Background: The U.S. Public Health Service and the Institute of Medicine recommend that all women capable of becoming pregnant consume 400 μg of folic acid daily to help prevent neural tube defects (NTDs). Hispanic women are at higher risk of having babies with NTDs than non-Hispanic White women. This study assessed multivitamin (MV) use, a main source of folic acid, among Hispanic women of reproductive age using a survey of solely U.S. Hispanic adults. Materials and Methods: MV use was assessed as part of Porter Novelli's Estilos survey, fielded annually through the largest online U.S. Hispanic panel, Offerwise's QueOpinas. During the study period of 2013-2022, 9,999 surveys were completed; selection was weighted to match the U.S. Census American Community Survey proportions. Log-binomial regression models were applied to estimate MV use trends by age groups, acculturation levels, and pregnancy intention. Results: Among 3,700 Hispanic women of reproductive age, overall no MV use increased from 39.3% in 2013 to 54.7% in 2022 (p for trend <0.0001), especially among Hispanic women aged 18-34 years and those classified as acculturated. Among women planning to get pregnant, daily MV use was 31.1% in 2013 compared with 18.7% in 2020-2022 (p = 0.04). Conclusions: Given the increase in no MV use among Hispanic women of reproductive age, targeted interventions may help reach at-risk groups for NTDs prevention.

OBJECTIVES: Examine characteristics associated with firearm homicides of children aged 0-17 years precipitated by intimate partner violence (IPV). METHODS: Data were from the Center for Disease Control and Prevention's National Violent Death Reporting System (49 states, District of Columbia, Puerto Rico; 2003-2020). Logistic regression was used to examine associations between various characteristics and IPV among child firearm homicides. RESULTS: From 2003-2020, a total of 11 594 child homicides were captured in the National Violent Death Reporting System, of which 49.3% (n = 5716) were firearm homicides; 12.0% (n = 686) of child firearm homicides were IPV-related. Among IPV-related child firearm homicides, 86.0% (n = 590) were child corollary victims (ie, children whose death was connected to IPV between others); 14.0% (n = 96) were teens killed by a current or former dating partner. Child firearm homicides had greater odds of involving IPV when precipitated by conflict, crises, and cooccurring with the perpetrator's suicide compared with those without these characteristics. Over half of IPV-related firearm homicides of child corollary victims included homicide of the adult intimate partner, of which 94.1% were the child victim's mother. Child firearm homicides perpetrated by mothers' male companions (adjusted odds ratio, 6.9; 95% confidence interval, 3.9-12.1) and children's fathers (adjusted odds ratio, 4.5; 95% confidence interval, 3.0-6.8) had greater odds of involving IPV compared with those perpetrated by mothers. CONCLUSIONS: Multiple factors were associated with greater odds of child firearm homicides being IPV-related. Strategies promoting healthy intimate partner relationships starting at a young age; assessment of danger to children in IPV situations; strengthening economic supports for families; creating safe, stable, and nurturing relationships and environments for children; and addressing social and structural inequities are important for preventing firearm homicides of children, including those involving IPV.

following which a substantial decline in neural tube defects at birth occurred. Studies also have suggested that lesion levels in cases of spina bifida are directly affected by folic acid fortification. Locations of such lesions contribute to outcome and prognosis of the condition. When compared with sacral and lower lumbar lesions, the greatest risks of disability and mortality are associated with cervical, thoracic, and high lumbar lesions. Individuals with thoracic or high lumbar lesions require a wheelchair and orthosis in adulthood for ambulation 70% to 99% of the time. As lesion levels therefore determine function and overall quality of life, assessment of whether folic acid fortification significantly impacts lesion levels is important. This study aimed to examine patterns of lesion levels in spina bifida following mandatory folic acid fortification in the United States. | | A call was issued by the National Birth Defects Prevention Network for State Birth Defects Programs' spina bifida lesion data before and after fortification mandate. To be eligible, programs needed to provide verbatim medical record text descriptions of spina bifida diagnoses. The 6 participating programs were from the states of Arizona, California (covering 8 counties), Oklahoma, South Carolina, Utah, and metropolitan Atlanta (Georgia). Birth years examined included the prefortification years of 1992–1996 and the postfortification period of 1999–2016. Central processing and analysis occurred as each program provided case-level data (deidentified) based on the exclusion/inclusion criteria to the Centers for Disease Control and Prevention. Medical and record text description of the spina bifida diagnosis and codes were the basis of case information, using the International Classification of Diseases, Ninth Edition, Clinical Modification or the Centers for Disease Control and Prevention and Prevention/British Pediatric Association coding system. Types of spina bifida included in the study were spinal rachischisis, myelomeningocele/meningomyelocele, meningocele, and spina bifida not otherwise specified. Cases excluded were cranial lesions, lipomyelomeningocele/lipomeningomyelocele, dysraphism related to split cord malformations, and spina bifida occulta. | | Lesion-level information was provided based on the highest lesion using nonradiographic clinical assessment. Classification of severe upper-level lesions included cervical or thoracic lesion-level cases, whereas lower-level lesions included cases with lumbar or sacral. The study defined open lesion as leaking spinal fluid or membrane covered only, whereas closed lesions were defined as having intact-skin covering and lacking fluid leakage. Spina bifida cases were considered isolated when no other anomalies related to the primary cause of abnormal neural tube closure were present (nor were secondary to the neurologic complications caused by it). Examining associations between fortification period and the outcomes (lesion level and spina bifida) occurred using the generalized estimating approach to logistic (case severity analyses) and log-linear (PR analyses) regression, which accounted for clustering of cases by state. | | From a total of 7,816,062 live births, 2593 cases of spina bifida met the case inclusion criteria. Overall, 573 cases were included in the prefortification period (birth prevalence of 4.07 per 10,000 live births), and 2020 cases were included in the postfortification period (birth prevalence of 3.15 per 10,000 live births). Overall, 80.2% of cases resulted in live births, and most cases of spina bifida involved lower-level lesions (81.3%). Most lesions were lumbar, and the proportions prefortification and postfortification were 61.4% and 72.0%, respectively, with a higher proportion of lumbar lesions seen in the postfortification period. The odds of upper-level to lower-level lesions decreased by 70% after fortification. The spina bifida live birth prevalence decreased significantly and remained consistently low throughout the early, mid, and recent postfortification periods. The study found a 72% decrease overall in prevalence of severe, upper-level lesions following mandatory folic acid fortification in the United States. | | The limitations of the study include the shortcomings of relying on diagnostic codes, the difficulty of coding lesion level using the International Classification of Diseases, Ninth Edition, Clinical Modification coding scheme, the lack of recorded functional outcome for children in medical records (indirect indicators of severity), the lack of preconception and prenatal folic acid data, and the possible variation of case ascertainment within programs contributing studies. A major study strength is its potential to address additional important questions regarding epidemiology and spina bifida. The classification of spinal defects is complex, and this study adds to the limited distribution data that exist for prefortification and postfortification subtypes. | | The study concluded that the overall prevalence of severe upper-level lesions in spina bifida cases experienced a steep reduction following mandatory folic acid fortification institution within the United States, whereas no change in the prevalence of less severe lower-level lesions took place. Additional examinations are warranted to better understand the magnitude and mechanism of spina bifida severity in relation to folic acid intake.

IMPORTANCE: COVID-19 and seasonal influenza vaccines are essential in preventing respiratory infections and their potentially severe complications. Simultaneous administration of vaccines is efficient and may improve coverage with each vaccine. However, the safety of simultaneous administration of COVID-19 and influenza vaccines has not been well described. OBJECTIVE: To evaluate adverse events and health impacts associated with simultaneously administered COVID-19 mRNA booster and seasonal influenza vaccines in the US population. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, self-reported vaccine data were collected on days 0 to 7 after vaccination from September 22, 2021, through May 1, 2022, through v-safe, a voluntary smartphone-based monitoring system established by the Centers for Disease Control and Prevention. Participants were persons who voluntarily registered in v-safe following COVID-19 vaccination. EXPOSURE: Receipt of simultaneously administered COVID-19 mRNA booster and seasonal influenza vaccines or COVID-19 mRNA booster alone. MAIN OUTCOMES AND MEASURES: Local injection site and systemic reactions (eg, fatigue, headache, and myalgia) and health impacts reported by v-safe respondents in the week following COVID-19 mRNA booster vaccination. Adjusted odds ratios (aORs) were estimated for simultaneous administration compared with booster dose alone, controlling for sex, age, and week of vaccination. RESULTS: Of a total of 981 099 persons aged 12 years or older registered with v-safe, simultaneous administration of COVID-19 mRNA booster and seasonal influenza vaccines was reported by 92 023 (9.4%) v-safe respondents; of these respondents, 54 926 (59.7%) were female, 36 234 (39.4%) were male, and sex was unknown for 863 (0.9%). In the week following vaccination, any systemic reactions were reported by 36 144 (58.9%) of 61 390 respondents who simultaneously received Pfizer-BioNTech booster and influenza vaccines and 21 027 (68.6%) of 30633 respondents who simultaneously received Moderna booster and influenza vaccines. Respondents who simultaneously received influenza and Pfizer-BioNTech booster vaccines (aOR, 1.08; 95% CI, 1.06-1.10) or influenza and Moderna booster vaccines (aOR, 1.11; 95% CI, 1.08-1.14) were slightly more likely to report any systemic reaction in the week following simultaneous vaccination than respondents who received only a COVID-19 mRNA vaccine booster. CONCLUSIONS AND RELEVANCE: In this study, compared with administration of COVID-19 mRNA booster vaccines alone, simultaneous administration of COVID-19 mRNA booster and seasonal influenza vaccines was associated with significant increases in reports of systemic reactions during days 0 to 7 following vaccination. These results may help better characterize the outcomes associated with simultaneously administered COVID-19 booster and influenza vaccines in the US population.

OBJECTIVE: To assess whether the severity of cases of spina bifida changed after mandatory folic acid fortification in the United States. STUDY DESIGN: Six active population-based birth defects programs provided data on cases of spina bifida for 1992-1996 (pre-fortification) and 1999-2016 (post-fortification); programs contributed varying years of data. Case information included both medical record verbatim text description of the spina bifida diagnosis and spina bifida codes (International Classification of Diseases, Clinical Modification, or a modified birth defects surveillance coding system). Comparing pre- with post-fortification periods, adjusted odds ratios (aOR) for case severity [upper-level (cervical, thoracic) to lower-level (lumbar, sacral) lesion cases] and prevalence ratios (PR) were estimated. RESULTS: A total of 2,593 cases of spina bifida (7,816,062 live births) met inclusion criteria, with 573 and 2,020 cases from the pre- and post-fortification periods respectively. Case severity decreased 70% (aOR: 0.30; 95% confidence interval [CI] 0.26, 0.35) between the fortification periods. The decrease was most pronounced for non-Hispanic white mothers. Overall spina bifida prevalence declined 23% (PR=0.77, 95% CI=0.71, 0.85), with similar reduction seen across early, mid, and recent post-fortification periods. A statistically significant decrease in upper-level lesions occurred in the post-fortification compared with pre-fortification periods (PR=0.28, 95% CI=0.22, 0.34), while prevalence of lower-level lesions remained relatively similar (PR: 0.94, 95% CI: 0.84, 1.05). CONCLUSIONS: Severity of cases of spina bifida decreased after mandatory folic acid fortification in the United States. Further examination is warranted to understand better the potential effect of folic acid on spina bifida severity.

BACKGROUND: Despite the considerable disease burden caused by the disease, rotavirus vaccine has not been introduced into routine national immunization schedule, and norovirus vaccines are being developed without a comprehensive understanding of gastroenteritis epidemiology. To bridge this knowledge gap, we investigated the disease burden of viral gastroenteritis in rural China. METHODS: Between October 2011 and December 2013, population-based surveillance was conducted in Zhengding and Sanjiang counties in China. Stool samples were collected from children <5 years of age with diarrhea. All specimens were tested for rotaviruses, noroviruses, sapoviruses, enteric adenoviruses, and astroviruses. RESULTS: The most common pathogen causing diarrhea was rotavirus (54.7 vs 45.6 cases/1,000 children/year in Zhengding and Sanjiang, respectively), followed by norovirus (28.4 vs 19.3 cases/1,000 children/year in Zhengding and Sanjiang, respectively). The highest incidence of these viruses was observed in children 6-18 months of age. Among the 5 viral pathogens, rotaviruses caused the most severe illness, followed by noroviruses. CONCLUSION: Rotavirus and norovirus are the 2 most important viral pathogens causing childhood diarrhea in both northern and southern China; they should be the major targets for viral gastroenteritis prevention strategies among children in China.

BACKGROUND: In China, measles-rubella vaccine and live attenuated SA 14-14-2 Japanese encephalitis vaccine (LJEV) are recommended for simultaneous administration at 8 months of age, which is the youngest recommended age for these vaccines worldwide. We aimed to assess the effect of the co-administration of these vaccines at 8 months of age on the immunogenicity of measles-rubella vaccine. METHODS: We did a multicentre, open-label, non-inferiority, two-group randomised controlled trial in eight counties or districts in China. We recruited healthy infants aged 8 months who had received all scheduled vaccinations according to the national immunisation recommendations and who lived in the county of the study site. Enrolled infants were randomly assigned (1:1) to receive either measles-rubella vaccine and LJEV simultaneously (measles-rubella plus LJEV group) or measles-rubella vaccine alone (measles-rubella group). The primary outcome was the proportion of infants with IgG antibody seroconversion for measles 6 weeks after vaccination, and a secondary outcome was the proportion of infants with IgG antibody seroconversion for rubella 6 weeks after vaccination. Analyses included all infants who completed the study. We used a 5% margin to establish non-inferiority. This trial was registered at ClinicalTrials.gov (NCT02643433). FINDINGS: 1173 infants were assessed for eligibility between Aug 13, 2015, and June 10, 2016. Of 1093 (93%) enrolled infants, 545 were randomly assigned to the measles-rubella plus LJEV group and 548 to the measles-rubella group. Of the infants assigned to each group, 507 in the measles-rubella plus LJEV group and 506 in the measles-rubella group completed the study. Before vaccination, six (1%) of 507 infants in the measles-rubella plus LJEV group and one (<1%) of 506 in the measles-rubella group were seropositive for measles; eight (2%) infants in the measles-rubella plus LJEV group and two (<1%) in the measles-rubella group were seropositive for rubella. 6 weeks after vaccination, measles seroconversion in the measles-rubella plus LJEV group (496 [98%] of 507) was non-inferior to that in the measles-rubella group (499 [99%] of 506; difference -0.8% [90% CI -2.6 to 1.1]) and rubella seroconversion in the measles-rubella plus LJEV group (478 [94%] of 507) was non-inferior to that in the measles-rubella group (473 [94%] of 506 infants; difference 0.8% [90% CI -1.8 to 3.4]). There were no serious adverse events in either group and no evidence of a difference between the two groups in the prevalence of any local adverse event (redness, rashes, and pain) or systemic adverse event (fever, allergy, respiratory infections, diarrhoea, and vomiting). Fever was the most common adverse event (97 [19%] of 507 infants in the measles-rubella plus LJEV group; 108 [21%] of 506 infants in the measles-rubella group). INTERPRETATION: The evidence of similar seroconversion and safety with co-administered LJEV and measles-rubella vaccines supports the co-administration of these vaccines to infants aged 8 months. These results will be important for measles and rubella elimination and the expansion of Japanese encephalitis vaccination in countries where it is endemic. FUNDING: US Centers for Disease Control and Prevention, US Department of Health and Human Services; China-US Collaborative Program on Emerging and Re-emerging Infectious Diseases.

OBJECTIVES: Influenza vaccination of healthcare personnel working in long-term care (LTC) facilities can reduce influenza-related morbidity and mortality among healthcare personnel and among resident populations who are at increased risk for complications from influenza and who may respond poorly to vaccination. The objective of this study was to investigate workplace interventions and healthcare personnel vaccination-related attitudes associated with higher influenza vaccination coverage among healthcare personnel working in LTC facilities. SETTING AND PARTICIPANTS: Data were obtained from an online survey of healthcare personnel conducted in April 2016 among a nonprobability sample of 2258 healthcare personnel recruited from 2 preexisting national opt-in Internet panels. Respondents were asked about influenza vaccination status, workplace vaccination policies and interventions, and their attitudes toward vaccination. Analyses were restricted to the 332 healthcare personnel who worked in nursing homes, assisted living facilities, or other LTC facilities. MEASURES: Logistic regression models were used to assess the independent associations between each workplace intervention and higher influenza vaccination coverage compared with referent levels, controlling for occupation, age, and race/ethnicity. Prevalence ratios were calculated under the assumption of simple random sampling. RESULTS: Approximately 77% of healthcare personnel working in LTC facilities reported receiving influenza vaccination in the 20152016 influenza season. Influenza vaccination was independently associated with an employer vaccination requirement (prevalence ratio (PR) [95% confidence interval] = 1.28 [1.11, 1.47]), being offered free onsite vaccination (PR = 1.20 [1.04, 1.39]), and employers publicizing vaccination coverage level to employees (PR = 1.24 [1.09, 1.41]). Vaccination was most highly associated with a combination of 3 or more workplace interventions. Most healthcare personnel working in LTC facilities reported positive attitudes toward the safety and effectiveness of influenza vaccination. CONCLUSIONS/IMPLICATIONS: Implementing employer vaccination interventions in LTC facilities, including employer vaccination requirements and free on-site influenza vaccination that is actively promoted, could increase influenza vaccination among healthcare personnel.

BACKGROUND: The Advisory Committee on Immunization Practices (ACIP) recommends all persons aged >/=6months get vaccinated for influenza annually, placing particular emphasis on persons who are at increased risk for influenza-related complications and persons living with or caring for them. METHODS: Data from the 2016 National Internet Flu Survey (NIFS), a nationally representative, probability-based Internet panel survey of the noninstitutionalized U.S. civilian population aged >/=18years, was used to compare influenza vaccination coverage among adults who live with household members at high-risk for complications from influenza with those who do not. Logistic regression was used to evaluate the difference in the adjusted vaccination coverage prevalence between persons living with and without high-risk household members. RESULTS: From the 2016 NIFS (n=4,113), we estimated that 29.2% of noninstitutionalized U.S. adults had at least one household member at increased risk for influenza-related complications. Unadjusted influenza vaccination coverage was significantly higher for adults with a high-risk household member compared with those without (46.7% vs 38.6%, respectively). After adjustment for demographic and access-to-care factors, adults with high-risk household members were more likely to be vaccinated than those without (adjusted prevalence difference=5.3 [0.3, 10.3]). Among vaccinated respondents with high-risk household members, 88.7% reported that protection of their family and close contacts was one of the reasons they were vaccinated. CONCLUSION: Approximately half of adults living with someone at increased risk of complications from influenza did not report receiving an influenza vaccination. Vaccination reminder/recall for persons at increased risk should include reminders for their household contacts.

The Advisory Committee on Immunization Practices (ACIP) recommends that all health care personnel receive an annual influenza vaccination to reduce influenza-related morbidity and mortality among health care personnel and their patients and to reduce absenteeism among health care personnel (1-4). CDC conducted an opt-in Internet panel survey of 2,265 U.S. health care personnel to estimate influenza vaccination coverage among these persons during the 2017-18 influenza season. Overall, 78.4% of health care personnel reported receiving influenza vaccination during the 2017-18 season, similar to reported coverage in the previous four influenza seasons (5). As in previous seasons, coverage was highest among personnel who were required by their employer to be vaccinated (94.8%) and lowest among those working in settings where vaccination was not required, promoted, or offered on-site (47.6%). Health care personnel working in long-term care settings, the majority of whom work as assistants or aides, have lower influenza vaccination coverage than do health care personnel working in all other health care settings, which puts the elderly in long-term settings at increased risk for severe complications for influenza. Implementing workplace strategies shown to improve vaccination coverage among health care personnel, including vaccination requirements and active promotion of on-site vaccinations at no cost, can help ensure health care personnel and patients are protected against influenza (6). CDC's long-term care web-based toolkit* provides resources, strategies, and educational materials for increasing influenza vaccination among health care personnel in long-term care settings.

To the Editor: | | Annual vaccination of HCP is a high priority for reducing influenza-associated morbidity in healthcare settings.1 Although the percentage of HCP nationwide who reported receiving influenza vaccination was 78.6% in the 2016–17 season, coverage remains incomplete, placing HCP and patients at risk of influenza.1,2 Employer influenza vaccination requirements are associated with higher coverage rates, and, though controversial, mandatory influenza vaccination is supported by multiple healthcare professional societies.3,4 We explored agreement with employer influenza vaccination requirements among HCP nationwide.

BACKGROUND: Infection with hepatitis A and hepatitis B virus can increase the risk of morbidity and mortality in persons with chronic liver disease (CLD). The Advisory Committee on Immunization Practices recommends hepatitis A (HepA) and hepatitis B (HepB) vaccination for persons with CLD. METHODS: Data from the 2014 and 2015 National Health Interview Surveys (NHIS), nationally representative, in-person interview surveys of the non-institutionalized US civilian population, were used to assess self-reported HepA (>/=1 and>/=2 doses) and HepB vaccination (>/=1 and>/=3 doses) coverage among adults who reported a chronic or long-term liver condition. Multivariable logistic regression was used to identify factors independently associated with HepA and HepB vaccination among adults with CLD. RESULTS: Overall, 19.4% and 11.5% of adults aged>/=18years with CLD reported receiving >/=1 dose and >/=2 doses of HepA vaccine, respectively, compared with 14.7% and 9.1% of adults without CLD (p<.05 comparing those with and without CLD, >/=1dose). Age, education, geographic region, and international travel were associated with receipt of>/=2 doses HepA vaccine among adults with CLD. Overall, 35.7% and 29.1% of adults with CLD reported receiving>/=1 dose and>/=3 doses of HepB vaccine, respectively, compared with 30.2% and 24.7% of adults without CLD (p<.05 comparing those with and without CLD, >/=1 dose). Age, education, and receipt of influenza vaccination in the past 12months were associated with receipt of >/=3 doses HepB vaccine among adults with CLD. Among adults with CLD and >/=10 provider visits, only 13.8% and 35.3% had received >/=2 doses HepA and >/=3 doses HepB vaccine, respectively. CONCLUSIONS: HepA and HepB vaccination among adults with CLD is suboptimal and missed opportunities to vaccinate occurred. Providers should adhere to recommendations to vaccinate persons with CLD to increase vaccination among this population.

OBJECTIVE: This research was aimed to investigate the correct dose of nitrite that would act as a protection against the ischemic effects induced by acute myocardial infarction (AMI). METHODS: Mice were randomly divided into a sham-operation group (sham), an AMI operation group (AMI), and a nitrite pretreatment+AMI operation group (N+AMI). Seven days before the AMI operation, mice in the N+AMI group were pretreated with sodium nitrite in drinking water. RESULTS: One week after the AMI operation, serum lactate dehydrogenase (LDH) and creatine kinase (CK) activities in both AMI and N+AMI group were significantly higher than those in the sham group, but there were no significant differences between AMI and N+AMI mice. Contents of inducible nitric oxide synthase (iNOS) in the noninfarct area of the left ventricle in the N+AMI mice were significantly higher than those in the AMI mice, with no difference in the infarct area. Coagulation necrosis in the cardiomyocytes was observed in both AMI and N+AMI mice; however, it was less severe in the N+AMI mice. Western blot analyses showed that nitrite pretreatment resulted in up-regulation of antiapoptotic factors Bcl-2 and p21waf1/cip1 signal proteins, but down-regulation of the proapoptotic factor Bax signal protein. Furthermore, nitrite pretreatment also showed significant alleviation of AMI-induced signal protein expressions of inflammatory factors of NF-K B and oxidative factors of Hsp 70 and HO-1. CONCLUSION: These results suggest that nitrite show certain protective effects against the ischemic effects induced by AMI in mice, which might be attributed to the synthesis of NO induced by iNOS through up-regulation of antiapoptotic factors and down-regulation of proapoptotic and inflammatory factors.

The Advisory Committee on Immunization Practices (ACIP) recommends that all health care personnel (HCP) receive an annual influenza vaccination to reduce influenza-related morbidity and mortality among HCP and their patients and to reduce absenteeism among HCP (1-4). To estimate influenza vaccination coverage among HCP in the United States during the 2016-17 influenza season, CDC conducted an opt-in Internet panel survey of 2,438 HCP. Overall, 78.6% of survey respondents reported receiving vaccination during the 2016-17 season, similar to reported coverage in the previous three influenza seasons (5). Vaccination coverage continued to be higher among HCP working in hospitals (92.3%) and lower among HCP working in ambulatory (76.1%) and long-term care (LTC) (68.0%) settings. As in previous seasons, coverage was highest among HCP who were required by their employer to be vaccinated (96.7%) and lowest among HCP working in settings where vaccination was not required, promoted, or offered on-site (45.8%). Implementing workplace strategies found to improve vaccination coverage among HCP, including vaccination requirements or active promotion of on-site vaccinations at no cost, can help ensure that HCP and patients are protected against influenza (6).

BACKGROUND: Vaccination of health care personnel (HCP) can reduce influenza-related morbidity and mortality among HCP and their patients. This study investigated workplace policies associated with influenza vaccination among HCP who work in ambulatory care settings without influenza vaccination requirements. METHODS: Data were obtained from online surveys conducted during April 2014 and April 2015 among nonprobability samples of HCP recruited from 2 preexisting national opt-in Internet panels. Respondents were asked about their vaccination status and workplace policies and interventions related to vaccination. Logistic regression models were used to assess the independent associations between each workplace intervention and influenza vaccination while controlling for occupation, age, and race or ethnicity. RESULTS: Among HCP working in ambulatory care settings without a vaccination requirement (n = 866), 65.7% reported receiving influenza vaccination for the previous influenza season. Increased vaccination coverage was independently associated with free onsite vaccination for 1 day (prevalence ratio [PR], 1.38; 95% confidence interval [CI], 1.07-1.78 or >1 day PR, 1.58; 95% CI, 1.29-1.94) and employers sending personal vaccination reminders (PR, 1.20; 95% CI, 0.99-1.46). Age ≥65 years (PR, 1.30; 95% CI, 1.07-1.56) and working as a clinical professional (PR, 1.26; 95% CI, 1.06-1.50) or clinical nonprofessional (PR, 1.28; 95% CI, 1.03-1.60) were also associated with higher coverage. Vaccination coverage increased with increasing numbers of workplace interventions. CONCLUSIONS: Implementing workplace vaccination interventions in ambulatory care settings, including free onsite influenza vaccination that is actively promoted, could help increase influenza vaccination among HCP.

The environmental transport of Cryptosporidium spp. through combined sewer overflow (CSO) and the occurrence of several emerging human-pathogenic Cryptosporidium species in developing countries remain unclear. In this study, we collected 40 CSO samples and 40 raw wastewater samples from Shanghai, China and examined them by PCR and DNA sequencing for Cryptosporidium species (targeting the small subunit rRNA gene) and Giardia duodenalis (targeting the triosphosphate isomerase, beta-giardin, and glutamate dehydrogenase genes) and Enterocytozoon bieneusi (targeting the ribosomal internal transcribed spacer) genotypes. Human-pathogenic Cryptosporidium species were further subtyped by sequence analysis of the 60-kDa glycoprotein gene, with additional multilocus sequence typing on the emerging zoonotic pathogen C. ubiquitumCryptosporidium spp., G. duodenalis, and E. bieneusi were detected in 12 and 15, 33 and 32, and 37 and 40 CSO and wastewater samples, respectively, including 10 Cryptosporidium species, 3 G. duodenalis assemblages, and 8 E. bieneusi genotypes. In addition to C. hominis and C. parvum, two new pathogens identified in industrialized nations, C. ubiquitum and C. viatorum, were frequently detected. The two novel C. ubiquitum subtype families identified appeared to be genetic recombinants of known subtype families. Similarly, the dominant Group 1 E. bieneusi genotypes and G. duodenalis subassemblage AII are known human pathogens. The similar distribution of human-pathogenic Cryptosporidium species and E. bieneusi and G. duodenalis genotypes between wastewater and CSO samples reaffirms that storm overflow is potentially a significant contamination source of pathogens in surface water. The frequent identification of C. ubiquitum and C. viatorum in urban wastewater suggests that these newly identified human pathogens could be endemic in China.ImportanceCryptosporidium spp., Giardia duodenalis, and Enterocytozoon bieneusi are major waterborne pathogens. Their transport into surface water through combined sewer overflow, which remains largely untreated in developing countries, has not been examined. In addition, the identification of them to genotypes and subtypes in urban storm overflow and wastewater is necessary for rapid and accurate assessment of pathogen transmission in humans and transport in the environment. Data from this study suggest that like untreated urban wastewater, combined sewer overflow is commonly contaminated with human pathogenic Cryptosporidium, G. duodenalis, and E. bieneusi genotypes and subtypes, and urban storm overflow potentially plays a significant role in the contamination of drinking source water and recreational water with human pathogens. They also indicate that C. ubiquitum and C. viatorum, two newly identified human-pathogens, could be common in China, and genetic recombination can lead to the emergence of novel C. ubiquitum subtype families.

Giardia duodenalis is a common parasitic protozoan in human and animals. Epidemiological and molecular data are available from dairy cattle in many industrialized countries, but information on genetic diversity at multiple genetic loci is limited, especially in pre-weaned dairy calves. In this study, 818 fecal specimens were collected from five dairy cattle farms located in suburbs of Shanghai, China, with two to five samplings per farm. G. duodenalis assemblages and subtypes were determined using multilocus genotyping (MLG) at the beta-giardin (bg), glutamate dehydrogenase (gdh), and triosephosphate isomerase (tpi) loci. The overall prevalence was 60.1% (492/818) combining data from the three genetic loci. Three G. duodenalis assemblages were detected, including E (n = 482), A (n = 5), and B (n = 1), with the concurrence of A and E in a few animals (n = 4). Intra-genotypic sequence diversity was high for assemblage E, showing 12, 13, and 17 subtypes at the bg, gdh, and tpi loci, including four, six, and eight new subtypes, respectively. All dominant subtypes (E3, E2, and E8 at the bg locus; E1 and E3 at the gdh locus; and E11 and E3 at the tpi locus) were detected on all farms at most sampling occasions, and only limited differences in subtype distribution were observed among five farms. Altogether, 58 assemblage E MLGs were identified, all of which had not been reported before, and seven (MLG-E1-MLG-E7) were each seen on multiple farms. These results indicate a high occurrence of G. duodenalis in dairy calves, the existence of high genetic heterogeneity of assemblage E on five farms, and frequent exchange of parasite populations among farms within a small geographic area. The clinical and epidemiologic significance of these observations warrants further investigations.

BACKGROUND: Health care personnel (HCP) working while experiencing influenza-like illness (ILI) contribute to influenza transmission in health care settings. Studies focused on certain HCP occupations or work settings have demonstrated that some HCP often continue to work while ill. METHODS: Using a national nonprobability Internet panel survey of 1,914 HCP during the 2014-2015 influenza season, we calculated the frequency of working with self-reported ILI (ie, fever and cough or sore throat) and examined reasons for working with ILI by occupation and work setting. RESULTS: Overall, 414 (21.6%) HCP reported ILI, and 183 (41.4%) reported working with ILI (median, 3 days; range, 0-30 days). Pharmacists (67.2%) and physicians (63.2%) had the highest frequency of working with ILI. By work setting, hospital-based HCP had the highest frequency of working with ILI (49.3%). The most common reasons for working while ill included still being able to perform job duties and not feeling bad enough to miss work. Among HCP at long-term care facilities, the most common reason was inability to afford lost pay. CONCLUSIONS: More than 40% of HCP with ILI work while ill. To reduce HCP-associated influenza transmission, potential interventions could target HCP misconceptions about working while ill and paid sick leave policies.

The Advisory Committee on Immunization Practices recommends annual influenza vaccination for all health care personnel to reduce influenza-related morbidity and mortality among both health care personnel and their patients (1-4). To estimate influenza vaccination coverage among U.S. health care personnel for the 2015-16 influenza season, CDC conducted an opt-in Internet panel survey of 2,258 health care personnel during March 28-April 14, 2016. Overall, 79.0% of survey participants reported receiving an influenza vaccination during the 2015-16 season, similar to the 77.3% coverage reported for the 2014-15 season (5). Coverage in long-term care settings increased by 5.3 percentage points compared with the previous season. Vaccination coverage continued to be higher among health care personnel working in hospitals (91.2%) and lower among health care personnel working in ambulatory (79.8%) and long-term care settings (69.2%). Coverage continued to be highest among physicians (95.6%) and lowest among assistants and aides (64.1%), and highest overall among health care personnel who were required by their employer to be vaccinated (96.5%). Among health care personnel working in settings where vaccination was neither required, promoted, nor offered onsite, vaccination coverage continued to be low (44.9%). An increased percentage of health care personnel reporting a vaccination requirement or onsite vaccination availability compared with earlier influenza seasons might have contributed to the overall increase in vaccination coverage during the past 6 influenza seasons.

Four Vibrio spp. isolates from the historical culture collection at the Centers for Disease Control and Prevention, obtained from human blood specimens (n = 3) and river water (n = 1), show characteristics distinct from those of isolates of the most closely related species, Vibrio navarrensis and Vibrio vulnificus, based on phenotypic and genotypic tests. They are specifically adapted to survival in both freshwater and seawater, being able to grow in rich media without added salts as well as salinities above that of seawater. Phenotypically, these isolates resemble V. navarrensis, their closest known relative with a validly published name, but the group of isolates is distinguished from V. navarrensis by the ability to utilize L-rhamnose. Average nucleotide identity and percent DNA-DNA hybridization values obtained from the pairwise comparisons of whole genome sequences of these isolates to V. navarrensis range from 95.4-95.8% and 61.9-64.3%, respectively, suggesting that the group represents a different species. Phylogenetic analysis of the core genome, including four protein-coding housekeeping genes (pyrH, recA, rpoA, and rpoB), places these four isolates into their own monophyletic clade, distinct from V. navarrensis and V. vulnificus. Based on these differences, we propose these isolates belong to a novel Vibrio species. The name Vibrio cidicii sp. nov. is proposed for these isolates; strain LMG 29267T (= CIP 111013T = 2756-81T), isolated from river water, is the type strain.

Cryptosporidiosis, giardiasis, and microsporidiosis are important waterborne diseases. In the standard for wastewater treatment plant (WWTP) effluents in China and other countries, the fecal coliform count is the only microbial indicator, raising concerns about the potential for pathogen transmission through WWTP effluent reuse. In this study, we collected 50 effluent samples (30 L/sample) from three municipal WWTPs in Shanghai, China, and analyzed for Cryptosporidium spp., Giardia duodenalis and Enterocytozoon bieneusi by microscopy and/or polymerase chain reaction (PCR). Moreover, propidium monoazide (PMA)-PCR was used to assess the viability of oocysts/cysts. The microscopy and PCR-positive rates for Cryptosporidium spp. were 62% and 40%, respectively. The occurrence rates of G. duodenalis were 96% by microscopy and 92-100% by PCR analysis of three genetic loci. Furthermore, E. bieneusi was detected in 70% (35/50) of samples by PCR. Altogether, 10 Cryptosporidium species or genotypes, two G. duodenalis genotypes, and 11 E. bieneusi genotypes were found, most of which were human-pathogenic. The chlorine dioxide disinfection employed in WWTP1 and WWTP3 failed to inactivate the residual pathogens; 93% of the samples from WWTP1 and 83% from WWTP3 did not meet the national standard on fecal coliform levels. Thus, urban WWTP effluents often contain residual waterborne human pathogens.

BACKGROUND: Controversies exist on the potential role of companion animals in the transmission of enteric pathogens in humans. This study was conducted to examine the genotype distribution of Cryptosporidium spp., Enterocytozoon bieneusi, and Giardia duodenalis in companion animals in Shanghai, China, and to assess their zoonotic potential. METHODS: Fecal specimens from 485 dogs and 160 cats were examined for the occurrence and genotype distribution of the three pathogens by PCR. PCR products were sequenced to determine the species and genotypes. The chi(2) test was used to compare differences in infection rates between living conditions or age groups. RESULTS: Cryptosporidium spp., E. bieneusi and G. duodenalis were found in 39 (8.0 %), 29 (6.0 %) and 127 (26.2 %) of dogs, and 6 (3.8 %), 9 (5.6 %) and 21 (13.1 %) of cats, respectively. Infection rates of the pathogens in dogs from pet shops and a clinic were higher than those in household dogs, and higher in cats from one animal shelter than from pet shops. No significant differences in infection rates were detected among age groups. Cryptosporidium canis and C. felis were the only Cryptosporidium species found in dogs and cats, respectively. Enterocytozoon bieneusi genotype PtEb IX was the dominant genotype in dogs, whereas Type IV and D were the most common ones in cats. Multi-locus sequence typing at the glutamate dehydrogenase, beta-giardin, and triosephosphate isomerase loci revealed the presence of G. duodenalis assemblages A (n = 23), B (n = 1), C (n = 26), and D (n = 58) in dogs (only A in household dogs) and assemblages A (n = 2), B (n = 6), C (n = 2), D (n = 1), and F (n = 7) in cats. Co-infection was detected in 24 dogs and 5 cats, especially those living in crowded conditions. CONCLUSIONS: Living condition is a major risk factor affecting the occurrence of enteric protists in companion animals in China, and although dogs and cats can be potential sources of human infections, the different distribution of pathogen species and genotypes between dogs and cats suggests that inter-species transmission of these pathogens is probably rare in the study area.

Post-traumatic stress disorder (PTSD) is a condition associated with traumatic brain injury (TBI). While the importance of PTSD and TBI among military personnel is widely recognized, there is less awareness of PTSD associated with civilian TBI. We examined the incidence and factors associated with PTSD six months post-injury in a civilian emergency department population using measures from the (NINDS) TBI Common Data Elements (TBI-CDE) Outcome Battery. Participants with mild TBI (mTBI) from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Pilot study with complete six-month outcome batteries (N=280) were analyzed. Screening for PTSD symptoms was conducted using the PTSD Checklist-Civilian Version (PCL-C). Descriptive measures are summarized and predictors for PTSD were examined using logistic regression. Incidence of screening positive for PTSD was 26.8% at six months following mTBI. Screening positive for PTSD was significantly associated with concurrent functional disability, postconcussive and psychiatric symptomatology, decreased satisfaction with life, and decreased performance in visual processing and mental flexibility. Multivariable regression showed injury mechanism of assault (odds ratio (OR) 3.59, 95% confidence interval (CI) 1.69-7.63, p=0.001) and prior psychiatric history (OR 2.56, 95% CI 1.42-4.61, p=0.002) remained significant predictors of screening positive for PTSD, while education (per-year OR 0.88, 95% CI 0.79-0.98, p=0.021) was associated with decreased odds of PTSD. Standardized data collection and review of pre-injury education, psychiatric history, and injury mechanism during initial hospital presentation can aid in identifying patients with mTBI at risk for developing PTSD symptoms, who may benefit from closer follow-up after initial injury care.

The Advisory Committee on Immunization Practices recommends annual influenza vaccination for all health care personnel (HCP) to reduce influenza-related morbidity and mortality among both HCP and their patients and to decrease absenteeism among HCP. To estimate influenza vaccination coverage among U.S. HCP for the 2014-15 influenza season, CDC conducted an opt-in Internet panel survey of 1,914 HCP during March 31-April 15, 2015. Overall, 77.3% of HCP survey participants reported receiving an influenza vaccination during the 2014-15 season, similar to the 75.2% coverage among HCP reported for the 2013-14 season. Vaccination coverage was highest among HCP working in hospitals (90.4%) and lowest among HCP working in long-term care (LTC) settings (63.9%). By occupation, coverage was highest among pharmacists (95.3%) and lowest among assistants and aides (64.4%). Influenza vaccination coverage was highest among HCP who were required by their employer to be vaccinated (96.0%). Among HCP without an employer requirement for vaccination, coverage was higher for HCP working in settings where vaccination was offered on-site at no cost for 1 day (73.6%) or multiple days (83.9%) and lowest among HCP working in settings where vaccine was neither required, promoted, nor offered on-site (44.0%). Comprehensive vaccination strategies that include making vaccine available at no cost at the workplace along with active promotion of vaccination might help increase vaccination coverage among HCP and reduce the risk for influenza to HCP and their patients.

Rubella remains a significant burden in mainland China. In this report, 667 viruses collected in 24 of 31 provinces of mainland China during 2010-2012 were sequenced and analyzed, significantly extending previous reports on limited numbers of viruses collected before 2010. Only viruses of genotypes 1E and 2B were found. Genotype 1E viruses were found in all 24 provinces. Genotype 1E viruses were likely introduced into mainland China around 1997 and endemic transmission of primarily one lineage became established. Viruses reported here from 2010-2012 are largely in a single cluster within this lineage. Genotype 2B viruses were rarely detected in China prior to 2010. This report documents a previously undetected 2B lineage, which likely became endemic in eastern provinces of China between 2010 and 2012. Bayesian analyses were performed to estimate the evolutionary rates and dates of appearance of the genotype 1E and 2B viral linages in China. A skyline plot of viral population diversity did not provide evidence of reduction of diversity as a result of vaccination, but should be useful as a baseline for such reductions as vaccination programs for rubella become widespread in mainland China.

BACKGROUND: In 2006, quadrivalent human papillomavirus (HPV4; Gardasil, Merck & Co., Inc.) vaccine was licensed in the US for use in females aged 9-26 years. HPV4 is not recommended during pregnancy; however, inadvertent administration during pregnancy may occur. OBJECTIVES: To evaluate and summarize reports to the Vaccine Adverse Event Reporting System (VAERS) in pregnant women who received HPV4 vaccine and assess for potentially concerning adverse events among non-manufacturer reports. METHODS: We searched the VAERS database for non-manufacturer reports of adverse events (AEs) in pregnant women who received HPV4 vaccine from 6/1/2006 to 12/31/2013. We conducted clinical review of reports and available medical records. RESULTS: We found 147 reports after HPV4 vaccine administered to pregnant women. The most frequent pregnancy-specific AE was spontaneous abortion in 15 (10.2%) reports, followed by elective terminations in 6 (4.1%). Maternal fever was the most frequent non-pregnancy-specific AE in 3 reports. Two reports of major birth defects were received. No maternal deaths were noted. One hundred-three (70.1%) reports did not describe an AE. CONCLUSIONS: This review of VAERS non-manufacturer reports following vaccination with HPV4 in pregnancy did not find any unexpected patterns in maternal or fetal outcomes.

Lofa County has one of the highest cumulative incidences of Ebola virus disease (Ebola) in Liberia. Recent situation reports from the Liberian Ministry of Health and Social Welfare (MoHSW) have indicated a decrease in new cases of Ebola in Lofa County. In October 2014, the Liberian MoHSW requested the assistance of CDC to further characterize recent trends in Ebola in Lofa County. Data collected during June 8-November 1, 2014 from three sources were analyzed: 1) aggregate data for newly reported cases, 2) case-based data for persons admitted to the dedicated Ebola treatment unit (ETU) for the county, and 3) test results for community decedents evaluated for Ebola. Trends from all three sources suggest that transmission of Ebola virus decreased as early as August 17, 2014, following rapid scale-up of response activities in Lofa County after a resurgence of Ebola in early June 2014. The comprehensive response strategy developed with participation from the local population in Lofa County might serve as a model to implement in other affected areas to accelerate control of Ebola.

The Advisory Committee on Immunization Practices recommends that all health care personnel (HCP) be vaccinated annually against influenza. Vaccination of HCP can reduce influenza-related morbidity and mortality among both HCP and their patients. To estimate influenza vaccination coverage among HCP during the 2013-14 season, CDC analyzed results of an opt-in Internet panel survey of 1,882 HCP conducted during April 1-16, 2014. Overall, 75.2% of participating HCP reported receiving an influenza vaccination during the 2013-14 season, similar to the 72.0% coverage among participating HCP reported in the 2012-13 season. Coverage was highest among HCP working in hospitals (89.6%) and lowest among HCP working in long-term care (LTC) settings (63.0%). By occupation, coverage was highest among physicians (92.2%), nurses (90.5%), nurse practitioners and physician assistants (89.6%), pharmacists (85.7%), and "other clinical personnel" (87.4%) compared with assistants and aides (57.7%) and nonclinical personnel (e.g., administrators, clerical support workers, janitors, and food service workers) (68.6%). HCP working in settings where vaccination was required had higher coverage (97.8%) compared with HCP working in settings where influenza vaccination was not required but promoted (72.4%) or settings where there was no requirement or promotion of vaccination (47.9%). Among HCP without an employer requirement for vaccination, coverage was higher for HCP working in settings where vaccination was offered on-site at no cost for 1 day (61.6%) or multiple days (80.4%) compared with HCP working in settings not offering free on-site vaccination (49.0%). Comprehensive vaccination strategies that include making vaccine available at no cost at the workplace along with active promotion of vaccination might be needed to increase vaccination coverage among HCP and minimize the risk for influenza to HCP and their patients.

OBJECTIVE: We characterized reports to the Vaccine Adverse Event (AE) Reporting System (VAERS) of pregnant women who received meningococcal polysaccharide-protein conjugate vaccine Menactra (MenACWY-D; Sanofi Pasteur Inc., Swiftwater, PA). STUDY DESIGN: We searched VAERS for reports of pregnant women who received MenACWY-D from Jan. 1, 2005 through Dec. 31, 2011. We conducted clinical review of reports and available medical records. RESULTS: Of 103 identified reports, 38 (36.7%) did not describe any AE. No maternal or infant deaths were reported. The most frequent pregnancy-specific AE was spontaneous abortion in 17 (16.5%) reports. Urinary tract infections and fever with vomiting were the most frequent nonpregnancy-specific AEs found in 4 (3.9%) and 3 (2.9%) reports, respectively. We identified 1 report with a major congenital anomaly (aqueductal stenosis and severe ventriculomegaly). CONCLUSION: Our comprehensive review of reports to VAERS in pregnant women after MenACWY-D did not identify any concerning patterns in maternal, infant, or fetal outcomes.

Benzene is an established leukotoxin and leukemogen in humans. We have previously reported that exposure of workers to benzene and to benzene metabolite hydroquinone in cultured cells induced DNA-dependent protein kinase catalytic subunit (DNA-PKcs) to mediate the cellular response to DNA double strand break (DSB) caused by DNA-damaging metabolites. In this study, we used a new, small molecule, a selective inhibitor of DNA-PKcs, 2-(morpholin-4-yl)-benzo[h]chomen-4-one (NU7026), as a probe to analyze the molecular events and pathways in hydroquinone-induced DNA DSB repair and apoptosis. Inhibition of DNA-PKcs by NU7026 markedly potentiated the apoptotic and growth inhibitory effects of hydroquinone in proerythroid leukemic K562 cells in a dose-dependent manner. Treatment with NU7026 did not alter the production of reactive oxygen species and oxidative stress by hydroquinone but repressed the protein level of DNA-PKcs and blocked the induction of the kinase mRNA and protein expression by hydroquinone. Moreover, hydroquinone increased the phosphorylation of Akt to activate Akt, whereas co-treatment with NU7026 prevented the activation of Akt by hydroquinone. Lastly, hydroquinone and NU7026 exhibited synergistic effects on promoting apoptosis by increasing the protein levels of pro-apoptotic proteins Bax and caspase-3 but decreasing the protein expression of anti-apoptotic protein Bcl-2. Taken together, the findings reveal a central role of DNA-PKcs in hydroquinone-induced hematotoxicity in which it coordinates DNA DSB repair, cell cycle progression, and apoptosis to regulate the response to hydroquinone-induced DNA damage.