BACKGROUND: From 2004 to 2019, suicide rates among Black youth increased by 122 % for females and 65 % for males. Guided by the interpersonal theory of suicide, this study explored how perceptions of social support and parental involvement may contribute to suicidal behavior among Black youth aged 12-17 years. METHODS: Data are from the 2004-2019 National Survey on Drug Use and Health (NSDUH). Multivariable logistic regression with backwards elimination was conducted to determine if characteristics associated with outcomes of interest (i.e., suicidal ideation, made a suicide plan, and made a suicide attempt) differed by sex. The characteristics examined included: age, poverty level, health insurance coverage, currently receiving mental health treatment, grades for last completed semester, parental involvement, frequency of arguments or fights with parents, frequency of fights at school or work, parental attitudes, and availability of emotional support. RESULTS: Over 400,000 Black youth with depression symptoms reported suicidal thoughts and behaviors (80 % female). Females had increased odds of suicidal ideation and making a plan if they had no one to talk to about serious problems. Males had increased odds of attempting suicide if they reported academic struggles. LIMITATIONS: This is a cross-sectional study and potential biases may affect generalizability of results. CONCLUSIONS: Risk and protective factors identified in this study aligned with the interpersonal theory of suicide. Evidence-based interventions that focus on increasing connectedness and self-esteem may be effective for Black youth struggling with suicidal ideation. Preventing suicide requires a comprehensive approach including prevention strategies for individuals, families, and communities.

Digital trace data and machine learning techniques are increasingly being adopted to predict suicide-related outcomes at the individual level; however, there is also considerable public health need for timely data about suicide trends at the population level. Although significant geographic variation in suicide rates exist by state within the United States, national systems for reporting state suicide trends typically lag by one or more years. We developed and validated a deep learning based approach to utilize real-time, state-level online (Mental Health America web-based depression screenings; Google and YouTube Search Trends), social media (Twitter), and health administrative data (National Syndromic Surveillance Program emergency department visits) to estimate weekly suicide counts in four participating states. Specifically, per state, we built a long short-term memory (LSTM) neural network model to combine signals from the real-time data sources and compared predicted values of suicide deaths from our model to observed values in the same state. Our LSTM model produced accurate estimates of state-specific suicide rates in all four states (percentage error in suicide rate of -2.768% for Utah, -2.823% for Louisiana, -3.449% for New York, and -5.323% for Colorado). Furthermore, our deep learning based approach outperformed current gold-standard baseline autoregressive models that use historical death data alone. We demonstrate an approach to incorporate signals from multiple proxy real-time data sources that can potentially provide more timely estimates of suicide trends at the state level. Timely suicide data at the state level has the potential to improve suicide prevention planning and response tailored to the needs of specific geographic communities.

Mosquitoes are a known public nuisance and can vector various diseases. Historically, New Orleans, LA, has long been acquainted with the burden of mosquito-borne diseases, such as malaria and yellow fever in the 20th century and West Nile virus in the 21st century. Government mosquito control awareness campaigns have been around for decades as has the use of organophosphate and pyrethroid insecticides by mosquito abatement districts. However, few data are available on public perception of mosquito control and public usage of insecticides to kill mosquitoes in New Orleans. We conducted a survey from August 2020 to July 2021 to evaluate New Orleans residents' 1) general knowledge regarding mosquito control and 2) what measures and products they use to control mosquitoes. The aim of this survey was to determine how residents contribute to backyard mosquito control by do-it-yourself or professional applications of insecticides. The survey was disseminated both online and via mail. Of the 396 survey participants, nearly all (99.48%) agreed that mosquito control is important in New Orleans because it prevents mosquito bites (30.85%), prevents mosquito borne-diseases (38.51%), and prevents nuisance mosquitoes (29.17%). More than one-third (35%) of survey participants indicated that they empty containers to reduce adult mosquitoes on their own property. More than two-thirds of the participants (69.95%) would not hire a pest management professional to spray their yard for adult mosquitoes, and only 20% of survey participants do apply a pesticide to kill adult mosquitoes on their own property. None of our findings were associated with the level of education, gender, or age of participants. This study suggests that the City of New Orleans Mosquito, Termite and Rodent Control Board educational and outreach campaigns may be an effective tool in spreading mosquito control awareness and contribute to residents' knowledge of mosquito control. The data we collected indicate that residents understand what mosquito control is and why it is important in New Orleans.

CONTEXT: In the northeastern United States, recommendations to prevent diseases spread by black-legged ticks (Ixodes scapularis) and lone star ticks (Amblyomma americanum) often rely on individuals to use personal protection or yard-based strategies. The 4-Poster deer treatment stations (4-Posters) suppress tick populations by treating deer hosts with acaricide, potentially offering a community-wide approach for reducing tick-borne diseases in endemic areas. The 4-Poster deployment logistics in mainland community settings are not well documented but are needed for future public health tick control efforts. PROGRAM: As part of a public health research effort to design a population-based 4-Poster effectiveness study aimed at reducing tick-borne disease incidence, TickNET researchers partnered with the Town of Ridgefield (Connecticut) to understand the feasibility and operational logistics of deploying 4-Posters on public land within a residential community to inform future public health interventions by municipalities or vector control agencies. IMPLEMENTATION: We deployed three 4-Posters on a municipal property from July to December 2020 and used motion-activated cameras to record wildlife activity nearby. We documented per-device operational details, costs, materials consumed, and animal activity. EVALUATION: Operation of 4-Posters was feasible, and device challenges were easily remedied. Deer visitation and heavy nontarget animal use were documented at all devices. Unexpectedly, monthly corn consumption was not correlated with monthly deer-view days. The monthly cost per device was US $1279 or US $305 per hectare with an average 21 minutes of weekly service time. DISCUSSION: Use of 4-Posters by communities, public health agencies, or vector control programs may be a practicable addition to tick management programs in tick-borne disease endemic areas in the Northeast. Such programs should carefully consider local and state regulations, follow manufacturer and pesticide label guidelines, and include wildlife monitoring. High labor costs incurred in this project could be mitigated by training vector control agency or municipality staff to service 4-Posters.

On July 26, 2022, a pediatric nephrologist alerted The Gambia's Ministry of Health (MoH) to a cluster of cases of acute kidney injury (AKI) among young children at the country's sole teaching hospital, and on August 23, 2022, MoH requested assistance from CDC. CDC epidemiologists arrived in The Gambia, a West African country, on September 16 to assist MoH in characterizing the illness, describing the epidemiology, and identifying potential causal factors and their sources. Investigators reviewed medical records and interviewed caregivers to characterize patients' symptoms and identify exposures. The preliminary investigation suggested that various contaminated syrup-based children's medications contributed to the AKI outbreak. During the investigation, MoH recalled implicated medications from a single international manufacturer. Continued efforts to strengthen pharmaceutical quality control and event-based public health surveillance are needed to help prevent future medication-related outbreaks.

Examine characteristics associated with increased odds of nonfatal suicidal behaviors among former active-duty servicemembers (F-ADSM) using data from the 20132019 National Survey on Drug Use and Health (NSDUH). F-ADSM were respondents who reported being separated/retired from the military and previously serving on active-duty. For each outcome of interest (suicidal ideation, made a suicide plan, made a suicide attempt), we used multivariable logistic regression with backwards elimination to identify characteristics with statistically significant associations. In the 12 months preceding the survey, 3.6% of F-ADSM reported suicidal ideation, 1.0% reported making a plan, and 0.3% reported making a suicide attempt. There were increased odds of self-reported suicide attempts among F-ADSM who were female; aged 1849 years; non-Hispanic black; gay or bisexual; divorced/separated or widowed; not employed; in poverty; binged alcohol in the past month; or ever had a major depressive episode. Suicide can be prevented through a comprehensive, upstream approach addressing veterans holistic needs to prevent them from becoming suicidal in the first place, and support veterans at increased risk. This work was authored as part of the Contributors official duties as an Employee of the United States Government and is therefore a work of the United States Government. In accordance with 17 U.S.C. 105, no copyright protection is available for such works under U.S. Law.

Examine characteristics associated with increased odds of nonfatal suicidal behaviors among former active-duty servicemembers (F-ADSM) using data from the 2013–2019 National Survey on Drug Use and Health (NSDUH). F-ADSM were respondents who reported being separated/retired from the military and previously serving on active-duty. For each outcome of interest (suicidal ideation, made a suicide plan, made a suicide attempt), we used multivariable logistic regression with backwards elimination to identify characteristics with statistically significant associations. In the 12 months preceding the survey, 3.6% of F-ADSM reported suicidal ideation, 1.0% reported making a plan, and 0.3% reported making a suicide attempt. There were increased odds of self-reported suicide attempts among F-ADSM who were female; aged 18–49 years; non-Hispanic black; gay or bisexual; divorced/separated or widowed; not employed; in poverty; binged alcohol in the past month; or ever had a major depressive episode. Suicide can be prevented through a comprehensive, upstream approach addressing veteran’s holistic needs to prevent them from becoming suicidal in the first place, and support veterans at increased risk. © This work was authored as part of the Contributor’s official duties as an Employee of the United States Government and is therefore a work of the United States Government. In accordance with 17 U.S.C. 105, no copyright protection is available for such works under U.S. Law.

INTRODUCTION: Geographic and urbanization differences in female suicide trends across the U.S. necessitates suicide prevention efforts on the basis of geographic variations. The purpose of this study was to assess female suicide rates by mechanism within Census divisions and by urbanicity to help inform geographically tailored approaches for suicide prevention strategies. METHODS: Data from 2004 to 2018 were obtained from the National Vital Statistics System (analyzed in 2021). Annual counts of female suicides were tabulated for firearm, suffocation, and drug poisoning and stratified by the U.S. Census division and urbanicity. Age-adjusted rates were calculated to describe female suicide incidence by geographic areas and urbanicity. Data were analyzed annually and by 5-year timeframes. Trends in annual female suicide rates by mechanism for 3 urbanization levels were identified using Joinpoint Regression. Annual percent change estimates were calculated for age-adjusted female suicide rates between 2004 and 2018. RESULTS: Female suicide rates by mechanism were not homogeneous within Census divisions or by urbanization levels. Suicide rates by mechanism across Census divisions within the same urbanization level varied (range=3.38-11.15 [per 100,000 person per year]). From 2014 to 2018 in large metropolitan areas in the northern divisions, rates for suffocation were higher than for firearms and drug poisoning. During the same period, in all urbanization levels in southern divisions, rates for firearms were higher than for suffocation and drug poisoning. CONCLUSIONS: Female suicide mechanisms vary by urbanization level, and this variation differs by region. These results could inform female suicide prevention strategies on the basis of mechanism, urbanization, and geographic region.

The control of medically important container-inhabiting mosquitoes is an ongoing challenge for mosquito control operations. Truck-mounted application equipment is a common option for rapid areawide larvicide deployment utilized by mosquito control operations. We tested the effectiveness of two truck-mounted sprayers (A1 Super Duty + Buffalo Turbine CSM3), for the deployment of water-dispersible biopesticides (VectoBac WDG:VectoLex WDG 50:50). Sixty residences within four residential neighborhoods in New Jersey were treated in 2019 and 2020. Three empty bioassay cups were placed in specific locations on each property (front yard/ back yard/ side of house), with an additional cup placed in an adjacent catch basin. This approach was replicated in two untreated control neighborhoods. Following larvicide application, cups were subjected to bioassays wherein larval mortality was tracked through adult eclosion. Overall, average larval mortality rates were 56% higher in treated cups compared against untreated controls. Mortality rates were affected by cup location, with 39% mortality in bioassay cups from back yards, 54% in those from the sides of houses, 73% in front yards, and 76% from cups in catch basins. Mortality did not differ significantly between the four treated neighborhoods, nor by the type of sprayer used. Our research shows that truck-mounted sprayers can be an effective method for larvicide deployment in residential neighborhoods, but effectiveness may depend upon the location of the target treatment area in relation to residences and other geographic obstacles.

Suicide was among the 10 leading causes of death in the United States in 2020 among persons aged 10-64 years, and the second leading cause of death among children and adolescents aged 10-14 and adults aged 25-34 years (1). During 1999-2020, nearly 840,000 lives were lost to suicide in the United States. During that period, the overall suicide rate peaked in 2018 and declined in 2019 and 2020 (1). Despite the recent decline in the suicide rate, factors such as social isolation, economic decline, family stressors, new or worsening mental health symptoms, and disruptions to work and school associated with the COVID-19 pandemic have raised concerns about suicide risk in the United States. During 2020, a total of 12.2 million U.S. adults reported serious thoughts of suicide and 1.2 million attempted suicide (2). To understand how changes in suicide death rates might have varied among subpopulations, CDC analyzed counts and age-adjusted suicide rates during 2019 and 2020 by demographic characteristics, mechanism of injury, county urbanization level, and state. From 2019 to 2020, the suicide rate declined by 3% overall, including 8% among females and 2% among males. Significant declines occurred in seven states but remained stable in the other states and the District of Columbia. Despite two consecutive years of declines, the overall suicide rate remains 30% higher compared with that in 2000 (1). A comprehensive approach to suicide prevention that uses data driven decision-making and implements prevention strategies with the best available evidence, especially among disproportionately affected populations (3), is critical to realizing further declines in suicide and reaching the national goal of reducing the suicide rate by 20% by 2025 (4).

IMPORTANCE: The association between online activities and youth suicide is an important issue for parents, clinicians, and policy makers. However, most information exploring potential associations is drawn from survey data and mainly focuses on risk related to overall screen time. OBJECTIVE: To evaluate the association between a variety of online risk factors and youth suicide-related behavior using real-world online activity data. DESIGN, SETTING, AND PARTICIPANTS: A matched case-control study was conducted from July 27, 2019, to May 26, 2020, with the sample drawn from more than 2600 US schools participating in an online safety monitoring program via the Bark online safety tool. For 227 youths having a severe suicide/self-harm alert requiring notification of school administrators, cases were matched 1:5 to 1135 controls on location, the amount of follow-up time, and general volume of online activity. EXPOSURES: Eight potential online risk factors (cyberbullying, violence, drug-related, hate speech, profanity, sexual content, depression, and low-severity self-harm) through assessment of text, image, and video data. MAIN OUTCOMES AND MEASURES: Severe suicide/self-harm alert requiring notification of school administrators; severe suicide alerts are statements by youths indicating imminent or recent suicide attempts and/or self-harm. RESULTS: The 1362 participants had a mean (SD) age of 13.3 (2.41) years; 699 (51.3%) were male. All 8 online risk factors studied exhibited differences between case and control populations and were significantly associated with subsequent severe suicide/self-harm alerts when examining total direct and indirect pathways. These associations ranged from an adjusted odds ratio (aOR) of 1.17 (95% CI, 1.09-1.26) for drug-related content to an aOR of 1.82 (95% CI, 1.63-2.03) for depression-related content. When considering the total number of different types of online risk factors among the 8 measured, there was an exponentially larger risk of severe suicide/self-harm alerts; youths with 5 or more of the 8 risk factors present in their online activity had a more than 70-fold increased odds of subsequently having a severe suicide/self-harm alert (aOR, 78.64; 95% CI, 34.39-179.84). CONCLUSIONS AND RELEVANCE: The findings of this study suggest that many discrete types of risk factors are identifiable from online data and associated with subsequent youth suicide-related behavior. Although each risk factor carries a specific association with suicide-related behavior, the greatest risk is evident for youths demonstrating multiple types of online risk factors.

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

Tick-borne diseases (TBDs) are increasing despite prevention recommendations. We explored whether cost is a barrier to prevention use in Connecticut and Maryland, using a cross-sectional survey. Respondents were queried regarding their willingness to pay for chemical, natural, and rodent-targeted yard pesticide treatments and permethrin-treated clothing. We evaluated associations between demographics, TBD knowledge and attitudes, and willingness to pay for prevention methods. Most respondents would pay for yard treatments (85%); 95% preferring natural pesticide, and 82% would pay for permethrin-treated clothing. Most did not want to pay more than $99 for any of the yard treatments. Having a household income of $100 000 was associated with willingness to pay $100 or more for chemical, natural, or rodent-targeted treatments and $25 or more for permethrin self-treated and pretreated clothing. Yard treatments, especially natural pesticides, were acceptable for TBD prevention; however, current pricing may be cost-prohibitive. Permethrin-treated clothing may be an affordable and acceptable prevention method.

IMPORTANCE: The coronavirus disease 2019 (COVID-19) pandemic, associated mitigation measures, and social and economic impacts may affect mental health, suicidal behavior, substance use, and violence. OBJECTIVE: To examine changes in US emergency department (ED) visits for mental health conditions (MHCs), suicide attempts (SAs), overdose (OD), and violence outcomes during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the Centers for Disease Control and Prevention's National Syndromic Surveillance Program to examine national changes in ED visits for MHCs, SAs, ODs, and violence from December 30, 2018, to October 10, 2020 (before and during the COVID-19 pandemic). The National Syndromic Surveillance Program captures approximately 70% of US ED visits from more than 3500 EDs that cover 48 states and Washington, DC. MAIN OUTCOMES AND MEASURES: Outcome measures were MHCs, SAs, all drug ODs, opioid ODs, intimate partner violence (IPV), and suspected child abuse and neglect (SCAN) ED visit counts and rates. Weekly ED visit counts and rates were computed overall and stratified by sex. RESULTS: From December 30, 2018, to October 10, 2020, a total of 187 508 065 total ED visits (53.6% female and 46.1% male) were captured; 6 018 318 included at least 1 study outcome (visits not mutually exclusive). Total ED visit volume decreased after COVID-19 mitigation measures were implemented in the US beginning on March 16, 2020. Weekly ED visit counts for all 6 outcomes decreased between March 8 and 28, 2020 (March 8: MHCs = 42 903, SAs = 5212, all ODs = 14 543, opioid ODs = 4752, IPV = 444, and SCAN = 1090; March 28: MHCs = 17 574, SAs = 4241, all ODs = 12 399, opioid ODs = 4306, IPV = 347, and SCAN = 487). Conversely, ED visit rates increased beginning the week of March 22 to 28, 2020. When the median ED visit counts between March 15 and October 10, 2020, were compared with the same period in 2019, the 2020 counts were significantly higher for SAs (n = 4940 vs 4656, P = .02), all ODs (n = 15 604 vs 13 371, P < .001), and opioid ODs (n = 5502 vs 4168, P < .001); counts were significantly lower for IPV ED visits (n = 442 vs 484, P < .001) and SCAN ED visits (n = 884 vs 1038, P < .001). Median rates during the same period were significantly higher in 2020 compared with 2019 for all outcomes except IPV. CONCLUSIONS AND RELEVANCE: These findings suggest that ED care seeking shifts during a pandemic, underscoring the need to integrate mental health, substance use, and violence screening and prevention services into response activities during public health crises.

BACKGROUND: The relationship between antibiotic use and antimicrobial resistance varies with cultural, socio-economic, and environmental factors. We examined these relationships in Kibera, an informal settlement in Nairobi-Kenya, characterized by high population density, high burden of respiratory disease and diarrhea. METHODS: Two-hundred households were enrolled in a 5-month longitudinal study. One adult (≥ 18 years) and one child (≤ 5 years) participated per household. Biweekly interviews (n = 1516) that included questions on water, sanitation, hygiene, and antibiotic use in the previous two weeks were conducted, and 2341 stool, 2843 hand swabs and 1490 drinking water samples collected. Presumptive E. coli (n = 34,042) were isolated and tested for susceptibility to nine antibiotics. RESULTS: Eighty percent of presumptive E. coli were resistant to ≥ 3 antibiotic classes. Stool isolates were resistant to trimethoprim (mean: 81%), sulfamethoxazole (80%), ampicillin (68%), streptomycin (60%) and tetracycline (55%). Ninety-seven households reported using an antibiotic in at least one visit over the study period for a total of 144 episodes and 190 antibiotic doses. Enrolled children had five times the number of episodes reported by enrolled adults (96 vs. 19). Multivariable linear mixed-effects models indicated that children eating soil from the household yard and the presence of informal hand-washing stations were associated with increased numbers of antimicrobial-resistant bacteria (counts increasing by 0·27-0·80 log(10) and 0·22-0·51 log(10) respectively, depending on the antibiotic tested). Rainy conditions were associated with reduced carriage of antimicrobial-resistant bacteria (1·19 to 3·26 log(10) depending on the antibiotic tested). CONCLUSIONS: Antibiotic use provided little explanatory power for the prevalence of antimicrobial resistance. Transmission of resistant bacteria in this setting through unsanitary living conditions likely overwhelms incremental changes in antibiotic use. Under such circumstances, sanitation, hygiene, and disease transmission are the limiting factors for reducing the prevalence of resistant bacteria.

Introduction: National estimates for nonfatal self-directed violence (SDV) presenting at EDs are calculated from the National Electronic Injury Surveillance System – All Injury Program (NEISS–AIP). In 2005, the Centers for Disease Control and Prevention and Consumer Product Safety Commission added several questions on patient characteristics and event circumstances for all intentional, nonfatal SDV captured in NEISS–AIP. In this study, we evaluated these additional questions along with the parent NEISS–AIP, which together is referred to as NEISS–AIP SDV for study purposes. Methods: We used a mixed methods design to evaluate the NEISS–AIP SDV as a surveillance system through an assessment of key system attributes. We reviewed data entry forms, the coding manual, and training materials to understand how the system functions. To identify strengths and weaknesses, we interviewed multiple key informants. Finally, we analyzed the NEISS–AIP SDV data from 2018—the most recent data year available—to assess data quality by examining the completeness of variables. Results: National estimates of SDV are calculated from NEISS–AIP SDV. Quality control activities suggest more than 99% of the cause and intent variables were coded consistently with the open text field that captures the medical chart narrative. Many SDV variables have open-ended response options, making them difficult to efficiently analyze. Conclusions: NEISS–AIP SDV provides the opportunity to describe systematically collected risk factors and characteristics associated with nonfatal SDV that are not regularly available through other data sources. With some modifications to data fields and yearly analysis of the additional SDV questions, NEISS–AIP SDV can be a valuable tool for informing suicide prevention. Practical Applications: NEISS-AIP may consider updating the SDV questions and responses and analyzing SDV data on a regular basis. Findings from analyses of the SDV data may lead to improvements in ED care.

The Zambia Field Epidemiology Training Program (ZFETP) was established by the Ministry of Health (MoH) during 2014, in order to increase the number of trained field epidemiologists who can investigate outbreaks, strengthen disease surveillance, and support data-driven decision making. We describe the ZFETP´s approach to public health workforce development and health security strengthening, key milestones five years after program launch, and recommendations to ensure program sustainability. Program description: ZFETP was established as a tripartite arrangement between the Zambia MoH, the University of Zambia School of Public Health, and the U.S. Centers for Disease Control and Prevention. The program runs two tiers: Advanced and Frontline. To date, ZFETP has enrolled three FETP-Advanced cohorts (training 24 residents) and four Frontline cohorts (training 71 trainees). In 2016, ZFETP moved organizationally to the newly established Zambia National Public Health Institute (ZNPHI). This re-positioning raised the program´s profile by providing residents with increased opportunities to lead high-profile outbreak investigations and analyze national surveillance data-achievements that were recognized on a national stage. These successes attracted investment from the Government of Republic of Zambia (GRZ) and donors, thus accelerating field epidemiology workforce capacity development in Zambia. In its first five years, ZFETP achieved early success due in part to commitment from GRZ, and organizational positioning within the newly formed ZNPHI, which have catalyzed ZFETP´s institutionalization. During the next five years, ZFETP seeks to sustain this momentum by expanding training of both tiers, in order to accelerate the professional development of field epidemiologists at all levels of the public health system.

The control of container Aedes species by house inspections usually achieves insufficient coverage and impact because a percentage of residents are absent and some residents refuse inspections and treatments. In addition, another fraction of the buildings may be uninhabited, such as those for rent or sale, or abandoned. Although the productivity of Aedes aegypti has been investigated in abandoned lots, less is known about the importance of uninhabited buildings. We investigated Ae. aegypti pupal productivity in inhabited, vacant, and abandoned houses and its interaction with socioeconomic levels (SELs). We found pupae in containers of 386 houses (66 abandoned, 62 vacant, and 258 inhabited) in 19 neighborhoods in southern Puerto Rico from May to August 2017. Using a generalized linear model, we found a significant interaction between the status of the house (abandoned, vacant, and inhabited) and SELs (low, medium) on Ae. aegypti pupal abundance. More pupae were found in abandoned and inhabited houses of low SELs. The lowest productivity was found in vacant houses, regardless of the SEL. Most containers producing Ae. aegypti in low-SEL houses were discarded on backyards, whereas in medium SELs, most productivity came from containers in use. Septic tanks producing Ae. aegypti were found only in houses of low SELs, where most emerging mosquitoes came from inhabited houses. We did not find any pupae of Ae. aegypti on roofs. These results indicate that proper yard management could significantly reduce the production of Ae. aegypti and the risk of dengue infections in low-SEL neighborhoods.

On October 6, 2017, the Zambia Ministry of Health declared a cholera outbreak in Lusaka. By December, 1,462 cases and 38 deaths had occurred (case fatality rate, 2.6%). We conducted a case-control study to identify risk factors and inform interventions. A case was any person with acute watery diarrhea (>/= 3 loose stools in 24 hours) admitted to a cholera treatment center in Lusaka from December 16 to 21, 2017. Controls were neighbors without diarrhea during the same time period. Up to two controls were matched to each case by age-group (1-4, 5-17, and >/= 18 years) and neighborhood. Surveyors interviewed cases and controls, tested free chlorine residual (FCR) in stored water, and observed the presence of soap in the home. Conditional logistic regression was used to generate matched odds ratios (mORs) based on subdistricts and age-groups with 95% CIs. We enrolled 82 cases and 132 controls. Stored water in 71% of case homes had an FCR > 0.2 mg/L. In multivariable analyses, those who drank borehole water (mOR = 2.4, CI: 1.1-5.6), had close contact with a cholera case (mOR = 6.2, CI: 2.5-15), and were male (mOR = 2.5, CI: 1.4-5.0) had higher odds of being a cholera case than their matched controls. The use of groundwater for drinking, contact with a cholera case, and male gender were associated with cholera. Based on these findings, we recommended health education about household water chlorination and hygiene in the home. Emergency responses included providing chlorinated water through emergency tanks and maintaining adequate FCR levels through close monitoring of water sources.

The Republic of Zambia declared a cholera outbreak in Lusaka, the capital, on October 6, 2017. By mid-December, 20 of 661 reported cases had died (case fatality rate 3%), prompting the CDC and the Zambian Ministry of Health through the Zambia National Public Health Institute to investigate risk factors for cholera mortality. We conducted a study of cases (cholera deaths from October 2017 to January 2018) matched by age-group and onset date to controls (persons admitted to a cholera treatment center [CTC] and discharged alive). A questionnaire was administered to each survivor (or relative) and to a family member of each decedent. We used univariable exact conditional logistic regression to calculate matched odds ratios (mORs) and 95% CIs. In the analysis, 38 decedents and 76 survivors were included. Median ages for decedents and survivors were 38 (range: 0.5-95) and 25 (range: 1-82) years, respectively. Patients aged > 55 years and those who did not complete primary school had higher odds of being decedents (matched odds ratio [mOR] 6.3, 95% CI: 1.2-63.0, P = 0.03; mOR 8.6, 95% CI: 1.8-81.7, P < 0.01, respectively). Patients who received immediate oral rehydration solution (ORS) at the CTC had lower odds of dying than those who did not receive immediate ORS (mOR 0.1, 95% CI: 0.0-0.6, P = 0.02). Cholera prevention and outbreak response should include efforts focused on ensuring access to timely, appropriate care for older adults and less educated populations at home and in health facilities.

BACKGROUND: Exposure to blacklegged ticks Ixodes scapularis that transmit pathogens is thought to occur peri-domestically. However, the locations where people most frequently encounter infected ticks are not well characterized, leading to mixed messages from public health officials about where risk is highest. METHODS: We conducted a systematic review and meta-analysis on spatial risk factors for tick-borne disease and tick bites in eastern North America. We examined three scales: the residential yard, the neighborhood surrounding (but not including) the yard, and outside the neighborhood. Nineteen eligible studies represented 2741 cases of tick-borne illness and 1447 tick bites. Using random effects models, we derived pooled odds ratio (OR) estimates. RESULTS: The meta-analysis revealed significant disease risk factors at the scale of the yard (OR 2.60 95% CI 1.96 - 3.46), the neighborhood (OR 4.08 95% CI 2.49 - 6.68), and outside the neighborhood (OR 2.03 95% CI 1.59 - 2.59). Although significant risk exists at each scale, neighborhood scale risk factors best explained disease exposure. Analysis of variance revealed risk at the neighborhood scale was 57% greater than risk at the yard scale and 101% greater than risk outside the neighborhood. CONCLUSIONS: This analysis emphasizes the importance of understanding and reducing tick-borne disease risk at the neighborhood scale. Risk-reducing interventions applied at each scale could be effective, but interventions applied at the neighborhood scale are most likely to protect human health. TRIAL REGISTRATION: The study was registered with PROSPERO: CRD42017079169 .

Zambia has experienced recurrent cholera outbreaks since the late 1970s, primarily during the rainy season. The 2017–2018 cholera outbreak started on October 6, 2017, initially localized to 2 peri-urban areas of Lusaka, the capital, and was linked to contaminated water consumption. From mid-December 2017 to early February 2018 cases spread city-wide, with 3938 cases and 82 deaths (case fatality rate, 2.1%) by February 17, 2018 (Figure 1).

On June 26, 2017, a hospital in southern Utah notified the Utah Department of Health of Shiga toxin-producing Escherichia coli (STEC) O157:H7 infections in two children from a small community on the Arizona-Utah border. Both children developed hemolytic uremic syndrome, characterized by hemolytic anemia, acute kidney failure, and thrombocytopenia and died within a few days of illness onset. Over the next few days, several more STEC-associated illnesses were reported in residents of the community. A joint investigation by local and state health agencies from Arizona and Utah and CDC was initiated to identify the outbreak source and prevent additional cases; a total of 12 cases were identified, including the two children who died. Investigators initially explored multiple potential sources of illness; epidemiologic and environmental information revealed cow manure contact as the likely initial cause of the outbreak, which was followed by subsequent person-to-person transmission. One of the outbreak strains was isolated from bull and horse manure collected from a yard near a community household with two ill children. Local health agencies made recommendations to the public related to both animal contact and hand hygiene to reduce the risk for STEC transmission. Animal or animal manure contact should be considered a potential source of STEC O157:H7 during outbreaks in communities where ruminants are kept near the home.

On October 6, 2017, an outbreak of cholera was declared in Zambia after laboratory confirmation of Vibrio cholerae O1, biotype El Tor, serotype Ogawa, from stool specimens from two patients with acute watery diarrhea. The two patients had gone to a clinic in Lusaka, the capital city, on October 4. Cholera cases increased rapidly, from several hundred cases in early December 2017 to approximately 2,000 by early January 2018 (Figure). In collaboration with partners, the Zambia Ministry of Health (MoH) launched a multifaceted public health response that included increased chlorination of the Lusaka municipal water supply, provision of emergency water supplies, water quality monitoring and testing, enhanced surveillance, epidemiologic investigations, a cholera vaccination campaign, aggressive case management and health care worker training, and laboratory testing of clinical samples. In late December 2017, a number of water-related preventive actions were initiated, including increasing chlorine levels throughout the city's water distribution system and placing emergency tanks of chlorinated water in the most affected neighborhoods; cholera cases declined sharply in January 2018. During January 10-February 14, 2018, approximately 2 million doses of oral cholera vaccine were administered to Lusaka residents aged >/=1 year. However, in mid-March, heavy flooding and widespread water shortages occurred, leading to a resurgence of cholera. As of May 12, 2018, the outbreak had affected seven of the 10 provinces in Zambia, with 5,905 suspected cases and a case fatality rate (CFR) of 1.9%. Among the suspected cases, 5,414 (91.7%), including 98 deaths (CFR = 1.8%), occurred in Lusaka residents.

Introduction: On 19 March 2017, an outbreak of unknown etiology was reported among students at a college in Lusaka, Zambia. We investigated to confirm the outbreak, identify exposures, determine the aetiological agent, and implement preventive measures. Methods: We conducted an unmatched case-control study. Cases and controls were selected conveniently. A suspected case was diarrhea or abdominal pains in any student at College A and Controls were asymptomatic students at College A during 18-23 March. We interviewed cases and controls about exposures to suspected food and water and collected saved food samples and swabs from food-handlers' hands and kitchen surfaces for culture. We analyzed data using Epi-info v 7.2 (Atlanta, Georgia). Results: We identified 59 suspected case-patients. Predominant symptoms were diarrhea (n = 51.83%) and abdominal pains (n = 44.75%). The outbreak started on 18 March, peaked on 19, and concluded on 20 March. We interviewed 30 case-patients and 71 controls. Exposures associated with increased odds of illness included eating food served at dinner on Saturday (18 March) in school cafeteria (OR = 5.8, 95% CI = 2.0-16.7); specifically, eating beans at Saturday dinner (OR = 21.6, 95% CI = 4.5-104) and drinking water supplied at school (OR = 8.8, 95% CI = 1.45-53.6). Samples from all food-handlers (n = 13) yielded Staphylococcus aureus and all food samples (n = 3) yielded Escherichia coli, Staphylococcus aureus and fecal coliforms. Conclusion: The results suggest a foodborne outbreak caused by consumption of contaminated food served at dinner on 18 March at College A. We educated the food handlers and school management about the importance of disinfection of preparation surfaces, supervision of food handling and handwashing practices.

Recent large-scale chikungunya virus (CHIKV) and Zika virus epidemics in the Americas pose a growing public health threat. Given that mosquito bite prevention and vector control are the main prevention methods available to reduce transmission of these viruses, we assessed adherence to these methods in the United States Virgin Islands (USVI). We interviewed 334 USVI residents between December 2014 and February 2015 to measure differences in mosquito prevention practices by gender, income, presence of CHIKV symptoms, and age. Only 27% (91/334) of participants reported having an air conditioner, and of the 91 with air-conditioners, 18 (20%) reported never using it. Annual household income > $50,000 was associated with owning and using an air conditioner (41%; 95% confidence interval [CI]: 28-53% compared with annual household income </= $50,000: 17%; 95% CI: 12-22%). The majority of participants reported the presence of vegetation in their yard or near their home (79%; 265) and a cistern on their property (78%; 259). Only 52 (16%) participants reported wearing mosquito repellent more than once per week. Although the majority (80%; 268) of participants reported having screens on all of their windows and doors, most (82%; 273) of those interviewed still reported seeing mosquitoes in their homes. Given the uniformly low adherence to household- and individual-level mosquito bite prevention measures in the USVI, these findings emphasize the need for improved public health messaging and investment in therapeutic and vaccine research to mitigate vector-borne disease outbreaks.

Prevention of tick-borne diseases requires an understanding of when and where exposure to ticks is most likely. We used an epidemiologic approach to define these parameters for residents of a Lyme-endemic region. Two persons in each of 500 Connecticut households were asked to complete a log each night for one week during June, 2013. Participants recorded their whereabouts in 15min increments (indoors, outdoors in their yard, outdoors on others' private property, or outdoors in public spaces) and noted each day whether they found a tick on themselves. Demographic and household information was also collected. Logs were completed for 934 participants in 471 households yielding 51,895 time-place observations. Median participant age was 49 years (range 2-91 years); 52% were female. Ninety-one participants (9.8%) reported finding a tick during the week, with slightly higher rates among females and minors. Household factors positively associated with finding a tick included having indoor/outdoor pets (odds ratio (OR)=1.7; 95% confidence interval (CI): 1.1-2.9), the presence of a bird feeder in the yard (OR=1.9; CI:1.2-3.2), and presence of an outdoor dining area (OR=2.2; CI:1.1-4.3). Individual factors associated with finding a tick on a given day were bathing or showering (OR=3.7; CI:1.3-10.3) and hours spent in one's own yard (OR=1.2, CI:1.1-1.3). Nineteen participants found ticks on multiple days, more than expected assuming independence (p<0.001). Participants who found ticks on multiple days did not spend more time outdoors but were significantly more likely to be male than those finding ticks on a single day (p<0.03). Our findings suggest that most tick exposures in the study area occurred on private property controlled by the respective homeowner. Interventions that target private yards are a logical focus for prevention efforts.

Background: On January 9, 2015, in a rural town in Mozambique, over 230 people became sick and 75 died from an illness linked to drinking pombe, a traditional alcoholic beverage. Methods: An investigation was conducted to identify cases and determine the cause of the outbreak. A case was defined as any resident of Chitima who developed any new or unexplained neurologic, gastrointestinal, or cardiovascular symptom from January 9 at 6:00 a.m. through January 12. We conducted medical record reviews; healthcare worker and community surveys; anthropological and toxicological investigations of local medicinal plants and commercial pesticides; and laboratory testing of the suspect and control pombe. Results: We identified 234 cases; 75 (32%) died and 159 recovered. Overall, 61% of cases were female (n=142), and ages ranged from 1-87 years (median: 30 years). Signs and symptoms included abdominal pain, diarrhea, vomiting, and generalized malaise. Death was preceded by psychomotor agitation and abnormal posturing. The median interval from pombe consumption to symptom onset was 16 hours. Toxic levels of bongkrekic acid (BA) were detected in the suspect pombe but not in the control pombe. Burkholderia gladioli pathovar cocovenenans, the bacteria that produces BA, was detected in the flour used to make the pombe. Conclusions: We report for the first time an outbreak of a highly lethal illness linked to BA, a deadly food-borne toxin in Africa. Given that no previous outbreaks have been recognized outside of Asia, our investigation suggests that BA might be an unrecognized cause of toxic outbreaks globally.

Since 2005, coccidioidomycosis has increased among inmates at a California prison. Our initial investigation found an incidence of 3,323 cases/100,000 persons. Black race, age ≥41 years, and residence on Yard C were significantly associated with coccidioidomycosis ( p < .05). Inmates at this prison have continued to be at risk for coccidioidomycosis.

Acute aflatoxin exposure can cause death and disease (aflatoxicosis) in humans. Aflatoxicosis fatality rates have been documented to be as high as 40% in Kenya. The inclusion in the diet of calcium silicate 100 (ACCS100), a calcium montmorillonite clay, may reduce aflatoxin bioavailability; thus potentially decreasing the risk of aflatoxicosis. We investigated the efficacy, acceptability, and palatability of ACCS100 in a population in Kenya with recurring aflatoxicosis outbreaks. Healthy adult participants were enrolled in this double-blinded, cross-over clinical trial in 2014. Following informed consent, participants (n=50) were randomized to receive either ACCS100 (3g/day) or placebo (3g/day) for seven days. Treatments were switched following a five-day washout period. Urine samples were collected daily and assessed for urinary aflatoxin M1 (AFM1). Blood samples were collected at the beginning and end of the trial and assessed for aflatoxin B1-lysine adducts from serum albumin (AFB1-lys). AFM1 concentrations in urine; were significantly reduced while taking ACCS100 compared to calcium carbonate placebo (beta=0.49, 95% confidence limit: 0.32-0.75). The 20 day interval included both the placebo and ACCS100 treatments as well as a washout period. There were no statistically significant differences in reported taste, aftertaste, appearance, color, or texture by treatment. There were no statistically significant differences in self-reported adverse events by treatment. Most participants would be willing to take ACCS100 (98%) and give it to their children (98%). ACCS100 was effective, acceptable, and palatable. More work is needed to test ACCS100 among vulnerable populations and to determine if ACCS100 remains effective at the levels of aflatoxin exposure that induce aflatoxicosis.