BACKGROUND: Quality assessments of gonococcal surveillance data are critical to improve data validity and to enhance the value of surveillance findings. Detecting data errors by systematic audits identifies areas for quality improvement. We designed and implemented an internal audit process to evaluate the accuracy and completeness of surveillance data for the Thailand Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP). METHODS: We conducted a data quality audit of source records by comparison with the data stored in the EGASP database for five audit cycles from 2015-2021. Ten percent of culture-confirmed cases of Neisseria gonorrhoeae were randomly sampled along with any cases identified with elevated antimicrobial susceptibility testing results and cases with repeat infections. Incorrect and incomplete data were investigated, and corrective action and preventive actions (CAPA) were implemented. Accuracy was defined as the percentage of identical data in both the source records and the database. Completeness was defined as the percentage of non-missing data from either the source document or the database. Statistical analyses were performed using the t-test and the Fisher's exact test. RESULTS: We sampled and reviewed 70, 162, 85, 68, and 46 EGASP records during the five audit cycles. Overall accuracy and completeness in the five audit cycles ranged from 93.6% to 99.4% and 95.0% to 99.9%, respectively. Overall, completeness was significantly higher than accuracy (p = 0.017). For each laboratory and clinical data element, concordance was >85% in all audit cycles except for two laboratory data elements in two audit cycles. These elements significantly improved following identification and CAPA implementation. DISCUSSION: We found a high level of data accuracy and completeness in the five audit cycles. The implementation of the audit process identified areas for improvement. Systematic quality assessments of laboratory and clinical data ensure high quality EGASP surveillance data to monitor for antimicrobial resistant Neisseria gonorrhoeae in Thailand.

Work-related deaths are a persistent occupational health issue that can be prevented. However, prevention opportunities can be hampered by a lack of adequate public health resources. The Western States Occupational Network (WestON) is a network of federal, state, and local occupational health professionals that includes a 19-state region of the United States. To encourage public health collaboration, WestON partners examined work-related fatalities within the region. Fatality counts (numerators) were obtained from the U.S. Bureau of Labor Statistics (BLS) Census of Fatal Occupational Injuries restricted-access research files for all workers ages ≥15 years and fatally injured in WestON states from 2011 through 2017. Estimates of full-time equivalent hours worked (FTE) (denominators) were retrieved from the BLS Current Population Survey. Annual average fatality rates were calculated as number of fatalities per 100,000 FTE over the study period. Rates were stratified by state, select demographics, industry sector, and event/exposure types. Pearson chi-squared tests and rate ratios with 95% confidence probability limits were used to assess rate differences. All analyses were conducted using SAS v.9.4. From 2011 through 2017, the annual average overall occupational fatality rate for the WestON region was 3.5 fatalities per 100,000 FTE, comparable to the overall U.S. fatality rate. Male workers had a fatality rate almost 10 times higher than female workers in the region. Fatality rates increased with successive age groups. Alaska and New Mexico had significantly higher fatality rates for all racial/ethnic groups compared to respective regional rates. Wyoming, North Dakota, and Montana had the three highest occupational fatality rates among foreign-born workers. Agriculture/forestry/fishing, mining/oil/gas extraction, and transportation/warehousing/utilities were industry sector groups with the three highest fatality rates regionally. Transportation-related incidents were the most frequent event type associated with occupational fatalities for all 19 states. Work-related fatalities are a crosscutting occupational public health priority. This analysis can be an impetus for collaborative multistate initiatives among a dynamic and varied occupational public health network to better meet the needs of a rapidly changing workforce.

Work-related respiratory diseases affect people in every industrial sector, constituting approximately 60% of all disease and injury mortality and 70% of all occupational disease mortality. There are two basic types: interstitial lung diseases, that is the pneumoconioses (asbestosis, byssinosis, chronic beryllium disease, coal workers' pneumoconiosis (CWP), silicosis, flock workers' lung, and farmers' lung disease), and airways diseases, such as work-related or exacerbated asthma, chronic obstructive pulmonary disease and bronchiolitis obliterans (a disease that was recognized in the production of certain foods only 10 years ago). Common factors in the development of these diseases are exposures to dusts, metals, allergens and other toxins, which frequently cause oxidative damage. In response, the body reacts by activating primary immune response genes (i.e. cytokines that often lead to further oxidative damage), growth factors and tissue remodelling proteins. Frequently, complex imbalances in these processes contribute to the development of disease. For example, tissue matrix metalloproteases can cause the degradation of tissue, as in the development of CWP small profusions, but usually overexpression of matrix metalloproteases is controlled by serum protein inhibitors. Thus, disruption of such a balance can lead to adverse tissue damage. Susceptibility to these types of lung disease has been investigated largely through candidate gene studies, which have been characteristically small, often providing findings that have been difficult to corroborate. An important exception to this has been the finding that the HLA-DPB11(E69) allele is closely associated with chronic beryllium disease and beryllium sensitivity. Although chronic beryllium disease is only caused by exposure to beryllium, inheritance of HLA-DPB1(E69) carries an increased risk of between two- and 30-fold in beryllium exposed workers. Most, if not all, of these occupationally related diseases are preventable; therefore, it is disturbing that rates of CWP, for example, are again increasing in the United States in the 21st century.

OBJECTIVES: Rising antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a global public health concern. Many ceftriaxone-resistant cases have been linked to Asia. In the WHO/CDC global Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP), we conducted AMR surveillance at two clinical sites in Bangkok, Thailand, 2015-21. METHODS: Urethral discharge samples, from males with urethral discharge and/or dysuria, were Gram-stained and cultured. ETEST was performed to determine AMR. EGASP MIC alert values, CLSI and EUCAST breakpoints were used. RESULTS: In 2015-21, gonococcal isolates were cultured from 1928 cases; most (64.1%) were males reporting having sex with females. The sensitivity and specificity of Gram-stained microscopy compared with culture for detection of gonococci were 97.5% and 96.6%, respectively. From 2015 to 2021, the azithromycin MIC(90) increased from 0.125 to 1 mg/L, and the MIC(90) of ceftriaxone and cefixime increased from 0.008 and ≤0.016 mg/L to 0.032 and 0.064 mg/L, respectively. Eight EGASP MIC alert values (in seven isolates) were identified. Five alert values were for cefixime (all resistant according to EUCAST breakpoints) and three for azithromycin (all resistant according to EUCAST breakpoints). The average annual resistance to ciprofloxacin during 2015-21 was 92%. CONCLUSIONS: A continuous high susceptibility to ceftriaxone, Thailand's first-line gonorrhoea treatment, was found. However, the increasing MICs of ceftriaxone, cefixime and azithromycin are a substantial threat, especially considering these are the last remaining options for the treatment of gonorrhoea. To monitor AMR, continuous and quality-assured gonococcal AMR surveillance such as the Thai WHO/CDC EGASP, ideally including WGS, is imperative globally.

The first 2 years of combatting the COVID-19 pandemic necessitated an unprecedented use of emergency powers. States responded with an equally unprecedented flurry of legislative changes to the legal underpinnings of emergency response and public health authorities. In this article, we provide a brief background on the framework and use of governors and state health officials' emergency powers. We then analyze several key themes, including both the enhancement and restriction of powers, emerging from emergency management and public health legislation introduced in state and territorial legislatures. During the 2020 and 2021 state and territorial legislative sessions, we tracked legislation related to the emergency powers of governors and state health officials. Legislators introduced hundreds of bills impacting these powers, some enhancing and others restricting emergency powers. Enhancements included increasing vaccine access and expanding the pool of eligible medical professions that could administer vaccinations, strengthening public health investigation and enforcement authority for state agencies, and preclusion of local orders by orders at the state level. Restrictions included establishing oversight mechanisms for executive actions, limits on the duration of the emergency, limiting the scope of emergency powers allowed during a declared emergency, and other restraints. By describing these legislative trends, we hope to inform governors, state health officials, policymakers, and emergency managers about how changes in the law may impact future public health and emergency response capabilities. Understanding this new legal landscape is critical to effectively preparing for future threats. © 2023 Weston Medical Publishing. All rights reserved.

Introduction: It is vital that households are prepared for a natural disaster to help mitigate potential negative impacts. Our goal was to characterize United States household preparedness on a national level to guide next steps to better prepare for and respond to disasters during the COVID-19 pandemic. Methods: We added 10 questions to the existing Porter Novelli's ConsumerStyles surveys in fall 2020 (N = 4,548) and spring 2021 (N = 6,455) to examine factors that contribute to overall household preparedness levels. Results: Being married (odds ratio (OR), 1.2), having children in the home (OR, 1.5), and having a household income of $150,000 or more (OR, 1.2) are all associated with increased preparedness levels. Those in the Northeast are least likely to be prepared (OR, 0.8). Persons living in mobile homes, Recreational Vehicles, boats, or vans are half as likely to have preparedness plans compared to those living in single family homes (OR, 0.6). Conclusions: As a nation, there is much work to be done in terms of preparedness to reach performance measure targets of 80 percent. These data can help inform response planning and the updating of communication resources such as websites, fact sheets, and other materials to reach a wide audience of disaster epidemiologists, emergency managers, and the public. © 2023 Weston Medical Publishing. All rights reserved.

Limited data significantly hinders our capability of biothreat assessment of novel bacterial strains. Integration of data from additional sources that can provide context about the strain can address this challenge. Datasets from different sources, however, are generated with a specific objective and which makes integration challenging. Here, we developed a deep learning-based approach called the neural network embedding model (NNEM) that integrates data from conventional assays designed to classify species with new assays that interrogate hallmarks of pathogenicity for biothreat assessment. We used a dataset of metabolic characteristics from a de-identified set of known bacterial strains that the Special Bacteriology Reference Laboratory (SBRL) of the Centers for Disease Control and Prevention (CDC) has curated for use in species identification. The NNEM transformed results from SBRL assays into vectors to supplement unrelated pathogenicity assays from de-identified microbes. The enrichment resulted in a significant improvement in accuracy of 9% for biothreat. Importantly, the dataset used in our analysis is large, but noisy. Therefore, the performance of our system is expected to improve as additional types of pathogenicity assays are developed and deployed. The proposed NNEM strategy thus provides a generalizable framework for enrichment of datasets with previously collected assays indicative of species.

Disseminated gonococcal infection (DGI) is a rare complication caused by the systemic dissemination of Neisseria gonorrhoeae to normally sterile anatomical sites. Little is known about the genetic diversity of DGI gonococcal strains and how they relate to other gonococcal strains causing uncomplicated mucosal infections. We used whole genome sequencing to characterize DGI isolates (n = 30) collected from a surveillance system in Georgia, United States, during 2017-2020 to understand phylogenetic clustering among DGI as well as uncomplicated uro- and extragenital gonococcal infection (UGI) isolates (n = 110) collected in Fulton County, Georgia, during 2017-2019. We also investigated the presence or absence of genetic markers related to antimicrobial resistance (AMR) as well as surveyed the genomes for putative virulence genetic factors associated with normal human-serum (NHS) resistance that might facilitate DGI. We found that DGI strains demonstrated significant genetic variability similar to the population structure of isolates causing UGI, with sporadic incidences of geographically clustered DGI strains. DGI isolates contained various AMR markers and genetic mechanisms associated with NHS resistance. DGI isolates had a higher frequency of the porB1A allele compared with UGI (67% vs 9%, P < .0001); however, no single NHS resistance marker was found in all DGI isolates. Continued DGI surveillance with genome-based characterization of DGI isolates is necessary to better understand specific factors that promote systemic dissemination.

The COVID-19 pandemic has highlighted and exacerbated long-standing inequities in the social determinants of health (1-3). Ensuring equitable access to effective COVID-19 therapies is essential to reducing health disparities. Molnupiravir (Lagevrio) and nirmatrelvir/ritonavir (Paxlovid) are oral antiviral agents effective at preventing hospitalization and death in patients with mild to moderate COVID-19 who are at high risk* for progression to severe COVID-19 when initiated within 5 days of symptom onset. These medications received Emergency Use Authorization from the Food and Drug Administration (FDA) in December 2021() and were made available at no cost to recipients through the U.S. Department of Health and Human Services (HHS) on December 23, 2021. Beginning March 7, 2022, a series of strategies was implemented to expand COVID-19 oral antiviral access, including the launch of the Test to Treat initiative.() Data from December 23, 2021-May 21, 2022, were analyzed to describe oral antiviral prescription dispensing overall and by week, stratified by zip code social vulnerability. Zip codes represented areas classified as low, medium, or high social vulnerability; approximately 20% of U.S. residents live in low-, 31% in medium-, and 49% in high-social vulnerability zip codes.() During December 23, 2021-May 21, 2022, a total of 1,076,762 oral antiviral prescriptions were dispensed (Lagevrio = 248,838; Paxlovid = 827,924). Most (70.3%) oral antivirals were dispensed during March 7-May 21, 2022. During March 6, 2022-May 21, 2022, the number of oral antivirals dispensed per 100,000 population increased from 3.3 to 77.4 in low-, from 4.5 to 70.0 in medium-, and from 7.8 to 35.7 in high-vulnerability zip codes. The number of oral antivirals dispensed rose substantially during the overall study period, coincident with the onset of initiatives to increase access. However, by the end of the study period, dispensing rates in high-vulnerability zip codes were approximately one half the rates in medium- and low-vulnerability zip codes. Additional public health, regulatory, and policy efforts might help decrease barriers to oral antiviral access, particularly in communities with high social vulnerability.

The global emergence of many severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants jeopardizes the protective antiviral immunity induced following infection or vaccination. To address the public health threat caused by the increasing SARS-CoV-2 genomic diversity, the National Institute of Allergy and Infectious Diseases (NIAID) within the National Institutes of Health (NIH) established the SARS-CoV-2 Assessment of Viral Evolution (SAVE) program. This effort was designed to provide a real-time risk assessment of SARS-CoV-2 variants potentially impacting transmission, virulence, and resistance to convalescent and vaccine-induced immunity. The SAVE program serves as a critical data-generating component of the United States Government SARS-CoV-2 Interagency Group to assess implications of SARS-CoV-2 variants on diagnostics, vaccines, and therapeutics and for communicating public health risk. Here we describe the coordinated approach used to identify and curate data about emerging variants, their impact on immunity, and effects on vaccine protection using animal models. We report the development of reagents, methodologies, models, and pivotal findings facilitated by this collaborative approach and identify future challenges. This program serves as a template for the response against rapidly evolving pandemic pathogens by monitoring viral evolution in the human population to identify variants that could erode the effectiveness of countermeasures.

BACKGROUND: Disseminated gonococcal infections (DGI) are thought to be uncommon; surveillance is limited and case reports are analyzed retrospectively or in case clusters. We describe the population-level burden of culture-confirmed DGI through the Active Bacterial Core surveillance (ABCs) system. METHODS: During 2015-2016, retrospective surveillance was conducted among residents in two ABCs areas and prospectively in three ABCs areas during 2017-2019. A DGI case was defined as isolation of Neisseria gonorrhoeae (Ng) from a normally sterile site. A case report form was completed for each case and antimicrobial susceptibility testing (AST) was performed on available isolates. RESULTS: During 2015-2019, 77 DGI cases were identified (~a rate of 0.13 cases per 100,000 population) and accounted for 0.06% of all reported gonorrhea cases in the three surveillance areas. Most DGI cases were male (64%), non-Hispanic Black (68%), and ranged from 16-67 years; blood (55%) and joint (40%) were the most common sterile sites. Among 29 isolates with AST results during 2017-2019, all were susceptible to ceftriaxone. CONCLUSIONS: DGI is an infrequent complication of Ng; since Ng can quickly develop antimicrobial resistance, continued DGI surveillance, including monitoring trends in antimicrobial susceptibility, could help inform DGI treatment recommendations.

On September 6 and 20, 2017, Hurricanes Irma and Maria made landfall as major hurricanes in the US Caribbean Territories of the Virgin Islands and Puerto Rico with devastating effects. As part of the initial response, a public health team (PHT) was initially deployed as part of the US Department of Health and Human Services Incident Response Coordination Team. As a result of increased demands for additional expertise and resources, a public health branch (PHB) was established for coordinating a broad spectrum of public health response activities in support of the affected territories. This paper describes the conceptual framework for organizing these activities; summarizes some key public health activities and roles; outlines partner support and coordination with key agencies; and defines best practices and areas for improvement in disaster future operations. © 2021 Weston Medical Publishing. All rights reserved.

Pandemics are stressful times, full of uncertainty and fear. During the COVID-19 pandemic, many Americans have experienced feelings of stress, grief, and loss. How Right Now (HRN) – and its Spanish-language counterpart, Qué Hacer Ahora (QHA) – is an evidence-based, culturally-relevant communication campaign designed to promote and strengthen the emotional well-being and resiliency of populations adversely affected by the COVID-19 pandemic and beyond. Developed by the Centers for Disease Control and Prevention (CDC) with support from the CDC Foundation, the campaign aims to help all Americans but has a specific focus on some of the disproportionately affected groups, including adults over 65 and their caregivers, individuals with pre-existing physical and mental health conditions, people experiencing violence, and those experiencing economic distress. Based on rapid, but robust, formative research, HRN offers audience-centric messages representing the real, everyday experiences and emotions that these audiences are having and addresses them in actionable ways. These include messages that address the social and structural barrier that disproportionately-affected groups have been facing long before the pandemic — and which are felt more acutely now. This paper provides an overview of the rapid, mixed-method, culturally-responsive formative research process undertaken to inform the development of HRN. Specifically, it describes how HRN’s disproportionately-affected audiences describe and discuss their emotiona well-being during COVID-19 through the lens of Social Determinants of Health (SDOH). We introduce a secondary theory, Vital Conditions for Health and Well-Being (VCHW), which conceptualizes holistic well-being and the conditions that give rise to it and identifies levers for community change and improvement. Data collection methods included an environmental scan (n≥700 publications); social listening (n≥1 million social media posts); partner needs-assessment calls (n=16); partner-convened listening sessions with community members (n=29), online focus groups (n=10), and a national probability survey (n=731), all in English and Spanish. Findings suggest that HRN’s priority audiences’ emotional well-being and SDOH are interconnected. Disruptions in SDOH du to the COVID-19 pandemic can lead to emotional well-being challenges (e.g., anxiety) for HRN’s priority audiences. While some disruptions may lead some people to adapt, connect with others, and be more resilient, there is a disparate impact of emotional well-being amid COVID-19 for those already experiencing disparities linked to SDOH. Understanding the perspectives and experiences of disproportionately affected populations through the lens of SDOH is vital to identifying the kinds of supports and services – like How Right Now/Qué Hacer Ahora – required for these populations. © 2021 Weston Medical Publishing. All rights reserved.

Sarcoidosis and chronic beryllium disease (CBD) are phenocopies, however the latter one has a clear trigger factor that is beryllium exposure. This study analyses single nucleotide polymorphisms (SNPs) in a large cohort for beryllium-exposed persons. SNPs were chosen for their relevance in sarcoidosis. Even though one of largest cohorts of beryllium-exposed persons was analysed, no statistically relevant association between any SNP and CBD could be verified. Notably, some SNPs exhibit inverse OR for beryllium sensitization and CBD with nominally statistical significance, which allows hypothesizing about pathophysiological role of genes for the disease triggering and development.

SARS-CoV-2, the virus that causes COVID-19, can spread rapidly in prisons and can be introduced by staff members and newly transferred incarcerated persons (1,2). On September 28, 2020, the Wisconsin Department of Health Services (DHS) contacted CDC to report a COVID-19 outbreak in a state prison (prison A). During October 6-20, a CDC team investigated the outbreak, which began with 12 cases detected from specimens collected during August 17-24 from incarcerated persons housed within the same unit, 10 of whom were transferred together on August 13 and under quarantine following prison intake procedures (intake quarantine). Potentially exposed persons within the unit began a 14-day group quarantine on August 25. However, quarantine was not restarted after quarantined persons were potentially exposed to incarcerated persons with COVID-19 who were moved to the unit. During the subsequent 8 weeks (August 14-October 22), 869 (79.4%) of 1,095 incarcerated persons and 69 (22.6%) of 305 staff members at prison A received positive test results for SARS-CoV-2. Whole genome sequencing (WGS) of specimens from 172 cases among incarcerated persons showed that all clustered in the same lineage; this finding, along with others, demonstrated that facility spread originated with the transferred cohort. To effectively implement a cohorted quarantine, which is a harm reduction strategy for correctional settings with limited space, CDC's interim guidance recommendation is to serial test cohorts, restarting the 14-day quarantine period when a new case is identified (3). Implementing more effective intake quarantine procedures and available mitigation measures, including vaccination, among incarcerated persons is important to controlling transmission in prisons. Understanding and addressing the challenges faced by correctional facilities to implement medical isolation and quarantine can help reduce and prevent outbreaks.

BACKGROUND: The most recent estimates of the number of prevalent and incident sexually transmitted infections (STIs) in the United States (US) were for 2008. We provide updated estimates for 2018 using new methods. METHODS: We estimated the total number of prevalent and incident infections in the US for eight STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus (HPV), sexually transmitted hepatitis B, and sexually transmitted HIV. Updated per capita prevalence and incidence estimates for each STI were multiplied by the 2018 full resident population estimates to calculate the number of prevalent and incident infections. STI-specific estimates were combined to generate estimates of the total number of prevalent and incident STIs overall, and by gender and age group. Primary estimates are represented by medians and uncertainty intervals are represented by the 25th (Q1) and 75th (Q3) percentiles of the empirical frequency distributions of prevalence and incidence for each STI. RESULTS: In 2018, there were an estimated 67.6 (Q1=66.6, Q3=68.7) million prevalent and 26.2 (Q1=24.0, Q3=28.7) million incident STIs in the US. Chlamydia, trichomoniasis, genital herpes, and HPV comprised 97.6% of all prevalent and 93.1% of all incident STIs. Persons aged 15-24 years comprised 18.6% (12.6 million) of all prevalent infections; however, they comprised 45.5% (11.9 million) of all incident infections. CONCLUSIONS: The burden of STIs in the US is high. Almost half of incident STIs occurred in persons aged 15-24 years in 2018. Focusing on this population should be considered essential for national STI prevention efforts.

BACKGROUND: The most recent prevalence and incidence estimates for chlamydia and gonorrhea, the two most reported nationally notifiable conditions in the United States (US), were for 2008. We present updated estimates for the number of prevalent and incident chlamydial and gonococcal infections for 2018. METHODS: We estimated chlamydial prevalence directly from the 2015-2018 cycles of the National Health and Nutrition Examination Survey (NHANES) and chlamydial incidence using a mathematical model primarily informed by NHANES and case report data. Total and antimicrobial resistant (AMR) gonococcal prevalence and incidence were estimated using mathematical models primarily informed by case report and Gonococcal Isolate Surveillance Program data. Estimates were calculated for the total population, all women, and all men aged 15-39 years, stratified by age group. Primary estimates represent medians and uncertainty intervals represent the 25th (Q1) and 75th (Q3) percentiles of the empirical frequency distributions of prevalence and incidence for each infection. RESULTS: Among persons aged 15-39 years in the US in 2018, we estimate 2.35 (Q1=2.20, Q3=2.51) million prevalent and 3.98 (Q1=3.77, Q3=4.22) million incident chlamydial infections, and an estimated 209,000 (Q1=183,000, Q3=241,000) prevalent and 1.57 (Q1=1.44, Q3=1.72) million incident gonococcal infections. Of all gonococcal infections, there were 107,000 (Q1=94,000, Q3=124,000) prevalent and 804,000 (Q1=738,000, Q3=883,000) incident infections demonstrating AMR or elevated minimum inhibitory concentrations (MICs) to selected antibiotics. CONCLUSIONS: Chlamydia and gonorrhea were very common in the US in 2018. Estimates show that more than 800,000 newly acquired gonococcal infections in 2018 demonstrated resistance or elevated MICs to currently or previously recommended antibiotics.

The objective of this study was to investigate biomechanical loads on the lumbar spine as a function of working in a confined vertical space, consistent with baggage handling inside the baggage compartment of an airplane. Ten male subjects performed baggage handling tasks using confined (kneeling, sitting) and unconfined (stooping) lifting styles. Dependent measures of torso flexion and three-dimensional spinal loads were assessed with an electromyography-driven biomechanical model. Lifting exertions typical to airline baggage handling posed significant risk to the lumbar spine, regardless of lifting style. Statistically significant differences attributable to lift style (stooping, kneeling, sitting) were not observed for peak compressive, lateral shear, or resultant spinal loads, but lifting while kneeling decreased anterior/posterior (A/P) shear spinal loads relative to stooping (p = 0.02). Collectively, kneeling offers the greatest benefit when lifting in confined spaces because of the ability to keep the torso upright, subsequently reducing shear forces on the lumbar spine.

Although understanding the local epidemiology of gonorrhoea is critical for local efforts, understanding the multinational epidemiology may support development of national and international prevention and control policies and strategies. In this paper, current epidemiology of gonorrhoea is reviewed through an international lens and with a focus on selected populations. The World Health Organization (WHO) estimates that ~87 million new gonococcal infections occurred among people aged 15-49 years in 2016. Gonorrhoea rates are rising in many countries. Gay, bisexual and other men who have sex with men, racial or ethnic minorities, Indigenous populations and sex workers appear to bear disproportionate burdens of gonorrhoea. International travel can facilitate spread of gonorrhoea, including resistant strains, across international borders. Critical gaps in epidemiological knowledge are highlighted, including data on gonorrhoea among transgender persons and the burden of extragenital gonorrhoea. Even as further data are gathered, action - informed by currently available data - is needed now to confront this growing international threat.

PURPOSE: We investigated the association between county-level trends in opioid prescribing rates, a proxy for opioid misuse, and rates of reported gonorrhea (GC) among males in the United States. METHODS: We used linear mixed-model regression analyses to evaluate the association between county-level trends in opioid prescribing rates and rates of reported GC among males during 2010-2015. RESULTS: There was a positive association between trends in county-level opioid prescribing rates and rates of GC among males (beta = 0.068, 95% confidence interval [CI] = 0.030, 0.105) during 2010-2015. However, the magnitude of this association decreased significantly over time in counties where opioid prescribing rates decreased (beta = -0.018, 95% CI = -0.030, -0.006) and remained stable (beta = -0.020, 95% CI = -0.038, -0.002) but was unchanged in counties where opioid prescribing rates increased (beta = -0.029, 95% CI = -0.058, 0.001). CONCLUSIONS: During 2010-2015, we found a positive association between increases in county-level opioid prescribing rates, a proxy for opioid misuse, and rates of reported GC among males especially in counties most affected by the opioid crisis. Integrating sexual health with opioid misuse interventions might be beneficial in addressing the GC burden in the United States.

The rate of reported gonorrhea among men who have sex with men (MSM) has been steadily increasing in recent years, but little is known about how much changing testing practices and incidence each contribute to this trend. We report that both factors are likely contributing to the observed rate increases.

Background: Gonorrhea is the second most commonly reported notifiable condition in the United States (U.S.). Infrequently, Neisseria gonorrhoeae can cause disseminated gonococcal infection (DGI). Eculizumab, a monoclonal antibody, inhibits terminal complement activation which impairs the ability of the immune system to respond effectively to Neisseria infections. This series describes cases of N. gonorrhoeae infection among patients receiving eculizumab. Methods: Pre- and postmarketing safety reports of N.gonorrhoeae infection in patients receiving eculizumab worldwide were obtained from FDA safety databases and the medical literature, including reports from the start of pivotal clinical trials in 2004 through December 31, 2017. Included patients had at least one eculizumab dose within the three months prior to N. gonorrhoeae infection. Results: Nine cases of N. gonorrhoeae infection were identified; eight were classified as disseminated (89%). Of the disseminated cases, eight patients required hospitalization, seven had positive blood cultures, and two required vasopressor support. One patient required mechanical ventilation. N. gonorrhoeae may have contributed to complications prior to death in one patient; however, the fatality was attributed to underlying disease per the reporter. Conclusion: Patients receiving eculizumab may be at higher risk for DGI than the general population. Prescribers are encouraged to educate patients receiving eculizumab on their risk for serious gonococcal infections and perform screening for sexually transmitted diseases (STDs) per Centers for Disease Control and Prevention STD treatment guidelines or in suspect cases. If antimicrobial prophylaxis is used during eculizumab therapy, prescribers should consider trends in gonococcal antimicrobial susceptibility due to emerging resistance concerns.

Antimicrobial-resistant Neisseria gonorrhoeae (NG) infection is a global public health threat, and there is a critical need to monitor patterns of resistance and risk factors. In collaboration with the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (CDC), and the Thailand Department of Disease Control (DDC), Ministry of Public Health (MoPH) implemented the first Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) in November 2015. Men presenting with urethritis at two clinical settings in Bangkok, Thailand (Bangrak Hospital [BH] and Silom Community Clinic @TropMed [SCC @TropMed]) provided demographic and behavioral information and had a urethral swab for Gram's stain and NG culture collected. The NG isolates were evaluated for antimicrobial susceptibility by the Epsilometer test (Etest) to determine minimum inhibitory concentrations (MICs) for cefixime (CFM), ceftriaxone (CRO), azithromycin (AZI), gentamicin (GEN), and ciprofloxacin (CIP). From November 2015 -October 2016, 1,102 specimens were collected from 1,026 symptomatic men; 861 (78.1%) specimens were from BH and 241 (21.9%) specimens were from SCC @TropMed. Among the 1,102 specimens, 582 (52.8%) had intracellular Gram-negative diplococci and 591 (53.6%) had NG growth (i.e., NG infection); antimicrobial susceptibility testing (AST) was performed on 590 (99.8%) NG isolates. Among all symptomatic men, 293 (28.6%) had sex with men only, 430 (41.9%) were ages 18-29 years, 349 (34.0%) had antibiotic use in the last 2 weeks, and 564 (55.0%) had NG infection. Among 23 men with repeat NG infection during this first year of surveillance, 20 (87.0%) were infected twice, 2 (8.7%) were infected three times, and 1 (4.3%) was infected more than four times. All NG isolates were susceptible to CFM and CRO, and had MICs below 2 mug/mL for AZI and below 16 mug/mL for GEN. Overall, 545 (92.4%) isolates were resistant to CIP. This surveillance activity assessed individual patients, and included demographic and behavioral data linked to laboratory data. The inclusion of both individual and laboratory information in EGASP could help identify possible persistent infection and NG treatment failures. Expansion of EGASP to additional global settings is critical to assess trends and risk factors for NG, and to monitor for the emergence of resistance.

Gonorrhea, the sexually transmitted disease (STD) caused by Neisseria gonorrhoeae, is the second most common notifiable disease in the United States after chlamydia; 468,514 cases were reported to state and local health departments in 2016, an increase of 18.5% from 2015 (1). N. gonorrhoeae has progressively developed resistance to most antimicrobials used to treat the infection (2). As a result, CDC recommends two antimicrobials (250 mg of ceftriaxone [IM] plus 1 g of azithromycin [PO]) for treating uncomplicated gonorrhea to improve treatment efficacy and, potentially, to slow the emergence and spread of antimicrobial resistance. To monitor adherence to the current CDC-recommended regimen for uncomplicated gonorrhea, CDC reviewed enhanced data collected on a random sample of reported cases of gonorrhea in seven jurisdictions participating in the STD Surveillance Network (SSuN) and estimated the proportion of patients who received the CDC-recommended regimen for uncomplicated gonorrhea, by patient characteristics and diagnosing facility type. In 2016, the majority of reported patients with gonorrhea (81%) received the recommended regimen. There were no differences in the proportion of patients receiving the recommended regimen by age or race/ethnicity; however, patients diagnosed with gonorrhea in STD (91%) or family planning/reproductive health (94%) clinics were more likely to receive this regimen than were patients diagnosed in other provider settings (80%). These data document high provider adherence to CDC gonorrhea treatment recommendations in specialty STD clinics, indicating high quality of care provided in those settings. Local and state health departments should monitor adherence with recommendations in their jurisdictions and consider implementing interventions to improve provider and patient compliance with gonorrhea treatment recommendations where indicated.

Information on spinal loading for using lift assist systems for airport baggage handling is lacking. We conducted a laboratory study to evaluate a vacuum lift system for reducing lumbar spinal loads during baggage loading/unloading tasks. Ten subjects performed the tasks using the industry average baggage weight of 14.5 kg on a typical two-shelved baggage cart with or without using the lift system (i.e. lifting technique). Repeated measures analysis of variance (2 tasks x 2 shelf heights x 2 techniques) was used. Spinal loads were estimated by an electromyography-driven biomechanical model. On average, the vacuum lift system reduced spinal compressive forces on the lumbar spine by 39% and below the 3400 N damage threshold. The system also resulted in a 25% reduction in the anterior-posterior shear force at the L5/S1 inferior endplate level. This study provides evidence for the potential to reduce spinal loads when using a vacuum lift system.

To assess trends in Neisseria gonorrhoeae among gay, bisexual, and other men who have sex with men (MSM), we reviewed existing and published gonorrhea surveillance data in the United States (U.S.). Data identified in this review include: national gonorrhea case report data and data from three other surveillance programs, the Gonococcal Isolate Surveillance Project (GISP), the STD Surveillance Network (SSuN), and National HIV Behavioral Surveillance (NHBS).Rates of reported cases of gonorrhea among men increased 54.8% during 2006-2015 compared to a 2.6% increase among women. Since 2012, the rate of reported gonorrhea cases among men surpassed the rate among women; the male-to-female case rate ratio increased from 0.97 in 2012 to 1.31 in 2015. The proportion of gonococcal urethral isolates collected in GISP that were collected from MSM increased from 21.5% to 38.1% during 2006-2015. During 2009-2015, the percent of MSM who tested positive for rectal and oropharyngeal gonorrhea in STD clinics increased by 73.4% and 12.6%, respectively. Estimated rates of gonorrhea among MSM increased 151% during 2010-2015 in jurisdictions participating in SSuN. Data from NHBS demonstrate that testing for gonorrhea among MSM increased 23.1% between 2011 and 2014.Together, surveillance data suggest a disproportionate burden of gonorrhea among MSM in the U.S. and suggest increases in both screening and disease in recent years. Since each data source has inherent limitations and biases, examining these data from different systems together strengthens this conclusion.

Monitoring trends in antimicrobial drug-resistant Neisseria gonorrhoeae is a critical public health and global health security activity because the number of antimicrobial drugs available to treat gonorrhea effectively is rapidly diminishing. Current global surveillance methods for antimicrobial drug-resistant N. gonorrhoeae have many limitations, especially in countries with the greatest burden of disease. The Enhanced Gonococcal Antimicrobial Surveillance Program is a collaboration between the World Health Organization and the Centers for Disease Control and Prevention. The program aims to monitor trends in antimicrobial drug susceptibilities in N. gonorrhoeae by using standardized sampling and laboratory protocols; to improve the quality, comparability, and timeliness of gonococcal antimicrobial drug resistance data across multiple countries; and to assess resistance patterns in key populations at highest risk for antimicrobial drug-resistant gonorrhea so country-specific treatment guidelines can be informed.

Background: Rhinoviruses (RVs) are ubiquitous respiratory pathogens that often cause mild or subclinical infections. Molecular detection of RV from the upper respiratory tract can be prolonged, complicating etiologic association in persons with severe lower respiratory tract infections. Little is known about RV viremia and its value as a diagnostic indicator in persons hospitalized with community-acquired pneumonia (CAP). Methods: Sera from RV-positive children and adults hospitalized with CAP were tested for RV by real-time RT-PCR. RV species and type were determined by partial genome sequencing. Results: Overall, 57/570 (10%) RV-positive patients were viremic and all were children <10 years old [57/375 (15.2%)]. Although RV-A was the most common RV species detected from respiratory specimens (48.8%), almost all viremias were RV-C (98.2%). Viremic patients had fewer co-detected pathogens and were more likely to have chest retractions, wheezing and a history of underlying asthma/reactive airway disease than patients without viremia. Conclusions: More than one out of seven RV-infected children <10 years old hospitalized with CAP were viremic. In contrast with other RV species, RV-C infections were highly associated with viremia and more often the only respiratory pathogen identified, suggesting that RV-C viremia may be an important diagnostic indicator in pediatric pneumonia.

Background: The role of human bocavirus (HBoV) in respiratory illness is uncertain. HBoV genomic DNA is frequently detected in both ill and healthy children. We hypothesized that spliced viral capsid messenger RNA (mRNA) produced during active replication might be a better marker for acute infection. Methods: As part of the Etiology of Pneumonia in the Community (EPIC) study, children aged <18 years who were hospitalized with community-acquired pneumonia (CAP) and children asymptomatic at the time of elective outpatient surgery (controls) were enrolled. Nasopharyngeal/oropharyngeal specimens were tested for HBoV mRNA and genomic DNA by quantitative polymerase chain reaction. Results: HBoV DNA was detected in 10.4% of 1295 patients with CAP and 7.5% of 721 controls (odds ratio [OR], 1.4 [95% confidence interval {CI}, 1.0-2.0]); HBoV mRNA was detected in 2.1% and 0.4%, respectively (OR, 5.1 [95% CI, 1.6-26]). When adjusted for age, enrollment month, and detection of other respiratory viruses, HBoV mRNA detection (adjusted OR, 7.6 [95% CI, 1.5-38.4]) but not DNA (adjusted OR, 1.2 [95% CI, .6-2.4]) was associated with CAP. Among children with no other pathogens detected, HBoV mRNA (OR, 9.6 [95% CI, 1.9-82]) was strongly associated with CAP. Conclusions: Detection of HBoV mRNA but not DNA was associated with CAP, supporting a pathogenic role for HBoV in CAP. HBoV mRNA could be a useful target for diagnostic testing.

Microbial N2 fixation (diazotrophy) represents an important nitrogen source to oligotrophic peatland ecosystems, which are important sinks for atmospheric CO2 and susceptible to changing climate. The objectives of this study were: (i) to determine the active microbial group and type of nitrogenase mediating diazotrophy in a ombrotrophic Sphagnum-dominated peat bog (the S1 peat bog, Marcell Experimental Forest, Minnesota, USA); and (ii) to determine the effect of environmental parameters (light, O2, CO2, CH4) on potential rates of diazotrophy measured by acetylene (C2H2) reduction and 15N2 incorporation. Molecular analysis of metabolically active microbial communities suggested that diazotrophy in surface peat was primarily mediated by Alphaproteobacteria (Bradyrhizobiaceae and Beijerinckiaceae). Despite higher dissolved vanadium (V; 11 nM) than molybdenum (Mo; 3 nM) in surface peat, a combination of metagenomic, amplicon sequencing and activity measurements indicated that Mo-containing nitrogenases dominate over the V-containing form. Acetylene reduction was only detected in surface peat exposed to light, with the highest rates observed in peat collected from hollows with the highest water content. Incorporation of 15N2 was suppressed 90% by O2 and 55% by C2H2, and was unaffected by CH4 and CO2 amendments. These results suggest that peatland diazotrophy is mediated by a combination of C2H2-sensitive and C2H2-insensitive microbes that are more active at low O2 and show similar activity at high and low CH4Importance Previous studies indicate that diazotrophy provides an important nitrogen source and is linked to methanotrophy in Sphagnum-dominated peatlands. However, the environmental controls and enzymatic pathways of peatland diazotrophy, as well as the metabolically active microbial populations that catalyze this process remain in question. Our findings indicate that oxygen levels and photosynthetic activity override low nutrient availability in limiting diazotrophy, and that members of the Alphaproteobacteria (Rhizobiales) catalyze this process at the bog surface using the molybdenum-based form of the nitrogenase enzyme.