ambient microbes in greener areas may be one pathway leading to health benefits such as improved immune system functioning, reduced systemic inflammation, and ultimately reduced morbidity and mortality. Previous studies observed differences in ambient outdoor bacterial diversity between areas of high and low vegetated land cover but didn't focus on residential environments which are important to human health. This research examined the relationship between vegetated land and tree cover near residence and outdoor ambient air bacterial diversity and composition. We used a filter and pump system to collect ambient bacteria samples outside residences in the Raleigh-Durham-Chapel Hill metropolitan area and identified bacteria by 16S rRNA amplicon sequencing. Geospatial quantification of total vegetated land or tree cover was conducted within 500 m of each residence. Shannon's diversity index and weighted UniFrac distances were calculated to measure α (within-sample) and β (between-sample) diversity, respectively. Linear regression for α-diversity and permutational analysis of variance (PERMANOVA) for β-diversity were used to model relationships between vegetated land and tree cover and bacterial diversity. Data analysis included 73 ambient air samples collected near 69 residences. Analysis of β-diversity demonstrated differences in ambient air microbiome composition between areas of high and low vegetated land (p = 0.03) and tree cover (p = 0.07). These relationships remained consistent among quintiles of vegetated land (p = 0.03) and tree cover (p = 0.008) and continuous measures of vegetated land (p = 0.03) and tree cover (p = 0.03). Increased vegetated land and tree cover were also associated with increased ambient microbiome α-diversity (p = 0.06 and p = 0.03, respectively). To our knowledge, this is the first study to demonstrate associations between vegetated land and tree cover and the ambient air microbiome's diversity and composition in the residential ecosystem.

INTRODUCTION: The Population Assessment of Tobacco and Health (PATH) Study is a longitudinal cohort study on tobacco use behavior, attitudes and beliefs, and tobacco-related health outcomes, including biomarkers of tobacco exposure in the U.S. population. In this report we provide a summary of urinary nicotine metabolite measurements among adult users and non-users of tobacco from Wave 1 (2013-2014) of the PATH Study. METHODS: Total nicotine and its metabolites including cotinine, trans-3'-hydroxycotinine (HCTT), and other minor metabolites were measured in more than 11 500 adult participants by liquid chromatography tandem mass spectrometry methods. Weighted geometric means (GM) and least square means from statistical modeling were calculated for non-users and users of various tobacco products. RESULTS: Among daily users, the highest GM concentrations of nicotine, cotinine and HCTT were found in exclusive smokeless tobacco users, and the lowest in exclusive e-cigarette users. Exclusive combustible product users had intermediate concentrations, similar to those found in users of multiple products (polyusers). Concentrations increased with age within the categories of tobacco users, and differences associated with gender, race/ethnicity and educational attainment were also noted among user categories. Recent (past 12 months) former users had GM cotinine concentrations that were more than threefold greater than never users. CONCLUSIONS: These urinary nicotine metabolite data provide quantification of nicotine exposure representative of the entire US adult population during 2013-2014 and may serve as a reference for similar analyses in future measurements within this study. IMPLICATIONS: Nicotine and its metabolites in urine provide perhaps the most fundamental biomarkers of recent nicotine exposure. This report, based on Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study, provides the first nationally representative data describing urinary nicotine biomarker concentrations in both non-users, and users of a variety of tobacco products including combustible, e-cigarette and smokeless products. These data provide a urinary biomarker concentration snapshot in time for the entire US population during 2013-2014, and will provide a basis for comparison with future results from continuing, periodic evaluations in the PATH Study.

Falls from residential roofs account for 80% of roofing industry fatalities. Furthermore, roofing work represents 44.7% of work in residual construction specialty trades and residential roofers count for 2.1% of overall workers in construction, with an anticipated growth in roofers of 14.9% by 2024. The purpose of the study was to evaluate the alterations in spatiotemporal gait parameters while traversing along a 6/12 pitched residential roof segment. Eighteen of the nineteen calculated spatiotemporal variables were statistically, significantly changed by walking across a 6/12 pitched simulated residential roof. The study clearly demonstrates that spatiotemporal gait variables increase and decrease while traversing across a residential roof. The changes in spatiotemporal parameters might suggest alterations to a person's balance system resulting in an increased risk of falling. The knowledge generated in the current study will be relevant to the residential roofing industry when it can be used in educational materials to increase awareness of how a roofer's altered gait while working on a pitched roof may increase their falling risk. © 2021

Measurement of skin exposure to particles using interception (e.g., cotton gloves) and removal (e.g., wiping) sampling techniques could be inaccurate because these substrates do not have the same topography and adhesion characteristics as skin. The objective of this study was to compare particle transfer and adherence to cotton gloves, cotton gloves with artificial sebum, and a pre-moistened polyvinyl alcohol (PVA) material with bare human skin (fingertip, palm). Experiments were performed with aluminum oxide powder under standardized conditions for three types of surfaces touched, applied loads, contact times, and powder mass levels. In the final mixed model, the fixed effects of substrate, surface type, applied load, and powder mass and their significant two-way interaction terms explained 71% (transfer) and 74% (adherence) of the observed total variance in measurements. For particle mass transfer, compared with bare skin, bias was -77% (cotton glove with sebum) to +197% (PVA material) and for adherence bias ranged from -40% (cotton glove) to +428% (PVA material), which indicated under- and over-sampling by these substrates, respectively. Dermal exposure assessment would benefit from sampling substrates that better reflect human skin characteristics and more accurately estimate exposures. Mischaracterization of dermal exposure has important implications for exposure and risk assessment.

INTRODUCTION: South Africa is the HIV epidemic epicentre; however, non-communicable diseases (NCDs) will be the most common cause of death by 2030. To improve identification and initiation of care for HIV and NCDs, we assessed proportion of clients referred and linked to care (LTC) for abnormal/positive screening results and time to LTC and treatment initiation from a HIV Testing Services (HTS) Centre before and after integrated testing for NCDs with optional peer-navigated linkage to care. MATERIALS AND METHODS: This two-phase prospective study was conducted at an adult HTS Centre in Soweto, South Africa. Phase 1 (February-June 2018) utilised standard of care (SOC) HTS services (blood pressure [BP], HIV rapid diagnostic testing (RDT), sexually transmitted infections [STI]/Tuberculosis [TB] symptom screening) with passive referral for abnormal/positive results. Phase 2 (June 2018-March 2019) further integrated blood glucose/cholesterol/chlamydia RDT, with optional peer-navigated referral. Enrolled referred clients completed telephonic follow-up surveys confirming LTC/treatment initiation ≤3 months post-screening. Socio-demographics, screening results, time to LTC/treatment initiation, peer-navigated referral uptake were reported. Analysis included Fisher's exact, chi-squared, Kruskal Wallis, and Student's T-tests. Thematic analysis was conducted for open-ended survey responses. RESULTS: Of all 320 referrals, 40.0% were HIV-infections, 11.9% STIs, 6.6% TB, and 28.8% high/low BP. Of Phase 2-only referrals, 29.4% were for glucose and 23.5% cholesterol. Integrated NCD-HTS had significantly more clients LTC for HIV (76.7%[n = 66/86] vs 52.4%[n = 22/42], p = 0.0052) and within a shorter average time (6-8 days [Interquartile range (IQR):1-18.5] vs 8-13 days [IQR:2-32]) as compared to SOC HTS. Integrated NCD-HTS clients initiated HIV/STIs/BP treatment on average more quickly as compared to SOC HTS (5 days for STIs [IQR:1-21], 8 days for HIV/BP [IQR:5-17 and 2-13, respectively] vs 10 days for STIs [IQR: 4-32], 19.5 days for HIV [IQR:6.5-26.5], 8 days for BP [IQR:2-29)]. Participants chose passive over active referral (89.1% vs 10.9%; p<0.0001). Participants rejecting peer-navigated referral preferred to go alone (55.7% [n = 39/70]). Non-LTC was due to being busy (41.1% [n = 39/95]) and not being ready/refusing treatment (31.6% [n = 30/95]). Normalised results assessed at referral clinic (49.7% [n = 98/196]), prescribed lifestyle modification/monitoring (30.9% [n = 61/196]), and poor clinic flow/congestion and/or further testing required (10.7% [n = 21/196]) were associated with non-treatment initiation. CONCLUSION: Same-day treatment initiation is not achieved across diseases, despite peer-navigated referral. There are psychosocial and health systems barriers at entry to care/treatment initiation. Additional research may identify best strategies for rapid treatment initiation.

Residential roofers have the highest rate of falls in the construction sector with injuries and fatalities costing billions of dollars annually. The sloped roof surface is the most predominant component within the residential roof work environment. Postural stability on a sloped work environment is not well studied. Calculating inclination angles (IAs) using the lateral ankle marker could be a quality measure to determine how cross-slope roof walking will influence stability. Will cross-slope roof-walking effect anterior-posterior (AP) and medial-lateral (ML) IAs in adult males? Eleven adult males participated in two testing sessions-level and cross-slope roof gait session on a 6/12 pitched roof segment. Changes in AP and ML IAs between conditions were compared at: heel strike (HS) and toe off (TO). Legs were analyzed separately due to the cross-slope walking. The left foot was 'higher' on the sloped roof and the right was 'lower.' Significant increases (p <= 0.006) in IAs were observed due to the sloped roof in all conditions except the AP 'lower' leg (p = 0.136). Increases in IA suggest a decrease in postural stability as the body will result in greater sway compared to a natural posture. Increases in AP IAs may cause slipping in the anterior or posterior direction as the normal force will decrease during HS and TO. In the ML direction, fall risk is increased and more stress is placed on the hip abductors in order to reduce falling. Thus traversing a sloped roof surface reduces stability of healthy workers and escalates injury/fall risk factors.

INTRODUCTION: The tobacco-specific nitrosamines (TSNAs) are an important group of carcinogens found in tobacco and tobacco smoke. To describe and characterize the levels of TSNAs in the Population Assessment of Tobacco and Health (PATH) Study Wave 1 (2013-2014), we present four biomarkers of TSNA exposure: N'-nitrosonornicotine, N'-nitrosoanabasine, N'-nitrosoanatabine, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) which is the primary urinary metabolite of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone. METHODS: We measured total TSNAs in 11 522 adults who provided urine using automated solid-phase extraction coupled to isotope dilution liquid chromatography-tandem mass spectrometry. After exclusions in this current analysis, we selected 11 004 NNAL results, 10 753 N'-nitrosonornicotine results, 10 919 N'-nitrosoanatabine results, and 10 996 N'-nitrosoanabasine results for data analysis. Geometric means and correlations were calculated using SAS and SUDAAN. RESULTS: TSNA concentrations were associated with choice of tobacco product and frequency of use. Among established, every day, exclusive tobacco product users, the geometric mean urinary NNAL concentration was highest for smokeless tobacco users (993.3; 95% confidence interval [CI: 839.2, 1147.3] ng/g creatinine), followed by all types of combustible tobacco product users (285.4; 95% CI: [267.9, 303.0] ng/g creatinine), poly tobacco users (278.6; 95% CI: [254.9, 302.2] ng/g creatinine), and e-cigarette product users (6.3; 95% CI: [4.7, 7.9] ng/g creatinine). TSNA concentrations were higher in every day users than in intermittent users for all the tobacco product groups. Among single product users, exposure to TSNAs differed by sex, age, race/ethnicity, and education. Urinary TSNAs and nicotine metabolite biomarkers were also highly correlated. CONCLUSIONS: We have provided PATH Study estimates of TSNA exposure among US adult users of a variety of tobacco products. These data can inform future tobacco product and human exposure evaluations and related regulatory activities.

Outbreaks associated with fresh or marine (i.e., untreated) recreational water can be caused by pathogens or chemicals, including toxins. Voluntary reporting of these outbreaks to CDC's National Outbreak Reporting System (NORS) began in 2009. NORS data for 2009-2017 are finalized, and data for 2018-2019 are provisional. During 2009-2019 (as of May 13, 2020), public health officials from 31 states voluntarily reported 119 untreated recreational water-associated outbreaks, resulting at least 5,240 cases; 103 of the outbreaks (87%) started during June-August. Among the 119 outbreaks, 88 (74%) had confirmed etiologies. The leading etiologies were enteric pathogens: norovirus (19 [22%] outbreaks; 1,858 cases); Shiga toxin-producing Escherichia coli (STEC) (19 [22%]; 240), Cryptosporidium (17 [19%]; 237), and Shigella (14 [16%]; 713). This report highlights three examples of outbreaks that occurred during 2018-2019, were caused by leading etiologies (Shigella, norovirus, or STEC), and demonstrate the wide geographic distribution of such outbreaks across the United States. Detection and investigation of untreated recreational water-associated outbreaks are challenging, and the sources of these outbreaks often are not identified. Tools for controlling and preventing transmission of enteric pathogens through untreated recreational water include epidemiologic investigations, regular monitoring of water quality (i.e., testing for fecal indicator bacteria), microbial source tracking, and health policy and communications (e.g., observing beach closure signs and not swimming while ill with diarrhea).

The beach environment creates many barriers to effective sun protection, putting beachgoers at risk for sunburn, a well-established risk factor for skin cancer. Our objective was to estimate incidence of sunburn among beachgoers and evaluate the relationship between sunburn incidence and sun-protective behaviors. A secondary analysis, of prospective cohorts at 12 locations within the U.S. from 2003 to 2009 (n=75,614), were pooled to evaluate sunburn incidence 10-12days after the beach visit. Behavioral and environmental conditions were cross-tabulated with sunburn incidence. Multivariable logistic regression was used to estimate the association between new sunburn and sun-protective behaviors. Overall, 13.1% of beachgoers reported sunburn. Those aged 13-18years (16.5%), whites (16.0%), and those at beach locations along the Eastern Seaboard (16.1%), had the highest incidence of sunburn. For those spending >/=5h in the sun, the use of multiple types of sun protection reduced odds of sunburn by 55% relative to those who used no sun protection (Odds Ratio=0.45 (95% Confidence Interval:0.27-0.77)) after adjusting for skin type, age, and race. Acute health effects of sunburn tend to be mild and self-limiting, but potential long-term health consequences are more serious and costly. Efforts to encourage and support proper sun-protective behaviors, and increase access to shade, protective clothing, and sunscreen, can help prevent sunburn and reduce skin cancer risk among beachgoers.

An ever-changing landscape for environmental health (EH) requires in-depth assessment and analysis of the current challenges and emerging issues faced by EH professionals. The Understanding the Needs, Challenges, Opportunities, Vision, and Emerging Roles in Environmental Health initiative addressed this need.After receiving responses from more than 1700 practitioners, during an in-person workshop, focus groups identified and described priority problems and supplied context on addressing the significant challenges facing EH professionals with state health agencies and local health departments. The focus groups developed specific problem statements detailing the EH profession and workforce's prevailing challenges and needs according to 6 themes, including effective leadership, workforce development, equipment and technology, information systems and data, garnering support, and partnerships and collaboration.We describe the identified priority problems and needs and provide recommendations for ensuring a strong and robust EH profession and workforce ready to address tomorrow's challenges. (Am J Public Health. Published online ahead of print January 16, 2020: e1-e7. doi:10.2105/AJPH.2019.305441).

Objective: In 2018, the Centers for Disease Control Prevention (CDC) published an evidence-based guideline on the diagnosis and management of mild traumatic brain injury (mTBI) among children. This commentary summarizes the key recommendations in the CDC Pediatric mTBI Guideline most relevant for neuropsychologists and discusses research gaps and topics that should receive attention in future iterations of the Guideline. Method: We described the methods used to develop the Guideline, which included a comprehensive Systematic Review. We also distilled and presented key practice strategies reflected in Guideline. Results: To optimize care of pediatric patients with mTBI, neuropsychologists should: use validated, age-appropriate symptom scales, assess evidence-based risk factors for prolonged recovery, provide patients with instructions on return to activity customized to their symptoms, and counsel patients to return gradually to nonsports activities after a short period of rest. Future iterations of the Guideline should encompass a review and guidance on care of patients with psychiatric and psychological difficulties, as well as the potential use of imaging to assess patients with persistent symptoms. Expanded research on mTBI among girls, children age 8 and under, and effective treatments for pediatric mTBI will be beneficial to inform care practices. Conclusions: Recommendations in the CDC Pediatric mTBI Guideline highlight multiple opportunities for neuropsychologists to take action to improve the care of young patients with mTBI and to advance research in the field. Multiple resources and tools are available to support implementation of these recommendations into clinical practice.

Working conditions of residential roofers expose them to a unique sloped environment. The purpose of this study is to determine in what way traversing across a sloped/roof surface alters lower extremity kinematics of the upslope and downslope legs compared to level walking. College aged males negotiated across a pitched (26 degrees) roof segment during which lower extremity three-dimensional kinematics were calculated. One foot was higher on the slope and one was lower for the duration of cross slope walking. Overall, cross-slope walking on a 26 degree roof significantly altered 77% of the measured lower extremity variables compared to level self-selected pace walking. The data suggest that roof pitch incite significant differences in crossslope walking of the kinematics in the lower extremity between the upslope and down slope limbs when compared to level surface walking. These alterations could temporarily alter proprioception which may in turn lead to increased falls and musculoskeletal injury, though further study is needed.

Importance: Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. Objective: To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. Evidence Review: The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. Findings: The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Conclusions and Relevance: This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

Importance: In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control's (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study. Objective: To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI. Evidence Review: Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search. Findings: Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking. Conclusions and Relevance: This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.

Outbreaks associated with untreated recreational water can be caused by pathogens, toxins, or chemicals in fresh water (e.g., lakes, rivers) or marine water (e.g., ocean). During 2000-2014, public health officials from 35 states and Guam voluntarily reported 140 untreated recreational water-associated outbreaks to CDC. These outbreaks resulted in at least 4,958 cases of disease and two deaths. Among the 95 outbreaks with a confirmed infectious etiology, enteric pathogens caused 80 (84%); 21 (22%) were caused by norovirus, 19 (20%) by Escherichia coli, 14 (15%) by Shigella, and 12 (13%) by Cryptosporidium. Investigations of these 95 outbreaks identified 3,125 cases; 2,704 (87%) were caused by enteric pathogens, including 1,459 (47%) by norovirus, 362 (12%) by Shigella, 314 (10%) by Cryptosporidium, and 155 (5%) by E. coli. Avian schistosomes were identified as the cause in 345 (11%) of the 3,125 cases. The two deaths were in persons affected by a single outbreak (two cases) caused by Naegleria fowleri. Public parks (50 [36%]) and beaches (45 [32%]) were the leading settings associated with the 140 outbreaks. Overall, the majority of outbreaks started during June-August (113 [81%]); 65 (58%) started in July. Swimmers and parents of young swimmers can take steps to minimize the risk for exposure to pathogens, toxins, and chemicals in untreated recreational water by heeding posted advisories closing the beach to swimming; not swimming in discolored, smelly, foamy, or scummy water; not swimming while sick with diarrhea; and limiting water entering the nose when swimming in warm freshwater.

Outbreaks associated with exposure to treated recreational water can be caused by pathogens or chemicals in venues such as pools, hot tubs/spas, and interactive water play venues (i.e., water playgrounds). During 2000-2014, public health officials from 46 states and Puerto Rico reported 493 outbreaks associated with treated recreational water. These outbreaks resulted in at least 27,219 cases and eight deaths. Among the 363 outbreaks with a confirmed infectious etiology, 212 (58%) were caused by Cryptosporidium (which causes predominantly gastrointestinal illness), 57 (16%) by Legionella (which causes Legionnaires' disease, a severe pneumonia, and Pontiac fever, a milder illness with flu-like symptoms), and 47 (13%) by Pseudomonas (which causes folliculitis ["hot tub rash"] and otitis externa ["swimmers' ear"]). Investigations of the 363 outbreaks identified 24,453 cases; 21,766 (89%) were caused by Cryptosporidium, 920 (4%) by Pseudomonas, and 624 (3%) by Legionella. At least six of the eight reported deaths occurred in persons affected by outbreaks caused by Legionella. Hotels were the leading setting, associated with 157 (32%) of the 493 outbreaks. Overall, the outbreaks had a bimodal temporal distribution: 275 (56%) outbreaks started during June-August and 46 (9%) in March. Assessment of trends in the annual counts of outbreaks caused by Cryptosporidium, Legionella, or Pseudomonas indicate mixed progress in preventing transmission. Pathogens able to evade chlorine inactivation have become leading outbreak etiologies. The consequent outbreak and case counts and mortality underscore the utility of CDC's Model Aquatic Health Code (https://www.cdc.gov/mahc) to prevent outbreaks associated with treated recreational water.

Provision of safe water in the United States is vital to protecting public health. Public health agencies in the U.S. states and territories report information on waterborne disease outbreaks to CDC through the National Outbreak Reporting System (NORS) (https://www.cdc.gov/healthywater/surveillance/index.html). During 2013-2014, 42 drinking water-associated outbreaks were reported, accounting for at least 1,006 cases of illness, 124 hospitalizations, and 13 deaths. Legionella was associated with 57% of these outbreaks and all of the deaths. Sixty-nine percent of the reported illnesses occurred in four outbreaks in which the etiology was determined to be either a chemical or toxin or the parasite Cryptosporidium. Drinking water contamination events can cause disruptions in water service, large impacts on public health, and persistent community concern about drinking water quality. Effective water treatment and regulations can protect public drinking water supplies in the United States, and rapid detection, identification of the cause, and response to illness reports can reduce the transmission of infectious pathogens and harmful chemicals and toxins.

Waterborne disease outbreaks in the United States are associated with a wide variety of water exposures and are reported annually to CDC on a voluntary basis by state and territorial health departments through the National Outbreak Reporting System (NORS). A majority of outbreaks arise from exposure to drinking water (1) or recreational water (2), whereas others are caused by an environmental exposure to water or an undetermined exposure to water. During 2013-2014, 15 outbreaks associated with an environmental exposure to water and 12 outbreaks with an undetermined exposure to water were reported, resulting in at least 289 cases of illness, 108 hospitalizations, and 17 deaths. Legionella was responsible for 63% of the outbreaks, 94% of hospitalizations, and all deaths. Outbreaks were also caused by Cryptosporidium, Pseudomonas, and Giardia, including six outbreaks of giardiasis caused by ingestion of water from a river, stream, or spring. Water management programs can effectively prevent outbreaks caused by environmental exposure to water from human-made water systems, while proper point-of-use treatment of water can prevent outbreaks caused by ingestion of water from natural water systems.

INTRODUCTION: Clinicians require tools to rapidly identify individuals with significant childhood adversity as part of routine primary care. The goal of this study was to shorten the 11-item Behavioral Risk Factor Surveillance System Adverse Childhood Experiences (ACEs) measure and evaluate the feasibility and validity of this shortened measure as a screener to identify adults who have experienced significant childhood adversity. METHODS: Statistical analysis was conducted in 2015. ACE item responses obtained from 2011-2012 Behavioral Risk Factor Surveillance System data were combined to form a sample of 71,413 adults aged ≥18 years. The 11-item Behavioral Risk Factor Surveillance System ACE measure was subsequently reduced to a two-item screener by maintaining the two dimensions of abuse and household stressors and selecting the most prevalent item within each dimension. RESULTS: The screener included household alcohol and childhood emotional abuse items. Overall, 42% of respondents and at least 75% of the individuals with four or more ACEs endorsed one or both of these experiences. Using the 11-item ACE measure as the standard, a cut off of one or more ACEs yielded a sensitivity of 99%, but specificity was low (66%). Specificity improved to 94% when using a cut off of two ACEs, but sensitivity diminished (70%). There was no substantive difference between the 11-and two-item ACE measures in their strength of association with an array of health outcomes. CONCLUSIONS: A two-item ACE screener appropriate for rapid identification of adults who have experienced significant childhood adversity was developed.

BACKGROUND: Competitive interactions among bacteria in the respiratory tract microbiota influence which species can colonize and potentially contribute to pathogenesis of community-acquired pneumonia (CAP). However, understanding of the role of respiratory tract microbiota in the clinical course of pediatric CAP is limited. METHODS: We sought to compare microbiota profiles in induced sputum and nasopharyngeal/oropharyngeal (NP/OP) samples from children and to identify microbiota profiles associated with CAP severity. We used 16S ribosomal RNA sequencing and several measures of microbiota profiles, including principal component analysis (PCA), to describe the respiratory microbiota in 383 children, 6 months to <18 years, hospitalized with CAP. We examined associations between induced sputum and NP/OP microbiota profiles and CAP severity (hospital length of stay and intensive care unit admission) using logistic regression. RESULTS: Relative abundance of bacterial taxa differed in induced sputum and NP/OP samples. In children 6 months to < 5 years, the sputum PCA factor with high relative abundance of Actinomyces, Veillonella, Rothia, and Lactobacillales was associated with decreased odds of length of stay ≥ 4 days [adjusted odds ratio (aOR) 0.69; 95 % confidence interval (CI) 0.48-0.99]. The sputum factor with high relative abundance of Haemophilus and Pasteurellaceae was associated with increased odds of intensive care unit admission [aOR 1.52; 95 % CI 1.02-2.26]. In children 5 to < 18 years, the sputum factor with high relative abundance of Porphyromonadaceae, Bacteriodales, Lactobacillales, and Prevotella was associated with increased odds of length of stay ≥ 4 days [aOR 1.52; 95 % CI 1.02-2.26]. Taxa in NP/OP samples were not associated with CAP severity. CONCLUSION: Certain taxa in the respiratory microbiota, which were detected in induced sputum samples, are associated with the clinical course of CAP.

Advances in water management and sanitation have substantially reduced waterborne disease in the United States, although outbreaks continue to occur. Public health agencies in the U.S. states and territories report information on waterborne disease outbreaks to the CDC Waterborne Disease and Outbreak Surveillance System (http://www.cdc.gov/healthywater/surveillance/index.html). For 2011-2012, 32 drinking water-associated outbreaks were reported, accounting for at least 431 cases of illness, 102 hospitalizations, and 14 deaths. Legionella was responsible for 66% of outbreaks and 26% of illnesses, and viruses and non-Legionella bacteria together accounted for 16% of outbreaks and 53% of illnesses. The two most commonly identified deficienciesdagger leading to drinking water-associated outbreaks were Legionella in building plumbing section sign systems (66%) and untreated groundwater (13%). Continued vigilance by public health, regulatory, and industry professionals to identify and correct deficiencies associated with building plumbing systems and groundwater systems could prevent most reported outbreaks and illnesses associated with drinking water systems.

Exposures to contaminated water can lead to waterborne disease outbreaks associated with various sources, including many that are classified and reported separately as drinking waterdagger or recreational water section sign. Waterborne disease outbreaks can also involve a variety of other exposures (e.g., consuming water directly from backcountry or wilderness streams, or inhaling aerosols from cooling towers and ornamental fountains). Additionally, outbreaks might be epidemiologically linked to multiple water sources or may not have a specific water source implicated.

Outbreaks of illness associated with recreational water use result from exposure to chemicals or infectious pathogens in recreational water venues that are treated (e.g., pools and hot tubs or spas) or untreated (e.g., lakes and oceans). For 2011-2012, the most recent years for which finalized data were available, public health officials from 32 states and Puerto Rico reported 90 recreational water-associated outbreaks to CDC's Waterborne Disease and Outbreak Surveillance System (WBDOSS) via the National Outbreak Reporting System (NORS). The 90 outbreaks resulted in at least 1,788 cases, 95 hospitalizations, and one death. Among 69 (77%) outbreaks associated with treated recreational water, 36 (52%) were caused by Cryptosporidium. Among 21 (23%) outbreaks associated with untreated recreational water, seven (33%) were caused by Escherichia coli (E. coli O157:H7 or E. coli O111). Guidance, such as the Model Aquatic Health Code (MAHC), for preventing and controlling recreational water-associated outbreaks can be optimized when informed by national outbreak and laboratory (e.g., molecular typing of Cryptosporidium) data.

Swimming in lakes and oceans is popular, but little is known about the demographic characteristics, behaviors, and health risks of beachgoers on a national level. Data from a prospective cohort study of beachgoers at multiple marine and freshwater beaches in the USA were used to describe beachgoer characteristics and health outcomes for swimmers and non-swimmers. This analysis included 54,250 participants. Most (73.2%) entered the water; of those, 65.1% put their head under water, 41.3% got water in their mouth and 18.5% swallowed water. Overall, 16.3% of beachgoers reported any new health problem. Among swimmers, 6.6% reported gastrointestinal (GI) illness compared with 5.5% of non-swimmers (unadjusted chi2 p < 0.001); 6.0% of swimmers and 4.9% of non-swimmers reported respiratory illness (p < 0.001); 1.8% of swimmers and 1.0% of non-swimmers reported ear problems (p < 0.001); and 3.9% of swimmers and 2.4% of non-swimmers experienced a rash (p < 0.001). Overall, swimmers reported a higher unadjusted incidence of GI illness and earaches than non-swimmers. Current surveillance systems might not detect individual cases and outbreaks of illness associated with swimming in natural water. Better knowledge of beachgoer characteristics, activities, and health risks associated with swimming in natural water can improve disease surveillance and prioritize limited resources.

BACKGROUND: Factors that influence exposure to silver particles from the use of textiles are not well understood. OBJECTIVES: The aim of this study was to evaluate the influence of product treatment and physiological factors on silver release from two textiles. METHODS: Atomic and absorbance spectroscopy, electron microscopy, and dynamic light scattering (DLS) were applied to characterize the chemical and physical properties of the textiles and evaluate silver release in artificial sweat and saliva under varying physiological conditions. One textile had silver incorporated into fiber threads (masterbatch process) and the other had silver nanoparticles coated on fiber surfaces (finishing process). RESULTS: Several complementary and confirmatory analytical techniques (spectroscopy, microscopy, etc.) were required to properly assess silver release. Silver released into artificial sweat or saliva was primarily in ionic form. In a simulated "use" and laundering experiment, the total cumulative amount of silver ion released was greater for the finishing process textile (0.51+/-0.04%) than the masterbatch process textile (0.21+/-0.01%); P<0.01. CONCLUSIONS: We found that the process (masterbatch vs finishing) used to treat textile fibers was a more influential exposure factor than physiological properties of artificial sweat or saliva.

Recreational water-associated disease outbreaks result from exposure to infectious pathogens or chemical agents in treated recreational water venues (e.g., pools and hot tubs or spas) or untreated recreational water venues (e.g., lakes and oceans). For 2009-2010, the most recent years for which finalized data are available, public health officials from 28 states and Puerto Rico electronically reported 81 recreational water-associated disease outbreaks to CDC's Waterborne Disease and Outbreak Surveillance System (WBDOSS) via the National Outbreak Reporting System (NORS). This report summarizes the characteristics of those outbreaks. Among the 57 outbreaks associated with treated recreational water, 24 (42%) were caused by Cryptosporidium. Among the 24 outbreaks associated with untreated recreational water, 11 (46%) were confirmed or suspected to have been caused by cyanobacterial toxins. In total, the 81 outbreaks resulted in at least 1,326 cases of illness and 62 hospitalizations; no deaths were reported. Laboratory and environmental data, in addition to epidemiologic data, can be used to direct and optimize the prevention and control of recreational water-associated disease outbreaks.

Harmful algal blooms (HABs) are excessive accumulations of microscopic photosynthesizing aquatic organisms (phytoplankton) that produce biotoxins or otherwise adversely affect humans, animals, and ecosystems. HABs occur sporadically and often produce a visible algal scum on the water. This report summarizes human health data and water sampling results voluntarily reported to CDC's Waterborne Disease and Outbreak Surveillance System (WBDOSS) via the National Outbreak Reporting System (NORS) and the Harmful Algal Bloom-Related Illness Surveillance System (HABISS)* for the years 2009-2010. For 2009-2010, 11 waterborne disease outbreaks associated with algal blooms were reported; these HABs all occurred in freshwater lakes. The outbreaks occurred in three states and affected at least 61 persons. Health effects included dermatologic, gastrointestinal, respiratory, and neurologic signs and symptoms. These 11 HAB-associated outbreaks represented 46% of the 24 outbreaks associated with untreated recreational water reported for 2009-2010, and 79% of the 14 freshwater HAB-associated outbreaks that have been reported to CDC since 1978. Clinicians should be aware of the potential for HAB-associated illness among patients with a history of exposure to freshwater.