BACKGROUND: Centers for Disease Control and Prevention recommends test-of-cure (TOC) for persons with pharyngeal gonorrhea (GC) 7-14 days after treatment. We investigated the yield and feasibility of routine pharyngeal GC TOC to detect treatment failures. METHODS: During May 2021-July 2022, four U.S. STD clinics implemented pharyngeal GC TOC. Sites collected demographic, clinical, and behavioral data on all treated pharyngeal GC and positive TOC cases. Cases were dispositioned with the suspected reason for positive TOC. To assess perceived feasibility, sites participated in qualitative interviews. RESULTS: During the study period, 1,968 pharyngeal GC infections were diagnosed. Among 1,829 treated cases, 97.3% (n = 1,777) received ceftriaxone and 45.7% (n = 836) returned for TOC, varying by site (range: 35.5%- 70.8%). Among those with TOC, 4.7% (n = 39) were positive by NAAT. Of these, 48.7% had culture attempted; six positive TOC (15.4%) were also positive by culture. Most positive TOC (66.7%) were attributed to re-infection (n = 13) or false-positive results (n = 13). Six (15.4%) were treatment failures. Four failed recommended treatment and had a positive culture: two were susceptible to ceftriaxone and two did not have antimicrobial susceptibility results. Seven positive TOC (17.9%) had insufficient data to disposition. Sites perceived TOC to be feasible, though substantial resources were required.ConclusionRoutine pharyngeal GC TOC yielded 5% positivity, though treatment failure was rare (<1%), and no cases of cephalosporin-resistant GC were identified. Low TOC return rates, limited culture collection, and limited culture yield highlight challenges to determining the cause of a positive TOC and the limitations of TOC in identifying cephalosporin resistance.

A global outbreak of clade II mpox associated with sexual contact, disproportionately affecting gay, bisexual, and other men who have sex with men (MSM), has been ongoing since May 2022. Information on types of contact most associated with transmission is limited. This report used data from a multijurisdictional vaccine effectiveness case-control study of sexually active persons aged 18-49 years who identified as MSM or transgender, collected during August 2022-July 2023. Odds of mpox associated with selected types of intimate and nonintimate close contact with a person with mpox were estimated. Among 457 case-patients and 1,030 control patients who met minimum data requirements, 150 (32.8%) case-patients and 57 (5.5%) control patients reported close contact with a person with mpox and were included in this analysis. Adjusted odds of mpox were 5.4 times as high among those who reported having condomless receptive anal sex with a person with mpox, compared with participants who reported close contact with a person with mpox and no condomless receptive anal sex with that person (OR = 5.4; p = 0.031). Although the mpox vaccine is highly effective, vaccination coverage remains low; a multifaceted approach to prevention remains important and should include vaccination promotion, safer sex practices, and increasing awareness that mpox continues to circulate.

BACKGROUND: During the 2022 mpox outbreak, most cases were associated with sexual contact, and many people with mpox sought care from sexual health clinics and programs. The National Network of STD Clinical Prevention Training Centers, in partnership with the Centers for Disease Control and Prevention, conducted a survey of US sexual health clinics and programs to assess knowledge, practices, and experiences around mpox to inform a future public health response. METHODS: Between August 31 and September 13, 2022, the National Network of STD Clinical Prevention Training Centers facilitated a web-based survey. Descriptive statistics were generated in R. RESULTS: Among 168 responses by clinicians (n = 131, 78%) and program staff (n = 37, 22%), more than half (51%) reported at least somewhat significant mpox-related clinical disruptions including burdensome paperwork requirements for mpox testing (40%) and tecovirimat use (88%). Long clinic visits (51%) added additional burden, and the median mpox-related visit lasted 1 hour. Few clinicians felt comfortable with advanced pain management, and clinicians felt most uninformed about preexposure (19%) and postexposure (24%) prophylaxis. Of 89 respondents involved in vaccination, 61% reported using equity strategies; however, accounts of these strategies revealed a focus on guideline or risk factor-based screenings instead of equity activities. CONCLUSIONS: These findings highlight the substantial impact of the 2022 mpox outbreak on sexual health care in the United States. Critical gaps and barriers were identified that may inform additional mpox training and technical assistance, including challenges with testing, diagnosis, and management as well as a disconnect between programs' stated goal of equity and operationalization of strategies to achieve equity.

As of March 31, 2023, more than 30,000 monkeypox (mpox) cases had been reported in the United States in an outbreak that has disproportionately affected gay, bisexual, and other men who have sex with men (MSM) and transgender persons (1). JYNNEOS vaccine (Modified Vaccinia Ankara vaccine, Bavarian Nordic) was approved by the Food and Drug Administration (FDA) in 2019 for the prevention of smallpox and mpox via subcutaneous injection as a 2-dose series (0.5 mL per dose, administered 4 weeks apart) (2). To expand vaccine access, an Emergency Use Authorization was issued by FDA on August 9, 2022, for dose-sparing intradermal injection of JYNNEOS as a 2-dose series (0.1 mL per dose, administered 4 weeks apart) (3). Vaccination was available to persons with known or presumed exposure to a person with mpox (postexposure prophylaxis [PEP]), as well as persons at increased risk for mpox or who might benefit from vaccination (preexposure mpox prophylaxis [PrEP]) (4). Because information on JYNNEOS vaccine effectiveness (VE) is limited, a matched case-control study was conducted in 12 U.S. jurisdictions,(†) including nine Emerging Infections Program sites and three Epidemiology and Laboratory Capacity sites,(§) to evaluate VE against mpox among MSM and transgender adults aged 18-49 years. During August 19, 2022-March 31, 2023, a total of 309 case-patients were matched to 608 control patients. Adjusted VE was 75.2% (95% CI = 61.2% to 84.2%) for partial vaccination (1 dose) and 85.9% (95% CI = 73.8% to 92.4%) for full vaccination (2 doses). Adjusted VE for full vaccination by subcutaneous, intradermal, and heterologous routes of administration was 88.9% (95% CI = 56.0% to 97.2%), 80.3% (95% CI = 22.9% to 95.0%), and 86.9% (95% CI = 69.1% to 94.5%), respectively. Adjusted VE for full vaccination among immunocompromised participants was 70.2% (95% CI = -37.9% to 93.6%) and among immunocompetent participants was 87.8% (95% CI = 57.5% to 96.5%). JYNNEOS is effective at reducing the risk for mpox. Because duration of protection of 1 versus 2 doses remains unknown, persons at increased risk for mpox exposure should receive the 2-dose series as recommended by the Advisory Committee on Immunization Practices (ACIP),(¶) regardless of administration route or immunocompromise status.

BACKGROUND: The Denver COVID-19 Joint Task Force is a multisector community partnership which formed to coordinate Denver's pandemic response in people experiencing homelessness (PEH). OBJECTIVES: Describe how interdisciplinary community partners collaborated to develop, implement, and pilot severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and isolation protocols in congregate shelters, and discuss lessons learned and subsequently applied. METHODS: In March through May 2020, community partners collaborated to design, implement and conduct pilot testing paired with isolation in a subset of PEH at a congregate shelter to assess feasibility and inform protocol development.Results and Lessons Learned: We performed SARS-CoV-2 testing in 52 PEH with 14 (27%) testing positive or inconclusive. Thirteen (93%) positive or inconclusive participants were transferred to isolation hotels with 9 of 13 (69%) transferred within 72 hours of testing. CONCLUSIONS: Our findings informed development of coronavirus disease 2019 surveillance testing and isolation protocols for PEH and highlight the value of community partnerships in nimbly responding to the pandemic.

Background: A better understanding of the risk for coronavirus disease 2019 (COVID-19) that people experiencing homelessness (PEH) face in congregate shelters versus unsheltered encampments is critical for an effective pandemic response.

OBJECTIVES: To describe COVID-19-related pediatric hospitalizations during a period of B.1.617.2 (Delta) variant predominance and to determine age-specific factors associated with severe illness. PATIENTS AND METHODS: We abstracted data from medical charts to conduct a cross-sectional study of patients aged <21 years hospitalized at 6 US children's hospitals during July-August 2021 for COVID-19 or with an incidental positive SARS-CoV-2 test. Among patients with COVID-19, we assessed factors associated with severe illness by calculating age-stratified prevalence ratios (PR). We defined severe illness as receiving high-flow nasal cannula, positive airway pressure, or invasive mechanical ventilation. RESULTS: Of 947 hospitalized patients, 759 (80.1%) had COVID-19, of whom 287 (37.8%) had severe illness. Factors associated with severe illness included coinfection with RSV (PR 3.64) and bacteria (PR 1.88) in infants; RSV coinfection in patients aged 1-4 years (PR 1.96); and obesity in patients aged 5-11 (PR 2.20) and 12-17 years (PR 2.48). Having ≥2 underlying medical conditions was associated with severe illness in patients aged <1 (PR 1.82), 5-11 (PR 3.72), and 12-17 years (PR 3.19). CONCLUSIONS: Among patients hospitalized for COVID-19, factors associated with severe illness included RSV coinfection in those aged <5 years, obesity in those aged 5-17 years, and other underlying conditions for all age groups <18 years. These findings can inform pediatric practice, risk communication, and prevention strategies, including vaccination against COVID-19.

BACKGROUND: Women who attend sexual health clinics are at high risk for sexually transmitted infections and unintended pregnancy. Long-acting reversible contraceptives (LARC) are very effective contraceptive methods, but the provision of LARC in such clinics is not well described in the literature. METHODS: We conducted a retrospective chart review of women who presented to Denver Sexual Health Clinic for any reason and received family planning services between April 1, 2016, and October 31, 2018. We assessed demographic and clinical factors associated with contraceptive method received and conducted a subanalysis of those with intrauterine device (IUD) insertions on the same-day versus delayed insertion. Among those who received an IUD, we assessed rates of pelvic inflammatory disease (PID) 30 days after insertion. RESULTS: Of the 5064 women who received family planning services in our clinic, 1167 (23%) were using a LARC method at the time of their visit. Of the 3897 who were not using a LARC, fewer women, 12.6%, chose LARC (IUD and progestin implant), compared with 33.3% who chose new short-acting reversible contraceptives. Further analysis of the 270 IUD initiators revealed 202 (74.8%) received the IUD on the same day, whereas 68 (25.2%) had delayed IUD insertion. There were 9 incident cases of gonorrhea or chlamydia in those who received same-day IUD and 1 incident case among those who had delayed IUD insertion. There were no cases of PID at 30 days after insertion in either group. CONCLUSIONS: Study findings support IUD provision in a sexual health clinic on the day of initial visit without increased risk of PID.

BACKGROUND: The National Network of Sexually Transmitted Disease Clinical Prevention Training Centers (NNPTC) trains clinical providers to diagnose and treat sexually transmitted infections (STIs) in the United States. The purpose of this study was to examine the demographics of clinical providers and to correlate the number of training episodes with STI rates at the county level. METHODS: Registration data were collected between April 1, 2015, and March 31, 2020, in a custom Learning Management System from clinical providers taking NNPTC training. Using the 2018 STI surveillance data, counties were divided into quartiles based on reportable STI case rates and the number of county-level training events was compared per quartile. Univariate and multivariate analyses were conducted in IBM SPSS Statistics 23 (Armonk, NY) and SAS Enterprise Guide 7.1 (Cary, NC). RESULTS: From 2015 to 2020, the NNPTC trained 21,327 individuals, predominantly in the nursing professions and working in a public health environment. In multivariate analysis, the number of training events was significantly associated with higher STI rates at the county level (P < 0.0001) and the state where a prevention training center is located (P < 0001). CONCLUSIONS: The analysis suggests that NNPTC trainings are reaching the clinical providers working in geographic areas with higher STI rates.

BACKGROUND: Cisgender women have been underrepresented in antibiotic-resistant gonorrhea (ARGC) surveillance systems. Three of 8 project sites (City of Milwaukee [MIL], Guilford County [GRB], Denver County [DEN]), funded under the Centers for Disease Control and Prevention's Strengthening the US Response to Resistant Gonorrhea (SURRG), focused efforts to better include cisgender women in ARGC surveillance. METHODS: MIL, GRB, and DEN partnered with diverse health care settings and developed gonorrhea culture criteria to facilitate urogenital specimen collection in cisgender women and men. Regional laboratories within the Antibiotic Resistance Laboratory Network performed agar dilution antibiotic susceptibility testing (AST) of gonococcal isolates. Data from 2018 and 2019 were analyzed. RESULTS: In SURRG, 90.5% (11,464 of 12,667) of the cisgender women from whom urogenital culture specimens were collected were from MIL, GRB, and DEN. Of women in SURRG whose gonococcal isolates underwent AST, 70% were from these 3 sites. In these 3 sites, a substantial proportion of cisgender women with positive urogenital cultures and AST were from health care settings other than sexually transmitted disease (STD) clinics (non-STD clinics; MIL, 56.0%; GRB, 80.4%; and DEN, 23.5%). Isolates with AST were obtained from 5.1%, 10.2%, and 2.4% of all diagnosed gonorrhea cases among cisgender women in MIL, GRB, and DEN, respectively, and were more often susceptible to all antibiotics than those from cisgender men from each of these sites. CONCLUSIONS: With focused efforts and partnerships with non-STD clinics, 3 SURRG sites were able to include robust ARGC surveillance from cisgender women. These findings may guide further efforts to improve gender equity in ARGC surveillance.

During June 2021, the highly transmissible(†) B.1.617.2 (Delta) variant of SARS-CoV-2, the virus that causes COVID-19, became the predominant circulating strain in the United States. U.S. pediatric COVID-19-related hospitalizations increased during July-August 2021 following emergence of the Delta variant and peaked in September 2021.(§) As of May 12, 2021, CDC recommended COVID-19 vaccinations for persons aged ≥12 years,(¶) and on November 2, 2021, COVID-19 vaccinations were recommended for persons aged 5-11 years.** To date, clinical signs and symptoms, illness course, and factors contributing to hospitalizations during the period of Delta predominance have not been well described in pediatric patients. CDC partnered with six children's hospitals to review medical record data for patients aged <18 years with COVID-19-related hospitalizations during July-August 2021.(††) Among 915 patients identified, 713 (77.9%) were hospitalized for COVID-19 (acute COVID-19 as the primary or contributing reason for hospitalization), 177 (19.3%) had incidental positive SARS-CoV-2 test results (asymptomatic or mild infection unrelated to the reason for hospitalization), and 25 (2.7%) had multisystem inflammatory syndrome in children (MIS-C), a rare but serious inflammatory condition associated with COVID-19.(§§) Among the 713 patients hospitalized for COVID-19, 24.7% were aged <1 year, 17.1% were aged 1-4 years, 20.1% were aged 5-11 years, and 38.1% were aged 12-17 years. Approximately two thirds of patients (67.5%) had one or more underlying medical conditions, with obesity being the most common (32.4%); among patients aged 12-17 years, 61.4% had obesity. Among patients hospitalized for COVID-19, 15.8% had a viral coinfection(¶¶) (66.4% of whom had respiratory syncytial virus [RSV] infection). Approximately one third (33.9%) of patients aged <5 years hospitalized for COVID-19 had a viral coinfection. Among 272 vaccine-eligible (aged 12-17 years) patients hospitalized for COVID-19, one (0.4%) was fully vaccinated.*** Approximately one half (54.0%) of patients hospitalized for COVID-19 received oxygen support, 29.5% were admitted to the intensive care unit (ICU), and 1.5% died; of those requiring respiratory support, 14.5% required invasive mechanical ventilation (IMV). Among pediatric patients with COVID-19-related hospitalizations, many had severe illness and viral coinfections, and few vaccine-eligible patients hospitalized for COVID-19 were vaccinated, highlighting the importance of vaccination for those aged ≥5 years and other prevention strategies to protect children and adolescents from COVID-19, particularly those with underlying medical conditions.

BACKGROUND: In 2016, CDC initiated Strengthening the U.S. Response to Resistant Gonorrhea (SURRG) in multiple jurisdictions to enhance antibiotic resistant gonorrhea rapid detection and response infrastructure and evaluate the impact of key strategies. METHODS: Eight jurisdictions were funded to establish or enhance local gonococcal culture specimen collection in STD and community clinics, conduct rapid antimicrobial susceptibility testing (AST) in local laboratories, modify systems for enhanced data collection and rapid communication of results, and initiate enhanced partner services among patients with gonorrhea demonstrating elevated minimum inhibitory concentrations (MICs) to ceftriaxone, cefixime or azithromycin. RESULTS: Grantees incorporated genital, pharyngeal, and rectal gonococcal culture collection from all genders at participating clinics. During 2018-2019, grantees collected 58,441 culture specimens from 46,822 patients and performed AST on 10,814 isolates (representing 6.8% (3,412) and 8.9% (4,883) of local reported cases in 2018 and 2019 respectively). Of isolates that underwent AST, 11% demonstrated elevated azithromycin MICs; fewer than 0.5% demonstrated elevated ceftriaxone or cefixime MICs. Among patients whose infections demonstrated elevated MICs, 81.7% were interviewed for partner elicitation; however, limited new cases were identified among partners and contacts. CONCLUSIONS: As a public health model to build capacity to slow the spread of emerging resistance, SURRG successfully expanded culture collection, implemented rapid AST, and implemented an enhanced partner services investigation approach in participating jurisdictions. Findings from SURRG may enhance preparedness efforts and inform a longer-term, comprehensive, and evidence-based public health response to emerging gonococcal resistance. Continued development of innovative approaches to address emerging resistance is needed.

Public health researchers recognize that determinants of youth violence exist across multiple contexts and social-ecological levels, which necessitates using a comprehensive approach to prevent youth violence (https://bit.ly/3hFqWCi). A large body of research has focused on developing and evaluating community-based interventions that address individual and family risk factors for youth violence.1 Despite the success of these interventions, youth violence remains a major public health issue. Community-level prevention strategies focus on the characteristics of settings (e.g., schools, workplaces, and neighborhoods) that increase the risk of or protect people from violence, particularly social, economic, and environmental characteristics. These strategies are distinct from community-based strategies, which are implemented in community settings but target individual, peer, or other proximal relationship or family factors.2 Community-level prevention strategies have the potential to impact a greater number of people, yet the current evidence base for youth violence prevention approaches at the outer social-ecological levels (i.e., community, societal) is thin.3

The Centers for Disease Control and Prevention (CDC)–funded Youth Violence Prevention Centers (YVPCs) apply different models to reduce youth violence that are applicable to firearm violence because they are comprehensive, cut across ecological levels, and involve multisector partners that inform firearm injury prevention strategies. In addition, all YVPCs engage youths and communities in reducing violence, which may also be a useful approach to the prevention of firearm violence. YVPCs’ role in helping to address firearm violence is vital for public health because in 2019 firearms were the leading mechanism of death among youths aged 10 to 24 years in the United States.1 Of the 7779 firearm-related deaths among youths in this age group in 2019, 4483 (57.6%) were attributable to homicide; 2972 (38.2%) to suicide; and 324 (4.2%) to unintentional, undetermined intent, or legal intervention.1 In addition, firearms accounted for 4483 (90.3%) of the 4965 youth homicide deaths and 2972 (45.8%) of the 6488 youth suicide deaths in 2019.1 In 2019, the youth firearm homicide rate was 7.06 per 100 000 and the youth firearm suicide rate was 4.68 per 100 000. Non-Hispanic Black youths experienced firearm homicide rates (31.02 per 100 000) that were 17.5 times higher than those of non-Hispanic White youths (1.77 per 100 000), and firearm homicides among non-Hispanic Black youths accounted for 66.2% of all youth firearm homicides in 2019.1 In total, 7455 youths aged 10 to 24 years died by firearm homicide or suicide in 2019, which translates to more than 20 youths dying every day from these firearm-related injuries.1 Overall, youth firearm mortality rates in 2019 were higher in rural areas (13.25 per 100 000) than in urban areas (12.00 per 100 000). Youth firearm suicide rates were higher in rural areas than urban areas (7.64 vs 3.48 per 100 000), and youth firearm homicide rates were higher in urban areas than rural area (8.14 vs 4.84 per 100 000).2 Firearm-related mortality rates for youths have surpassed rates of motor vehicle (MV)–related deaths in the United States since 2016.1 The fact is that between 2008 and 2017, the federal government spent on average $1 million annually on research addressing firearm-related deaths among those aged 1 to 18 years, compared with $88 million annually on research for MV-related deaths among youths.3

BACKGROUND: Nasopharyngeal specimens (NPS) are commonly used for SARS-CoV-2 testing but can be uncomfortable for patients. Self-collected saliva or anterior nasal specimens (ANS) for SARS-CoV-2 detection are less invasive but the sensitivity of these specimen types has not been thoroughly evaluated. METHODS: During September-November 2020, 730 adults undergoing SARS-CoV-2 testing at community testing events and homeless shelters in Denver provided self-collected saliva and ANS specimens before NPS collection and answered a short survey about symptoms and specimen preference. Specimens were tested for SARS-CoV-2 by rRT-PCR; viral culture was performed on a subset of specimens positive by rRT-PCR. Sensitivity of saliva and ANS for SARS-CoV-2 detection by rRT-PCR was measured against NPS. Subgroup analyses included test outcomes by symptom status and culture results. RESULTS: Sensitivity for SARS-CoV-2 detection by rRT-PCR appeared higher for saliva than for ANS (85% vs. 80%) and among symptomatic participants than among those without symptoms (94% vs. 29% for saliva; 87% vs. 50% for ANS). Among participants with culture-positive SARS-CoV-2 by any specimen type, sensitivity of saliva and ANS by rRT-PCR was 94% and 100%, respectively. Saliva and ANS were equally preferred by participants; most would undergo NPS again despite being least preferred. CONCLUSIONS: Saliva was slightly more sensitive than ANS for SARS-CoV-2 detection by rRT-PCR. Both saliva and ANS reliably detected SARS-CoV-2 among participants with symptoms. Self-collected saliva and ANS offer practical advantages, are preferred by patients, and might be most useful for testing people with COVID-19 symptoms.

What would you want to know before your children attend a day care opening in a former industrial building or adjacent to a nail salon? Are children at risk if their new preschool is located on former farmland where lead arsenate pesticide might have been used? What site-related environmental risks are most concerning for children attending early care and education (ECE) facilities? | | States involved with the Agency for Toxic Substances and Disease Registry’s (ATSDR) Choose Safe Places for Early Care and Education (CSPECE) effort are addressing site-related questions like these to help protect children from harmful environmental exposures.

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014 with a mortality rate of 18.0 per 100,000, higher than many other developed countries. In 2012 the first "Putting the 'M' back in Maternal Fetal Medicine" session was held at the Society for Maternal Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified urgent needs to: (i) enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) improve the medical care and management of pregnant women across the country; and (iii) address critical research gaps in maternal medicine. Since that first meeting a broad collaborative effort has made a number of major steps forward including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 "M in MFM" meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next five years given that too many mothers still experience preventable harm and adverse outcomes.

Transportation investments have the potential to improve health, but readily available data to guide transportation decisions that could promote health are limited. In October 2015, the U.S. Department of Transportation (USDOT) and the Centers for Disease Control and Prevention (CDC) released the Transportation and Health Tool (THT). The tool is a resource to help transportation professionals in states and metropolitan areas access data about transportation and health in their jurisdictions and stimulate discussions on how to improve public health through transportation planning and policy. To develop the tool, a multidisciplinary team identified 190 possible data indicators. Using input from expert panel workshops and criteria that addressed data availability, geographic scale, timeliness, feasibility, validity, and topic area, the team selected 14 transportation and health indicators that covered the four priority topic areas of safety, active transportation, air quality, and connectivity. The THT contains the raw values for each indicator and a standardized score to enable comparisons. Additionally, the THT contains 25 evidence-based strategies that can help practitioners in states and metropolitan areas take action to improve health outcomes.

During September to October, 2006, state and local health departments and the Centers for Disease Control and Prevention investigated a large, multistate outbreak of Escherichia coli O157:H7 infections. Case patients were interviewed regarding specific foods consumed and other possible exposures. E. coli O157:H7 strains isolated from human and food specimens were subtyped using pulsed-field gel electrophoresis and multiple-locus variable-number tandem repeat analyses (MLVA). Two hundred twenty-five cases (191 confirmed and 34 probable) were identified in 27 states; 116 (56%) case patients were hospitalized, 39 (19%) developed hemolytic uremic syndrome, and 5 (2%) died. Among 176 case patients from whom E. coli O157:H7 with the outbreak genotype (MLVA outbreak strain) was isolated and who provided details regarding spinach exposure, 161 (91%) reported fresh spinach consumption during the 10 days before illness began. Among 116 patients who provided spinach brand information, 106 (91%) consumed bagged brand A. E. coli O157:H7 strains were isolated from 13 bags of brand A spinach collected from patients' homes; isolates from 12 bags had the same MLVA pattern. Comprehensive epidemiologic and laboratory investigations associated this large multistate outbreak of E. coli O157:H7 infections with consumption of fresh bagged spinach. MLVA, as a supplement to pulsed-field gel electrophoresis genotyping of case patient isolates, was important to discern outbreak-related cases. This outbreak resulted in enhanced federal and industry guidance to improve the safety of leafy green vegetables and launched an independent collaborative approach to produce safety research in 2007.

Parks and recreation departments and public health organizations both work to improve the well-being of their communities. Measuring residential proximity to parks could be a specific area of shared interest, given that proximity to parks is needed for walking access, and the use of parks is, in turn, associated with many physical, social, and mental health benefits. The CDC's publicly available National Environmental Public Health Tracking Network (NEPHTN) Access to Parks Indicator (API) focuses on one major component of access, residential proximity to parks. The API uses a commercial parks database and U.S. Census data to estimate the number and percentage of individuals in the U.S. that live within a half-mile of a park boundary, a measure commonly used to represent park proximity. The API is calculated at the state and county levels and is available for all states and counties in the U.S. Using estimates from the API, we examined the distribution of residential proximity to parks by geography and race/ethnicity. Additionally, we evaluated differences in park proximity by rural/urban status of counties. In 2010, 39% of the total U.S. population lived within a half-mile of a park. This percentage varied widely between states, ranging from 9% in West Virginia to 67% in Hawaii and 88% in the District of Columbia (DC). Park proximity was lowest among non-Hispanic whites (34.2%) and highest among individuals belonging to the non-Hispanic other race category (52.0%). Metropolitan counties had the highest percentage of residents living within a half-mile of a park (43.3%); the percentage was lower in non-metropolitan counties adjacent to a metropolitan county (15.0%) and non-metropolitan counties not adjacent to a metropolitan county (18.5%). Park proximity was higher in metropolitan counties with a larger population size and in non-metropolitan counties with a higher degree of urbanization. The NEPHTN Access to Parks Indicator provides an opportunity to understand park proximity in counties and states throughout the U.S., including identifying disparities that may exist between population subgroups and comparing geographic areas. Parks and recreational professionals can use this information to compare their county or state to other geographic areas and, in combination with local data on parks within their jurisdiction, inform decisions to improve the distribution of parks and the well-being of their communities.

This report summarizes and discusses current knowledge on the impact that climate change can have on occupational safety and health (OSH), with a particular focus on the Americas. Worker safety and health issues are presented on topics related to specific stressors (e.g., temperature extremes), climate associated impacts (e.g., ice melt in the Arctic), and a health condition associated with climate change (chronic kidney disease of non-traditional etiology). The article discusses research needs, including hazards, surveillance, and risk assessment activities to better characterize and understand how OSH may be associated with climate change events. Also discussed are the actions that OSH professionals can take to ensure worker health and safety in the face of climate change.

CONTEXT: Health Impact Assessment (HIA) has emerged as a promising tool to integrate health considerations into decision making. The growth and success of HIA practice in the United States will be dependent on building the capacity of practitioners. OBJECTIVE: This article seeks to identify the role of state health agencies (SHAs) in building capacity for conducting HIAs and the key components of initiatives that produced effective HIAs and HIA programs. The authors proposed to answer 3 research questions: (1) What can be the role of the SHA in HIA? (2) What are the characteristics of successful state HIA programs? and (3) What are some effective strategies for building capacity for HIA in SHAs and local health departments? DESIGN: The authors reviewed program reports from the ASTHO's pilot state health agencies (California, Minnesota, Oregon, and Wisconsin) that, between 2009 and 2011, created HIA programs to provide HIA training, conduct HIAs, and build practitioner networks. MAIN OUTCOME MEASURES: Program reports were examined for shared themes on the role of SHAs in a statewide HIA initiative, the characteristics of successful programs, and effective strategies for building capacity. RESULTS: Despite differences among the programs, many shared themes existed. These include stressing the importance of a basic, sustained infrastructure for HIA practice; leveraging existing programs and networks; and working in partnership with diverse stakeholders. CONCLUSIONS: SHAs can build capacity for HIA, and SHAs can both lead and support the completion of individual HIAs. States and territories interested in starting comprehensive statewide HIA initiatives could consider implementing the strategies identified by the pilot programs.

We conducted an ecological study to determine whether parking prices are associated with active commuting across US cities. We obtained parking prices for 107 US cities from the Drexel University Central Business District Public Parking Survey, obtained city prevalence of walking and bicycling to work from the American Community Survey, and used weighted least squares linear regression to explore associations between parking prices and active commuting. After adjusting for several covariates, walking to work was 3.1% higher for every additional dollar charged for off-street daily parking, but only among more densely populated cities, and no such association was detected for bicycling to work. These preliminary results hint at the potential for parking policies to influence commuting mode choice, a link that city planners and public health officials could consider when evaluating parking policies and active transportation behaviors.

Creating environments that support all types of physical activity, including active transportation, is a public health priority. Public health surveillance that identifies the locations where community members walk and bicycle (i.e., engage in active transportation) can inform such efforts. Traditional population-representative active transportation surveillance incurs a considerable time lag between data collection and dissemination, and often lacks geographic specificity. Conversely, user-generated active transportation data from Global Positioning System (GPS)-based activity tracking devices and mobile applications can provide near real-time information, but might be subject to self-selection bias among users. CDC analyzed the association between GPS-based commuting data from a company that allows tracking of activity with a mobile application (Strava, Inc., San Francisco, California) and population-representative commuting data from the U.S. Census Bureau's American Community Survey (ACS) for four U.S. cities. The level of analysis was the Census block group. The number of GPS-tracked commuters in Strava was associated with the number of ACS active commuters (Spearman's rho = 0.60), suggesting block groups were ranked similarly based on these distinct but related measurements. The correlation was higher in high population density areas. User-generated active transportation data might complement traditional surveillance systems by providing near real-time, location-specific information on where active transportation occurs.

The Integrated Transport and Health Impact Model (ITHIM) is a comprehensive tool that estimates the hypothetical health effects of transportation mode shifts through changes to physical activity, air pollution, and injuries. The purpose of this paper is to describe the implementation of ITHIM in greater Nashville, Tennessee (USA), describe important lessons learned, and serve as an implementation guide for other practitioners and researchers interested in running ITHIM. As might be expected in other metropolitan areas in the US, not all the required calibration data was available locally. We utilized data from local, state, and federal sources to fulfill the 14 ITHIM calibration items, which include disease burdens, travel habits, physical activity participation, air pollution levels, and traffic injuries and fatalities. Three scenarios were developed that modeled stepwise increases in walking and bicycling, and one that modeled reductions in car travel. Cost savings estimates were calculated by scaling national-level, disease-specific direct treatment costs and indirect lost productivity costs to the greater Nashville population of approximately 1.5 million. Implementation required approximately one year of intermittent, part-time work. Across the range of scenarios, results suggested that 24-123 deaths per year could be averted in the region through a 1-5% reduction in the burden of several chronic diseases. This translated into $10-$63 million in estimated direct and indirect cost savings per year. Implementing ITHIM in greater Nashville has provided local decision makers with important information on the potential health effects of transportation choices. Other jurisdictions interested in ITHIM might find the Nashville example as a useful guide to streamline the effort required to calibrate and run the model. © 2016.

PURPOSE: Develop strategic priorities to guide future physical activity surveillance in the United States. METHODS: The Centers for Disease Control and Prevention and the American College of Sports Medicine convened a Scientific Roundtable of physical activity and measurement experts. Participants summarized the current state of aerobic physical activity surveillance for adults, focusing on practice and research needs in three areas: 1) behavior, 2) human movement, and 3) community supports. Needs and challenges for each area were identified. At the conclusion of the meeting, experts identified one overarching strategy and five strategic priorities to guide future surveillance. RESULTS: The identified overarching strategy was to develop a national plan for physical activity surveillance similar to the U.S. National Physical Activity Plan for promotion. The purpose of the plan would be to enhance coordination and collaboration within and between sectors, such as transportation and public health, and to address specific strategic priorities identified at the Roundtable. These strategic priorities were: 1) identify and prioritize physical activity constructs, 2) assess the psychometric properties of instruments for physical activity surveillance, 3) provide training and technical assistance for those collecting, analyzing, or interpreting surveillance data, 4) explore accessing data from alternative sources, and 5) improve communication, translation, and dissemination about estimates of physical activity from surveillance systems. CONCLUSION: This Roundtable provided strategic priorities for physical activity surveillance in the United States. A first step is to develop a national plan for physical activity surveillance that would provide an operating framework from which to execute these priorities.

When most people hear “models,” they probably think about people, not transportation. Models—the people version—help predict how clothes will look when we wear them. Models—the transportation version—help predict how our transportation system will function based on current and future infrastructure investments. Neither type of model is entirely accurate; they attempt to predict the future, and the future rarely fully cooperates. Despite this, models can provide useful information for planning and predicting health outcomes. | | Environmental health practitioners already utilize model predictions. Prediction of disease risk, such as West Nile virus, may be based on models of vector spread (Harrigan, 2014). The risk of flooding in a given area is predicted based on historical stream-flow records (U.S. Geological Survey, 2008). In transportation, opportunities for environmental health professionals may arise as transportation models expand beyond predicting congestion and air pollution to predicting health impacts of walking and bicycling. | | The well-established health benefits of increased physical activity have created much interest in health impacts of the transportation built environment related to walking, bicycling, and public transit (Besser, 2005). Ideally, models could predict changes in health outcomes such as mortality or disease prevalence for a given built environment change, such as a bike path or complete street initiative. This process has two steps: first, predicting changes in travel behavior (e.g., mode shift or total distance walked/bicycled) following an environmental or policy change; second, predicting health outcomes following the change in travel behavior. In practice, the former is currently more difficult than the latter. Each is explained below.

PROBLEM/CONDITION: Physical activity is a health-enhancing behavior, and most U.S. adults do not meet the 2008 Physical Activity Guidelines for Americans. Active transportation, such as by walking or bicycling, is one way that persons can be physically active. No comprehensive, multiyear assessments of active transportation surveillance in the United States have been conducted. PERIOD COVERED: 1999-2012. DESCRIPTION OF SYSTEMS: Five surveillance systems assess one or more components of active transportation. The American Community Survey and the National Household Travel Survey (NHTS) both assess the mode of transportation to work in the past week. From these systems, the proportion of respondents who reported walking or bicycling to work can be calculated. NHTS and the American Time Use Survey include 1-day assessments of trips or activities. With that information, the proportion of respondents who report any walking or bicycling for transportation can be calculated. The National Health and Nutrition Examination Survey and the National Health Interview Survey both assess recent (i.e., in the past week or past month) habitual physical activity behaviors, including those performed during active travel. From these systems, the proportion of respondents who report any recent habitual active transportation can be calculated. RESULTS: The prevalence of active transportation as the primary commute mode to work in the past week ranged from 2.6% to 3.4%. The 1-day assessment indicated that the prevalence of any active transportation ranged from 10.5% to 18.5%. The prevalence of any habitual active transportation ranged from 23.9% to 31.4%. No consistent trends in active transportation across time periods and surveillance systems were identified. Among systems, active transportation was usually more common among men, younger respondents, and minority racial/ethnic groups. Among education groups, the highest prevalence of active transportation was usually among the least or most educated groups, and active transportation tended to be more prevalent in densely populated, urban areas. INTERPRETATION: Active transportation is assessed in a wide variety of ways in multiple surveillance systems. Different assessment techniques and construct definitions result in widely discrepant estimates of active transportation; however, some consistent patterns were detected across covariates. Although each type of assessment (i.e., transportation to work, single day, and habitual behavior) measures a different active transportation component, all can be used to monitor population trends in active transportation participation. PUBLIC HEALTH ACTION: An understanding of the strengths, limitations, and lack of comparability of active transportation assessment techniques is necessary to correctly evaluate findings from the various surveillance systems. When used appropriately, these systems can be used by public health and transportation professionals to monitor population participation in active transportation and plan and evaluate interventions that influence active transportation.

Physical activity, including bicycling, is linked with multiple health benefits. However, although bicycles account for only about 1% of trips across all modes of transportation, on a per trip basis, bicyclists die on U.S. roads at a rate double that of vehicle occupants. In 2009, an estimated 392 billion trips (across all modes) were taken in the United States, including 4.1 billion bicycle trips, and 33,808 deaths occurred on U.S roadways (across all modes), including 630 bicyclist deaths. This report examines mortality trends among cyclists using national collision data from the Fatality Analysis Reporting System (FARS) for the period 1975-2012. Annual rates for cyclist mortality decreased 44%, from 0.41 to 0.23 deaths per 100,000 during this period, with the steepest decline among children aged <15 years. In recent years, reductions in cyclist deaths have slowed. However, age-specific cyclist mortality rates for adults aged 35-74 years have increased since 1975. Multifaceted approaches to bicyclist safety have been shown to be effective in increasing bicycling while decreasing traffic injuries and fatalities. With U.S. adults choosing to walk and cycle more, implementation of these approaches might help counter recent increases in adult cyclist deaths.