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Issue 10, March 14, 2017

CDC Science Clips: Volume 9, Issue 10, March 14, 2017

Each Tuesday, to enhance awareness of emerging scientific knowledge, selected science clips will be posted here for the public health community. The focus is applied public health research and prevention science that has the capacity to improve health now.

The report consists of these components:

  1. Key Scientific Articles in Featured Topic Areas - Drug Safety
    Subject matter experts decide what topic to feature, and articles are selected from the last 3 to 6 months of published literature. Key topic coincides monthly with other CDC products (e.g. Vital Signs).
    This Science Clips feature focuses on the rare but severe cutaneous reactions Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN), which are typically caused by prescription or over-the-counter drugs, including commonly used antibiotics and analgesics. SJS and TEN describe varying severities of the immune-system mediated reaction, which results in sloughing of skin and mucous membranes. Mortality is high, with estimates ranging from under 1% to more than 30-40%, depending on the degree of skin involvement. Life-long sequelae are common, including internal-organ damage and loss of vision. Articles selected include descriptions of clinical characteristics of both acutely ill patients and survivors, and reviews of recent discoveries about the underlying immunological processes. While exact figures for the incidence of these reactions are not available owing to challenges in surveillance and reporting, epidemiologic trends are discussed in several papers. Updates on genetic markers that may predispose certain individuals to reactions to specific medications, and on the pharmacogenomics research that has already yielded a screening test that is cost-effective for certain populations, are included. World-wide, several jurisdictions have drug-injury compensation systems, which are discussed in the final two papers.
    • Drug Safety RSS Word feed
      1. Review of toxic epidermal necrolysis
        Harris V, Jackson C, Cooper A.
        Int J Mol Sci. 2016 Dec 18;17(12).
        Toxic epidermal necrolysis (TEN) is a rare but life threatening mucocutaneous reaction to drugs or their metabolites. It is characterised by widespread keratinocyte apoptosis and sloughing of the skin, erosions of the mucous membranes, painful blistering, and severe systemic disturbance. The pathophysiology of TEN is incompletely understood. Historically, it has been regarded as a drug-induced immune reaction initiated by cytotoxic lymphocytes via a human leukocyte antigen (HLA)-restricted pathway. Several mediators have been identified as contributors to the cell death seen in TEN, including; granulysin, soluble Fas ligand, perforin/granzyme, tumour necrosis factor-alpha (TNF-alpha), and TNF-related apoptosis-inducing ligand. Currently, granulysin is accepted as the most important mediator of T cell proliferation. There is uncertainty around the accepted management of TEN. The lack of definitive management guidelines for TEN is explained in part by the rarity of the disease and its high mortality rate, which makes it difficult to conduct randomised control trials on emerging therapies. Developments have been made in pharmacogenomics, with numerous HLA alleles identified; however, these have largely been ethnically specific. These associations have translated into screening recommendations for Han Chinese.

      2. Drug induced exfoliative dermatitis: state of the art
        Yacoub MR, Berti A, Campochiaro C, Tombetti E, Ramirez GA, Nico A, Di Leo E, Fantini P, Sabbadini MG, Nettis E, Colombo G.
        Clin Mol Allergy. 2016 ;14:9.
        Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Overall, T cells are the central player of these immune-mediated drug reactions. Here we provide a systematic review on frequency, risk factors, pathogenesis, clinical features and management of patients with drug induced ED.

      3. Nationwide survey of Stevens-Johnson syndrome and toxic epidermal necrolysis in children in the United States
        Okubo Y, Nochioka K, Testa MA.
        Pediatr Dermatol. 2016 Dec 19.
        Although Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are serious, life-threatening reactions to drug therapies, no efforts have been made to investigate the comprehensive change in epidemiology with respect to age, sex, and race and ethnicity in children. The risk of death was 0.3% to 1.5%, and the highest hospitalization rates were in children 15 to 19 years of age, boys, and black children. The highest proportions of hospitalizations were children with very low household income, those with private insurance, and those treated at large urban teaching hospitals in the West. A significant winter-autumn predominance was observed.

      4. Long term complications of Stevens-Johnson syndrome / Toxic epidermal necrolysis: The spectrum of chronic problems in patients who survive an episode of SJS/TEN necessitates multi-disciplinary follow up
        Lee HY, Walsh SA, Creamer D.
        Br J Dermatol. 2017 Feb 01.
        Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe adverse reactions to drugs which cause a life-threatening eruption of mucocutaneous blistering and epithelial sloughing. The two terms describe phenotypes occurring at either end of a severity spectrum: SJS is the less extensive form (<10% body surface area (BSA) detachment), while TEN is the more extensive (>30% BSA detachment). Cases in which there is 10-30% epidermal detachment are referred to as SJS-TEN overlap.

      5. Clinical characteristics and treatment outcome of Stevens-Johnson syndrome and toxic epidermal necrolysis
        Chantaphakul H, Sanon T, Klaewsongkram J.
        Exp Ther Med. 2015 Aug;10(2):519-524.
        Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are erythematous skin lesions with blister formation accompanied by mucosal involvement. These conditions are considered to be life-threatening illnesses. Understanding the clinical presentation, risk factors, treatment options and results will be advantageous for physicians in the management of patients in the future. The aim of the present study was to review and analyze the clinical manifestations, drug implications, treatment and outcome of patients with SJS and/or TEN who had been hospitalized in a tertiary care center. All hospitalized patients with SJS and/or TEN during a 5-year period were retrospectively reviewed. The clinical severity was graded according to the score of toxic epidermal necrolysis (SCORTEN) scale. Clinical symptoms, diagnosis, possible precipitating factors, management and outcome data were collected for analysis. A total of 43 patients (mean age, 49.5 years) were hospitalized and classified into the SJS group (55.8%), SJS/TEN overlap group (20.9%) and TEN group (23.3%). The majority of the patients (90.7%) had mucocutaneous eruptions associated with oral drug administration. Allopurinol, anticonvulsants and antibiotics were the most common causative agents for the mucocutaneous eruption. Twenty-eight patients (65.1%) were treated with corticosteroids. The mortality rate was 6.9%. Comparison between the survival group and the non-survival group revealed that patient age >70 years (P=0.014) and body surface area involvement >20% (P<0.01) were the significant factors associated with mortality. The use of systemic steroids was higher in the survival group in comparison with the non-survival group (65.1 vs. 0%, respectively; P=0.014). The mucocutaneous eruptions in SJS and TEN are mostly caused by medication. With early recognition and treatment, the mortality rate in this study was lower than that in previous reports. Patient age and the area of mucocutaneous involvement were significant factors associated with mortality.

      6. Stevens-Johnson syndrome and toxic epidermal necrolysis associated with acetaminophen use during viral infections
        Ban GY, Ahn SJ, Yoo HS, Park HS, Ye YM.
        Immune Netw. 2016 Aug;16(4):256-60.
        An association between drug treatment for viral infections and severe cutaneous adverse reactions has been noted. We investigated six patients diagnosed with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) after being prescribed acetaminophen for suspected viral illnesses. Multiplex analysis was performed to measure cytokine levels in sera before and after treatment. IL-2Ralpha levels significantly decreased during the convalescence phase. Although acetaminophen is relatively safe, the drug can trigger SJS/TEN in patients with suspected viral infections. T-cells and monocytes may be key components of the link between viral infection and acetaminophen-induced SJS/TEN.

      7. Recent advances of pharmacogenomics in severe cutaneous adverse reactions: immune and nonimmune mechanisms
        Dao RL, Su SC, Chung WH.
        Asia Pac Allergy. 2015 Apr;5(2):59-67.
        Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) are severe cutaneous adverse reactions (SCAR) which are majorly caused by drugs. Though the incidence rate is low, SCAR sometimes can be life-threatening and leads to lifelong sequelae. Many pharmacogenomic associations in immune and nonimmune related genes with the development of SCAR have been discovered recently and the pharmacogenetic tests have been applied to prevent specific drug-induced SCAR. In this review, we discuss the recent advances of pharmacogenomics in SCAR.

      8. New genetic findings lead the way to a better understanding of fundamental mechanisms of drug hypersensitivity
        Pirmohamed M, Ostrov DA, Park BK.
        J Allergy Clin Immunol. 2015 Aug;136(2):236-44.
        Drug hypersensitivity reactions are an important clinical problem for both health care and industry. Recent advances in genetics have identified a number of HLA alleles associated with a range of these adverse reactions predominantly affecting the skin but also other organs, such as the liver. The associations between abacavir hypersensitivity and HLA-B*57:01 and carbamazepine-induced Stevens-Johnson syndrome and HLA-B*15:02 have been implemented in clinical practice. There are many different mechanisms proposed in the pathogenesis of drug hypersensitivity reactions, including the hapten hypothesis, direct binding to T-cell receptors (the pharmacologic interaction hypothesis), and peptide-binding displacement. A problem with all the hypotheses is that they are largely based on in vitro findings, with little direct in vivo evidence. Although most studies have focused on individual mechanisms, it is perhaps more important to consider them all as being complementary, potentially occurring at the same time with the same drug in the same patient. This might at least partly account for the heterogeneity of the immune response seen in different patients. There is a need to develop novel methodologies to evaluate how the in vitro mechanisms relate to the in vivo situation and how the highly consistent genetic findings with different HLA alleles can be more consistently used for both prediction and prevention of these serious adverse reactions.

      9. Don't live in a town where there are no doctors: toxic epidermal necrolysis initially misdiagnosed as oral thrush
        Wani AM, Hussain WM, Fatani MI, Ali KS, Khoujah AM, Akhtar M, Maimani GA, Raja SH, Basraheel A, Fareed K.
        BMJ Case Rep. 2009 ;2009.
        Toxic epidermal necrolysis (TEN) is a rare but life threatening skin disease that is most commonly drug induced. The exact pathogenesis of TEN is still unknown and many drugs, including prednisolone, cyclosporin and intravenous immunoglobulin (IVIG), have been used in an attempt to halt the disease process. The use of IVIG in particular is controversial. Recently, the US Food and Drug Administration (FDA) has made a labelling change to the drug information for carbamazepine. Owing to recent data implicating the HLA allele B*1502 as a marker for carbamazepine induced Stevens-Johnson syndrome and TEN in Han Chinese, the FDA recommends genotyping all Asians for the allele. We present an interesting case of carbamazepine induced TEN which was confused with oral thrush, had no skin lesions on presentation, and had an excellent response to a 5 day course of methylprednisolone and high dose IVIG in combination.

      10. Severe cutaneous adverse reactions: The pharmacogenomics from research to clinical implementation
        Su SC, Hung SI, Fan WL, Dao RL, Chung WH.
        Int J Mol Sci. 2016 Nov 15;17(11).
        Severe cutaneous adverse reactions (SCARs), previously thought to be idiosyncratic or unpredictable, are a deadly form of adverse drug reactions with skin manifestations. Current pharmacogenomic studies of SCARs have made important strides, as the prevention of SCARs, to some extent, appears attainable with the identification of genetic variants for genes encoding drug-metabolizing enzymes and human leukocyte antigens (HLAs). Despite the improvement of incidence, a treatment guideline for this devastating condition is still unavailable, highlighting the inadequacy of contemporary accepted therapeutic interventions. As such, prompt withdrawal of causative drugs is believed to be a priority of patient management. In this review, we discuss recent cutting-edge findings concerning the discovery of biomarkers for SCARs and their clinical utilities in the better prediction and early diagnosis of this disease. The knowledge compiled herein provides clues for future investigations on deciphering additional genetic markers for SCARs and the design of clinical trials for the prospective identification of subjects at genetic risk for this condition, ultimately personalizing the medicine.

      11. Real-world efficiency of pharmacogenetic screening for carbamazepine-induced severe cutaneous adverse reactions
        Chen Z, Liew D, Kwan P.
        PLoS One. 2014 ;9(5):e96990.
        OBJECTIVES: We evaluated the cost and efficiency of routine HLA-B*15 ratio 02 screening to prevent carbamazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis (CBZ-SJS/TEN) in Hong Kong. METHODS: Data were extracted from patients who commenced CBZ as the first-ever AED treatment or tested for HLA-B*15 ratio 02 allele in three years before policy implementation (pre-policy: 16 September 2005 to 15 September 2008) and three years after (post-policy: 16 September 2008 to 15 September 2011). Using published unit costs, we estimated the cost of screening by comparing the costs to prevent and treat CBZ-SJS/TEN. We compared the number of person-tests needed and the cost to prevent resultant death with cancer screening programs. RESULTS: The number of screening tests needed to prevent one case of CBZ-SJS/TEN was 442, and to prevent one resultant death was 1,474 to 8,840. The screening cost was $332 per person, of which 42% was attributed to an additional consultation to review result and prescribe appropriate medication. HLA-B*15 ratio 02 screening expended $146,749 to prevent a case of CBZ-SJS/TEN, and $489,386- $2,934,986 to prevent a resultant death. The corresponding numbers of tests and costs for mammography and Pap smear to prevent death due to breast and cervical cancers were 7,150 and 7,000, and $614,900 and $273,000, respectively. Comparing to the SJS/TEN treatment cost, HLA-B*15 ratio 02 screening would become cost saving if a point-of-care test of less than $37 was available. CONCLUSIONS: HLA-B*15 ratio 02 screening is as efficient as mammography and Pap smear in preventing death. Development of point-of-care testing will vastly improve efficiency.

      12. Who should support the costs of severe adverse drug reactions?
        Roujeau JC, Le Pallec S.
        Ther Adv Drug Saf. 2011 Feb;2(1):5-8.
        [No abstract]

      13. A unique drug-injury relief system in Taiwan: comparing drug-injury compensation in different countries
        On AW, Chih LH, Liu C, Lin KH, Huang YW, Tai HY, Hsiao ML.
        J Pharm Health Serv Res. 2012 ;3(1):3-9.
        Taiwan operates a unique no-fault compensation-based scheme for injuries caused by medication use. This article describes the operation of the Taiwan Drug Relief Foundation and some results since the Taiwan Drug Hazard Relief Act was enacted in 2000. We also briefly review similar no-fault compensation systems in Germany, Japan, New Zealand and Nordic countries. The existence of these schemes provides timely relief and compensation to victims by avoiding the otherwise lengthy court process; however, medication safety education and applied pharmacogenomic and pharmacoepidemiological research are future aspirations to proactively address and prevent drug-induced injuries.


  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions RSS Word feed
      1. Information seeking and satisfaction with information sources among spouses of men with newly diagnosed local-stage prostate cancer
        Bansal A, Koepl LM, Fedorenko CR, Li C, Smith JL, Hall IJ, Penson DF, Ramsey SD.
        J Cancer Educ. 2017 Feb 25.
        Information sources about prostate cancer treatment and outcomes are typically designed for patients. Little is known about the availability and utility of information for partners. The objectives of our study were to evaluate information sources used by partners to understand prostate cancer management options, their perceived usefulness, and the relationship between sources used and satisfaction with treatment experience. A longitudinal survey of female partners of men newly diagnosed with local-stage prostate cancer was conducted in three different geographic regions. Partners and associated patients were surveyed at baseline (after patient diagnosis but prior to receiving therapy) and at 12 months following diagnosis. Information sources included provider, literature, friends or family members, Internet websites, books, traditional media, and support groups. Utility of an information source was defined as whether the partner would recommend it to caregivers of other patients with local-stage prostate cancer. Our study cohort included 179 partner-patient pairs. At diagnosis, partners consulted an average of 4.6 information sources. Non-Hispanic white partners were more likely than others to use friends and family as an information source (OR = 2.44, 95% CI (1.04, 5.56)). More educated partners were less likely to use support groups (OR = 0.31, 95% CI (0.14, 0.71)). At 12-month follow-up, partners were less likely to recommend books (OR = 0.23, 95% CI (0.11, 0.49)) compared to baseline. Partners consulted a large number of information sources in researching treatment options for local-stage prostate cancer and the types of sources accessed varied by race/ethnicity and educational attainment. Additional resources to promote selection of high-quality non-provider information sources are warranted to enable partners to better aid patients in their treatment decision-making process.

      2. Association of diabetes and tuberculosis disease among US-bound adult refugees, 2009-2014
        Benoit SR, Gregg EW, Jonnalagadda S, Phares CR, Zhou W, Painter JA.
        Emerg Infect Dis. 2017 Mar;23(3):543-545.
        Diabetes is associated with an increased risk for active tuberculosis (TB) disease. We conducted a case-control study and found a significant association between diabetes and TB disease among US-bound refugees. These findings underscore the value of collaborative management of both diseases.

      3. Association of type 1 diabetes vs type 2 diabetes diagnosed during childhood and adolescence with complications during teenage years and young adulthood
        Dabelea D, Stafford JM, Mayer-Davis EJ, D'Agostino R, Dolan L, Imperatore G, Linder B, Lawrence JM, Marcovina SM, Mottl AK, Black MH, Pop-Busui R, Saydah S, Hamman RF, Pihoker C.
        Jama. 2017 Feb 28;317(8):825-835.
        Importance: The burden and determinants of complications and comorbidities in contemporary youth-onset diabetes are unknown. Objective: To determine the prevalence of and risk factors for complications related to type 1 diabetes vs type 2 diabetes among teenagers and young adults who had been diagnosed with diabetes during childhood and adolescence. Design, Setting, and Participants: Observational study from 2002 to 2015 in 5 US locations, including 2018 participants with type 1 and type 2 diabetes diagnosed at younger than 20 years, with single outcome measures between 2011 and 2015. Exposures: Type 1 and type 2 diabetes and established risk factors (hemoglobin A1c level, body mass index, waist-height ratio, and mean arterial blood pressure). Main Outcomes and Measures: Diabetic kidney disease, retinopathy, peripheral neuropathy, cardiovascular autonomic neuropathy, arterial stiffness, and hypertension. Results: Of 2018 participants, 1746 had type 1 diabetes (mean age, 17.9 years [SD, 4.1]; 1327 non-Hispanic white [76.0%]; 867 female patients [49.7%]), and 272 had type 2 (mean age, 22.1 years [SD, 3.5]; 72 non-Hispanic white [26.5%]; 181 female patients [66.5%]). Mean diabetes duration was 7.9 years (both groups). Patients with type 2 diabetes vs those with type 1 had higher age-adjusted prevalence of diabetic kidney disease (19.9% vs 5.8%; absolute difference [AD], 14.0%; 95% CI, 9.1%-19.9%; P < .001), retinopathy (9.1% vs 5.6%; AD, 3.5%; 95% CI, 0.4%-7.7%; P = .02), peripheral neuropathy (17.7% vs 8.5%; AD, 9.2%; 95% CI, 4.8%-14.4%; P < .001), arterial stiffness (47.4% vs 11.6%; AD, 35.9%; 95% CI, 29%-42.9%; P < .001), and hypertension (21.6% vs 10.1%; AD, 11.5%; 95% CI, 6.8%-16.9%; P < .001), but not cardiovascular autonomic neuropathy (15.7% vs 14.4%; AD, 1.2%; 95% CI, -3.1% to 6.5; P = .62). After adjustment for established risk factors measured over time, participants with type 2 diabetes vs those with type 1 had significantly higher odds of diabetic kidney disease (odds ratio [OR], 2.58; 95% CI, 1.39-4.81; P=.003), retinopathy (OR, 2.24; 95% CI, 1.11-4.50; P = .02), and peripheral neuropathy (OR, 2.52; 95% CI, 1.43-4.43; P = .001), but no significant difference in the odds of arterial stiffness (OR, 1.07; 95% CI, 0.63-1.84; P = .80) and hypertension (OR, 0.85; 95% CI, 0.50-1.45; P = .55). Conclusions and Relevance: Among teenagers and young adults who had been diagnosed with diabetes during childhood or adolescence, the prevalence of complications and comorbidities was higher among those with type 2 diabetes compared with type 1, but frequent in both groups. These findings support early monitoring of youth with diabetes for development of complications.

      4. BMI z-Scores are a poor indicator of adiposity among 2- to 19-year-olds with very high BMIs, NHANES 1999-2000 to 2013-2014
        Freedman DS, Butte NF, Taveras EM, Lundeen EA, Blanck HM, Goodman AB, Ogden CL.
        Obesity (Silver Spring). 2017 Feb 28.
        OBJECTIVE: Although the Centers for Disease Control and Prevention (CDC) growth charts are widely used, BMI-for-age z-Scores (BMIz) are known to be uninformative above the 97th percentile. This study compared the relations of BMIz and other BMI metrics (%BMIp95 , percent of 95th percentile, and DeltaBMIp95 , BMI minus 95th percentile) to circumferences, skinfolds, and fat mass. We were particularly interested in the differences among children with severe obesity (%BMIp95 >/= 120). METHODS: Data was used from 30,003 2- to 19-year-olds who were examined from 1999-2000 through 2013-2014 in the National Health and Nutrition Examination Survey (NHANES). RESULTS: The theoretical maximum BMIz based on the growth charts varied by more than threefold across ages. The BMI metrics were strongly intercorrelated, but BMIz was less strongly related to the adiposity measures than were DeltaBMIp95 and %BMIp95 . Among children with severe obesity, circumferences and triceps skinfold showed almost no association with BMIz (r </= 0.10), whereas associations with %BMIp95 and DeltaBMIp95 ranged from r = 0.32 to 0.79. Corresponding associations with fat mass / height2 ranged from r = 0.40 (BMIz) to r =0.82 (%BMIp95 ) among 8- to 19-year-olds. CONCLUSIONS: Among children with severe obesity, BMIz is only weakly associated with other measures of body fatness. Very high BMIs should be expressed relative to the CDC 95th percentile, particularly in studies that evaluate obesity interventions.

      5. Indicators of abdominal size relative to height associated with sex, age, socioeconomic position and ancestry among US adults
        Kahn HS, Bullard KM.
        PLoS One. 2017 ;12(3):e0172245.
        BACKGROUND/OBJECTIVES: The supine sagittal abdominal diameter (SAD) and standing waist circumference (WC) describe abdominal size. The SAD/height ratio (SADHtR) or WC/height ratio (WHtR) may better identify cardiometabolic disorders than BMI (weight/height2), but population-based distributions of SADHtR and WHtR are not widely available. Abdominal adiposity may differ by sociodemographic characteristics. SUBJECTS/METHODS: Anthropometry, including SAD by sliding-beam caliper, was performed on 9894 non-pregnant adults >/=20 years in the US National Health and Nutrition Examination Surveys of 2011-2014. Applying survey design factors and sampling weights, we estimated nationally representative SADHtR and WHtR distributions by sex, age, educational attainment, and four ancestral groups. RESULTS: The median (10th percentile, 90th percentile) for men's SADHtR was 0.130 (0.103, 0.165) and WHtR 0.569 (0.467, 0.690). For women, median SADHtR was 0.132 (0.102, 0.175) and WHtR 0.586 (0.473, 0.738). Medians for SADHtR and WHtR increased steadily through age 79. The median BMI, however, reached maximum values at ages 40-49 (men) or 60-69 (women) and then declined. Low educational attainment, adjusted for age and ancestry, was associated with elevated SADHtR more strongly than elevated BMI. While non-Hispanic Asians had substantially lower BMI compared to all other ancestral groups (adjusted for sex, age and education), their relative reductions in SADHtR and WHtR, were less marked. CONCLUSIONS: These cross-sectional data are consistent with monotonically increasing abdominal adipose tissue through the years of adulthood but decreasing mass in non-abdominal regions beyond middle age. They suggest also that visceral adipose tissue, estimated by SADHtR, expands differentially in association with low socioeconomic position. Insofar as Asians have lower BMIs than other populations, employing abdominal indicators may attenuate the adiposity differences reported between ancestral groups. Documenting the distribution and sociodemographic features of SADHtR and WHtR supports the clinical and epidemiologic adoption of these adiposity indicators.

      6. Comparing two waist-to-height ratio measurements with cardiometabolic risk factors among youth with diabetes
        Liu LL, Kahn HS, Pettitt DJ, Fino NF, Morgan T, Maahs DM, Crimmins NA, Lamichhane AP, Liese AD, D'Agostino RB, Bell RA.
        Int J Child Health Nutr. 2016 ;5(3):87-94.
        BACKGROUND: Waist circumference (WC) is commonly measured by either the World Health Organization (WHO) or National Health and Nutrition Examination Survey (NHANES) protocol. OBJECTIVE: Compare the associations of WHO vs. NHANES WC-to-height ratio (WHtR) protocols with cardiometabolic risk factors (CMRFs) in a sample of youth with diabetes. METHODS: For youth (10-19 years old with type 1 [N=3082] or type 2 [N=533] diabetes) in the SEARCH for Diabetes in Youth Study, measurements were obtained of WC (by two protocols), weight, height, fasting lipids (total cholesterol, triglycerides, HDL cholesterol, Non-HDL cholesterol) and blood pressures. Associations of CMRFs with WHO and NHANES WHtR were modeled stratified by body mass index (BMI) percentiles for age/sex: lower BMI (<85th BMI percentile; N=2071) vs. higher BMI (>/=85th percentile; N=1594). RESULTS: Among lower-BMI participants, both NHANES and WHO WHtR were associated (p<0.005) with all CMRFs except blood pressure. Among higher-BMI participants, both NHANES and WHO WHtR were associated (p<0.05) with all CMRFs. WHO WHtR was more strongly associated (p<0.05) than NHANES WHtR with triglycerides, non-HDL cholesterol, and systolic blood pressure in lower-BMI participants. Among high-BMI participants, WHO WHtR was more strongly associated (p<0.05) than NHANES WHtR with triglycerides and systolic blood pressure. CONCLUSION: Among youth with diabetes, WHtR calculated from either WC protocol captures cardiometabolic risk. The WHO WC protocol may be preferable to NHANES WC.

      7. Evaluating a modular decision support application for colorectal cancer screening
        Militello LG, Diiulio JB, Borders MR, Sushereba CE, Saleem JJ, Haverkamp D, Imperiale TF.
        Appl Clin Inform. 2017 Feb 15;8(1):162-179.
        BACKGROUND: There is a need for health information technology evaluation that goes beyond randomized controlled trials to include consideration of usability, cognition, feedback from representative users, and impact on efficiency, data quality, and clinical workflow. This article presents an evaluation illustrating one approach to this need using the Decision-Centered Design framework. OBJECTIVE: To evaluate, through a Decision-Centered Design framework, the ability of the Screening and Surveillance App to support primary care clinicians in tracking and managing colorectal cancer testing. METHODS: We leveraged two evaluation formats, online and in-person, to obtain feedback from a range primary care clinicians and obtain comparative data. Both the online and in-person evaluations used mock patient data to simulate challenging patient scenarios. Primary care clinicians responded to a series of colorectal cancer-related questions about each patient and made recommendations for screening. We collected data on performance, perceived workload, and usability. Key elements of Decision-Centered Design include evaluation in the context of realistic, challenging scenarios and measures designed to explore impact on cognitive performance. RESULTS: Comparison of means revealed increases in accuracy, efficiency, and usability and decreases in perceived mental effort and workload when using the Screening and Surveillance App. CONCLUSION: The results speak to the benefits of using the Decision-Centered Design approach in the analysis, design, and evaluation of Health Information Technology. Furthermore, the Screening and Surveillance App shows promise for filling decision support gaps in current electronic health records.

      8. Cancer screening test use - United States, 2015
        White A, Thompson TD, White MC, Sabatino SA, de Moor J, Doria-Rose PV, Geiger AM, Richardson LC.
        MMWR Morb Mortal Wkly Rep. 2017 Mar 03;66(8):201-206.
        Healthy People 2020 (HP2020) includes objectives to increase screening for breast, cervical, and colorectal cancer as recommended by the U.S. Preventive Services Task Force (USPSTF). Progress toward meeting these objectives is monitored by measuring cancer screening test use against national targets using data from the National Health Interview Survey (NHIS). Analysis of 2015 NHIS data indicated that screening test use remains substantially below HP2020 targets for selected cancer screening tests. Although colorectal cancer screening test use increased from 2000 to 2015, no improvements in test use were observed for breast and cervical cancer screening. Disparities exist in screening test use by race/ethnicity, socioeconomic status, and health care access indicators. Increased measures to implement evidence-based interventions and conduct targeted outreach are needed if the HP2020 targets for cancer screening are to be achieved and the disparities in screening test use are to be reduced.

    • Communicable Diseases RSS Word feed
      1. Clostridium difficile infection among US emergency department patients with diarrhea and no vomiting
        Abrahamian FM, Talan DA, Krishnadasan A, Citron DM, Paulick AL, Anderson LJ, Goldstein EJ, Moran GJ.
        Ann Emerg Med. 2017 Feb 24.
        STUDY OBJECTIVE: The incidence of Clostridium difficile infection has increased and has been observed among persons from the community who have not been exposed to antibiotics or health care settings. Our aims are to determine prevalence of C difficile infection among emergency department (ED) patients with diarrhea and the prevalence among patients without traditional risk factors. METHODS: We conducted a prospective observational study of patients aged 2 years or older with diarrhea (>/=3 episodes/24 hours) and no vomiting in 10 US EDs (2010 to 2013). We confirmed C difficile infection by positive stool culture result and toxin assay. C difficile infection risk factors were antibiotic use or overnight health care stay in the previous 3 months or previous C difficile infection. We typed strains with pulsed-field gel electrophoresis. RESULTS: Of 422 participants, median age was 46 years (range 2 to 94 years), with median illness duration of 3.0 days and 43.4% having greater than or equal to 10 episodes of diarrhea during the previous 24 hours. At least one risk factor for C difficile infection was present in 40.8% of participants; 25.9% were receiving antibiotics, 26.9% had health care stay within the previous 3 months, and 3.3% had previous C difficile infection. Forty-three participants (10.2%) had C difficile infection; among these, 24 (55.8%) received antibiotics and 19 (44.2%) had health care exposure; 17 of 43 (39.5%) lacked any risk factor. Among participants without risk factors, C difficile infection prevalence was 6.9%. The most commonly identified North American pulsed-field gel electrophoresis (NAP) strains were NAP type 1 (23.3%) and NAP type 4 (16.3%). CONCLUSION: Among mostly adults presenting to US EDs with diarrhea and no vomiting, C difficile infection accounted for approximately 10%. More than one third of patients with C difficile infection lacked traditional risk factors for the disease. Among participants without traditional risk factors, prevalence of C difficile infection was approximately 7%.

      2. Acute respiratory infections among returning Hajj pilgrims-Jordan, 2014
        Al-Abdallat MM, Rha B, Alqasrawi S, Payne DC, Iblan I, Binder AM, Haddadin A, Nsour MA, Alsanouri T, Mofleh J, Whitaker B, Lindstrom SL, Tong S, Ali SS, Dahl RM, Berman L, Zhang J, Erdman DD, Gerber SI.
        J Clin Virol. 2017 Feb 08;89:34-37.
        BACKGROUND: The emergence of Middle East Respiratory Syndrome coronavirus (MERS-CoV) has prompted enhanced surveillance for respiratory infections among pilgrims returning from the Hajj, one of the largest annual mass gatherings in the world. OBJECTIVES: To describe the epidemiology and etiologies of respiratory illnesses among pilgrims returning to Jordan after the 2014 Hajj. STUDY DESIGN: Surveillance for respiratory illness among pilgrims returning to Jordan after the 2014 Hajj was conducted at sentinel health care facilities using epidemiologic surveys and molecular diagnostic testing of upper respiratory specimens for multiple respiratory pathogens, including MERS-CoV. RESULTS: Among the 125 subjects, 58% tested positive for at least one virus; 47% tested positive for rhino/enterovirus. No cases of MERS-CoV were detected. CONCLUSIONS: The majority of pilgrims returning to Jordan from the 2014 Hajj with respiratory illness were determined to have a viral etiology, but none were due to MERS-CoV. A greater understanding of the epidemiology of acute respiratory infections among returning travelers to other countries after Hajj should help optimize surveillance systems and inform public health response practices.

      3. Prevalence of internalized HIV-related stigma among HIV-infected adults in care, United States, 2011-2013
        Baugher AR, Beer L, Fagan JL, Mattson CL, Freedman M, Skarbinski J, Shouse RL.
        AIDS Behav. 2017 Feb 14.
        HIV-infected U.S. adults have reported internalized HIV-related stigma; however, the national prevalence of stigma is unknown. We sought to determine HIV-related stigma prevalence among adults in care, describe which socio-demographic groups bear the greatest stigma burden, and assess the association between stigma and sustained HIV viral suppression. The Medical Monitoring Project measures characteristics of U.S. HIV-infected adults receiving care using a national probability sample. We used weighted data collected from June 2011 to May 2014 and assessed self-reported internalized stigma based on agreement with six statements. Overall, 79.1% endorsed >/=1 HIV-related stigma statements (n = 13,841). The average stigma score was 2.4 (out of a possible high score of six). White males had the lowest stigma scores while Hispanic/Latina females and transgender persons who were multiracial or other race had the highest. Although stigma was associated with viral suppression, it was no longer associated after adjusting for age. Stigma was common among HIV-infected adults in care. Results suggest individual and community stigma interventions may be needed, particularly among those who are <50 years old or Hispanic/Latino. Stigma was not independently associated with viral suppression; however, this sample was limited to adults in care. Examining HIV-infected persons not in care may elucidate stigma's association with viral suppression.

      4. Environmental factors associated with childhood norovirus diarrhoea in Leon, Nicaragua
        Becker-Dreps S, Cuthbertson CC, Bucardo F, Vinje J, Paniagua M, Giebultowicz S, Espinoza F, Emch M.
        Epidemiol Infect. 2017 Feb 28:1-9.
        Norovirus is detected in one in five diarrhoea episodes in children, yet little is known about environmental risk factors associated with this disease, especially in low-income settings. The objective of this study was to examine environmental risk factors, and spatial and seasonal patterns of norovirus diarrhoea episodes in children in Leon, Nicaragua. We followed a population-based cohort of children under age 5 years for norovirus diarrhoea over a 1-year period. At baseline, characteristics of each household were recorded. Households were geocoded and spatial locations of garbage dumps, rivers, and markets were collected. In bivariate analysis we observed younger children and those with animals in their households were more likely to have experienced norovirus episodes. In adjusted models, younger children remained at higher risk for norovirus episodes, but only modest associations were observed with family and environmental characteristics. We next identified symptomatic children living in the same household and within 500 m buffer zones around the household of another child infected with the same genotype. Norovirus diarrhoea episodes peaked early in the rainy season. These findings contribute to our understanding of environmental factors and norovirus infection.

      5. Trends in racial and ethnic disparities in antiretroviral therapy prescription and viral suppression in the United States, 2009-2013
        Beer L, Bradley H, Mattson CL, Johnson CH, Hoots B, Shouse RL.
        J Acquir Immune Defic Syndr. 2016 Dec 01;73(4):446-453.
        OBJECTIVES: To examine trends in racial/ethnic disparities in antiretroviral therapy (ART) prescription and viral suppression among HIV-infected persons in care, overall and among men who have sex with men (MSM), from 2009 to 2013. DESIGN: The Medical Monitoring Project (MMP) is a complex sample survey of HIV-infected adults receiving medical care in the United States. METHODS: We used weighted interview and medical record data collected June 2009-May 2014 to estimate the prevalence of ART prescription and viral suppression among racial/ethnic groups overall and among MSM. RESULTS: We found significant increases in ART prescription and viral suppression among all racial/ethnic groups from 2009 to 2013, both overall and among MSM. By 2013, overall and among MSM, the Hispanic-white disparity in ART prescription was nonexistent, and the black-white disparity was not significant after accounting for differences between blacks and whites in age and length of HIV diagnosis. Despite reductions in racial/ethnic disparities in viral suppression over the time period, significant disparities remained among the total population, even after adjusting for differences in racial/ethnic group characteristics. Encouragingly, however, there was no significant Hispanic-white disparity in viral suppression among MSM by 2013. CONCLUSIONS: Despite significant improvements in ART prescription and viral suppression in recent years, racial and ethnic disparities persist, particularly for black persons. If the United States is to achieve the National HIV/AIDS Strategy goal of reducing HIV-related health disparities, continued efforts to accelerate the rate of improvement in ART prescription and viral suppression among Hispanic and black persons may need to be prioritized.

      6. Keeping it in the family: The childhood burden of tuberculosis
        Chorba T, Jereb J.
        Emerg Infect Dis. 2017 ;23(3):561-562.
        [No abstract]

      7. Reduced susceptibility to cefixime but not ceftriaxone: an uncertain perspective for the treatment of gonorrhoea in Brazil
        da Costa Lourenco AP, Abrams AJ, Bastos Dos Santos KT, Coelho Souza T, Moreira BM, Fracalanzza SE, Trees D, Bonelli RR.
        Int J Antimicrob Agents. 2017 Feb 21.
        [No abstract]

      8. Decline in HIV seroprevalence in street youth 2006-2012, St. Petersburg, Russia: moving toward an AIDS-free generation
        Kornilova MS, Batluk JV, Yorick RV, Baughman AL, Hillis SD, Vitek CR.
        Int J STD AIDS. 2017 Mar;28(4):345-356.
        A 2006 survey of street youth at pre-mapped street youth locations in St. Petersburg, Russia, found extremely high HIV seroprevalence (37.4%) among 313 street youth aged 15-19 years of age, strongly associated with injection drug use, which was reported by 50.6% of participants. In response, multi-sectoral social support and prevention measures were instituted. In 2012, we conducted a follow-up survey of 15- to 19-year-old street youth using the same study procedures as in 2006. Of 311 participants, 45 (14.5%) reported injection drug use; 31 participants (10.0%, 95% confidence interval, 6.0%-16.2%) were HIV-seropositive . Predictors independently associated with HIV seropositivity included injection drug use (adjusted prevalence ratio 53.1) and transactional sex (adjusted prevalence ratio 1.3). None of the 178 participants aged 15-17 years were HIV-positive. Thirty of 31 (96.8%) HIV-seropositive individuals reported injection drug use. Street youth in St Petersburg had a 73% decrease in HIV seroprevalence from 2006 to 2012, primarily due to decreased initiation of injection drug use. This marked reduction in the HIV epidemic among street youth occurred after implementation of extensive support programs and socio-economic improvements.

      9. Continued endemic wild poliovirus transmission in security-compromised areas - Nigeria, 2016
        Nnadi C, Damisa E, Esapa L, Braka F, Waziri N, Siddique A, Jorba J, Nganda GW, Ohuabunwo C, Bolu O, Wiesen E, Adamu U.
        MMWR Morb Mortal Wkly Rep. 2017 Feb 24;66(7):190-193.
        On August 10, 2016, 2 years after the most recent wild poliovirus (WPV) case was reported in Nigeria (in July 2014), two WPV cases were reported in the northeastern state of Borno, which has been severely affected by insurgency-related insecurity since 2013. On September 9 and 26, 2016, two additional WPV cases were reported in Borno in children whose families migrated from security-compromised, inaccessible areas of the state. All four cases were WPV serotype 1 (WPV1), with genetic differences indicating prolonged undetected transmission. A large-scale emergency response plan was developed and implemented. The plan initially called for vaccination of 815,791 children during August 15-18 in five local government areas (LGAs) in the immediate vicinity of the first two WPV cases. Subsequently, the plan was expanded to regionally synchronized supplementary immunization activities (SIAs), conducted during August 27-December 6 in five Lake Chad basin countries at increased risk for national and regional WPV1 transmission (Cameroon, Central African Republic, Chad, Niger, and Nigeria). In addition, retrospective searches for missed cases of acute flaccid paralysis (AFP), enhanced environmental surveillance for polioviruses, and polio surveillance system reviews were conducted. Prolonged undetected WPV1 transmission in Borno State is a consequence of low population immunity and severe surveillance limitations associated with insurgency-related insecurity and highlights the risk for local and international WPV spread. Increasing polio vaccination coverage and implementing high-quality polio surveillance, especially among populations in newly secured and difficult-to-access areas in Borno and other Lake Chad basin areas are urgently needed.

      10. Comparison of sputum-culture conversion for Mycobacterium bovis and M. tuberculosis
        Scott C, Cavanaugh JS, Silk BJ, Ershova J, Mazurek GH, LoBue PA, Moonan PK.
        Emerg Infect Dis. 2017 Mar;23(3):456-462.
        Current US guidelines recommend longer treatment for tuberculosis (TB) caused by pyrazinamide-resistant organisms (e.g., Mycobacterium bovis) than for M. tuberculosis TB. We compared treatment response times for patients with M. bovis TB and M. tuberculosis TB reported in the United States during 2006-2013. We included culture-positive, pulmonary TB patients with genotyping results who received standard 4-drug treatment at the time of diagnosis. Time to sputum-culture conversion was defined as time between treatment start date and date of first consistently culture-negative sputum. We analyzed 297 case-patients with M. bovis TB and 30,848 case-patients with M. tuberculosis TB. After 2 months of treatment, 71% of M. bovis and 65% of M. tuberculosis TB patients showed conversion of sputum cultures to negative. Likelihood of culture conversion was higher for M. bovis than for M. tuberculosis, even after controlling for treatment administration type, sex, and a composite indicator of bacillary burden.

      11. Molecular, spatial, and field epidemiology suggesting TB transmission in community, not hospital, Gaborone, Botswana
        Surie D, Fane O, Finlay A, Ogopotse M, Tobias JL, Click ES, Modongo C, Zetola NM, Moonan PK, Oeltmann JE.
        Emerg Infect Dis. 2017 Mar;23(3):487-490.
        During 2012-2015, 10 of 24 patients infected with matching genotypes of Mycobacterium tuberculosis received care at the same hospital in Gaborone, Botswana. Nosocomial transmission was initially suspected, but we discovered plausible sites of community transmission for 20 (95%) of 21 interviewed patients. Active case-finding at these sites could halt ongoing transmission.

    • Disease Reservoirs and Vectors RSS Word feed
      1. Toxicological, enzymatic, and molecular assessment of the insecticide susceptibility profile of Triatoma infestans (Hemiptera: Reduviidae, Triatominae) populations from rural communities of Santa Cruz, Bolivia
        Santo-Orihuela PL, Vassena CV, Carvajal G, Clark E, Menacho S, Bozo R, Gilman RH, Bern C, Marcet PL.
        J Med Entomol. 2016 Dec 22.
        A wide range of insecticide resistance profiles has been reported across Bolivian domestic and sylvatic populations of Triatoma infestans (Klug, 1834) (Hemiptera, Reduviidae), including some with levels proven to be a threat for vector control. In this work, the insecticide profile of domestic T. infestans was studied with standardized toxicological bioassays, in an area that has not undergone consistent vector control. F1 first-instar nymphs hatched in laboratory from bugs captured in three communities from the Santa Cruz Department were evaluated with different insecticides. Moreover, the enzymatic activity of esterases and cytochrome P450 monooxygenases was measured in individual insects to evaluate the possible mechanism of metabolic resistance to pyrethroids. In addition, the DNA sequence of sodium channel gene (kdr) was screened for two point mutations associated with pyrethroid resistance previously reported in T. infestansAll populations showed reduced susceptibility to deltamethrin and alpha-cypermethrin, albeit the RR50 values varied significantly among them. Increased P450 monooxygenases and permethrate esterases suggest the contribution, as detoxifying mechanisms, to the observed resistance to deltamethrin in all studied populations. No individuals presented either mutation associated to resistance in the kdr gene. The level of susceptibility to alpha-cypermethrin, the insecticide used by the local vector control program, falls within an acceptable range to continue its use in these populations. However, the observed RR50 values evidence the possibility of selection for resistance to pyrethroids, especially to deltamethrin. Consequently, the use of pyrethroid insecticides should be closely monitored in these communities, which should be kept under entomological surveillance and sustained interventions.

    • Drug Safety RSS Word feed
      1. Surveillance systems and methods for monitoring the post-marketing safety of influenza vaccines at the Centers for Disease Control and Prevention
        Moro PL, Li R, Haber P, Weintraub E, Cano M.
        Expert Opin Drug Saf. 2016 Sep;15(9):1175-83.
        INTRODUCTION: Annual influenza vaccine safety monitoring is an important component of the influenza vaccination program in the United States to ensure that vaccines are safe, which is important for maintaining public trust in the national vaccination program. This is specially the case for influenza vaccines since the antigen composition of the viruses of which the vaccine is made often changes from one season to the next, based on the circulating strain of influenza virus. AREAS COVERED: This review describes the two surveillance systems used by the Centers for Disease Control and Prevention (CDC) to monitor the safety of influenza vaccines: 1) the Vaccine Adverse Event Reporting System (VAERS); and 2) the Vaccine Safety datalink (VSD). EXPERT OPINION: VAERS and VSD are used routinely to monitor the safety of influenza vaccines in the United States, and over the years they have demonstrated their value in monitoring vaccine safety since their implementation in 1990. Both systems, although different, complemented each other well to study febrile seizures in young children following influenza vaccination during the 2010-2011 influenza season. Other examples of potential safety concerns after influenza vaccines are also presented and discussed.

    • Environmental Health RSS Word feed
      1. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers - United States, 2011-2014
        Santos C, Kieszak S, Wang A, Law R, Schier J, Wolkin A.
        MMWR Morb Mortal Wkly Rep. 2017 Mar 03;66(8):223-226.
        Hand sanitizers are effective and inexpensive products that can reduce microorganisms on the skin, but ingestion or improper use can be associated with health risks. Many hand sanitizers contain up to 60%-95% ethanol or isopropyl alcohol by volume, and are often combined with scents that might be appealing to young children. Recent reports have identified serious consequences, including apnea, acidosis, and coma in young children who swallowed alcohol-based (alcohol) hand sanitizer. Poison control centers collect data on intentional and unintentional exposures to hand sanitizer solutions resulting from various routes of exposure, including ingestion, inhalation, and dermal and ocular exposures. To characterize exposures of children aged </=12 years to alcohol hand sanitizers, CDC analyzed data reported to the National Poison Data System (NPDS). The major route of exposure to both alcohol and nonalcohol-based (nonalcohol) hand sanitizers was ingestion. The majority of intentional exposures to alcohol hand sanitizers occurred in children aged 6-12 years. Alcohol hand sanitizer exposures were associated with worse outcomes than were nonalcohol hand sanitizer exposures. Caregivers and health care providers should be aware of the potential dangers associated with hand sanitizer ingestion. Children using alcohol hand sanitizers should be supervised and these products should be kept out of reach from children when not in use.

    • Food Safety RSS Word feed
      1. Outbreaks of disease associated with food imported into the United States, 1996-2014
        Gould LH, Kline J, Monahan C, Vierk K.
        Emerg Infect Dis. 2017 Mar;23(3):525-528.
        The proportion of US food that is imported is increasing; most seafood and half of fruits are imported. We identified a small but increasing number of foodborne disease outbreaks associated with imported foods, most commonly fish and produce. New outbreak investigation tools and federal regulatory authority are key to maintaining food safety.

      2. Diarrhoeal disease in children due to contaminated food
        Kirk MD, Angulo FJ, Havelaar AH, Black RE.
        Bull World Health Organ. 2017 Mar 01;95(3):233-234.
        [No abstract]

    • Genetics and Genomics RSS Word feed
      1. Complete genome sequence of Mycoplasma pneumoniae type 2 reference strain FH using single-molecule real-time sequencing technology
        Desai HP, Morrison SS, Diaz MH, Benitez AJ, Wolff BJ, Winchell JM.
        Genome Announc. 2017 Feb 23;5(8).
        Mycoplasma pneumoniae type 2 strain FH was previously sequenced with Illumina (FH-Illumina) and 454 (FH-454) technologies according to Xiao et al. (2015) and Krishnakumar et al. (2010). Comparative analyses revealed differences in genomic content between these sequences, including a 6-kb region absent from the FH-454 submission. Here, we present a complete genome sequence of FH sequenced with the Pacific Biosciences RSII platform.

      2. Genomic changes associated with the evolutionary transition of an insect gut symbiont into a blood-borne pathogen
        Segers FH, Kesnerova L, Kosoy M, Engel P.
        ISME J. 2017 Feb 24.
        The genus Bartonella comprises facultative intracellular bacteria with a unique lifestyle. After transmission by blood-sucking arthropods they colonize the erythrocytes of mammalian hosts causing acute and chronic infectious diseases. Although the pathogen-host interaction is well understood, little is known about the evolutionary origin of the infection strategy manifested by Bartonella species. Here we analyzed six genomes of Bartonella apis, a honey bee gut symbiont that to date represents the closest relative of pathogenic Bartonella species. Comparative genomics revealed that B. apis encodes a large set of vertically inherited genes for amino acid and cofactor biosynthesis and nitrogen metabolism. Most pathogenic bartonellae have lost these ancestral functions, but acquired specific virulence factors and expanded a vertically inherited gene family for harvesting cofactors from the blood. However, the deeply rooted pathogen Bartonella tamiae has retained many of the ancestral genome characteristics reflecting an evolutionary intermediate state toward a host-restricted intraerythrocytic lifestyle. Our findings suggest that the ancestor of the pathogen Bartonella was a gut symbiont of insects and that the adaptation to blood-feeding insects facilitated colonization of the mammalian bloodstream. This study highlights the importance of comparative genomics among pathogens and non-pathogenic relatives to understand disease emergence within an evolutionary-ecological framework.The ISME Journal advance online publication, 24 February 2017; doi:10.1038/ismej.2016.201.

      3. Genome sequences of three Brucella canis strains isolated from humans and a dog
        Viana MV, Wattam AR, Govil Batra D, Boisvert S, Brettin TS, Frace M, Xia F, Azevedo V, Tiller R, Hoffmaster AR.
        Genome Announc. 2017 Feb 23;5(8).
        Brucella canis is a facultative intracellular pathogen that preferentially infects members of the Canidae family. Here, we report the genome sequencing of two Brucella canis strains isolated from humans and one isolated from a dog host.

    • Health Disparities RSS Word feed
      1. A comprehensive analysis of the mortality experience of Hispanic subgroups in the United States: Variation by age, country of origin, and nativity
        Fenelon A, Chinn JJ, Anderson RN.
        SSM - Population Health. 2017 ;3:245-254.
        Although those identifying as "Hispanic or Latino" experience lower adult mortality than the more socioeconomically advantaged non-Hispanic white population, the ethnic category Hispanic conceals variation by country of origin, nativity, age, and immigration experience. The current analysis examines adult mortality differentials among 12 Hispanic subgroups by region of origin and nativity, and non-Hispanic whites, adjusting for socioeconomic and demographic characteristics. We use the National Health Interview Survey Linked Mortality Files pooled 1990-2009 to obtain sufficient sample of each subgroup to calculate mortality estimates by sex and age group (25-64, 65+). Among adults aged 65 and over, all foreign born subgroups have an advantage over non-Hispanic whites, and many USB subgroups exhibit an advantage in the adjusted model. Foreign-born Dominicans, Central/South Americans, and other Hispanics exhibit consistent advantages across models for both men and women, aged 25-64 and 65 and over, and both unadjusted and adjusted for socioeconomic covariates. Both US-born and foreign-born Mexicans between ages 25 and 64 have mortality disadvantaged relative to non-Hispanic whites, while older Mexicans exhibit clear advantages. Our results complicate the traditional formulation of the Hispanic Paradox and cast doubt on the singularity of the mortality experience of those of Hispanic origin.

      2. Health risk behaviors by length of time in the United States among high school students in five sites
        Jones SE, Pezzi C, Rodriguez-Lainz A, Whittle L.
        J Immigr Minor Health. 2016 Feb;18(1):150-60.
        One in five public school students is from an immigrant-headed household. We used Youth Risk Behavior Survey data from one state and four large urban school districts to examine whether length of time living in the US was associated with health risk behaviors. Logistic regression models, using weighted data, controlled for sex, race/ethnicity, and grade. Compared to US natives, not having always lived in the US was correlated with lower risk for some behaviors (e.g., current marijuana use and alcohol use) among high school students, but higher risk for other behaviors (e.g., attempted suicide, physical inactivity). Many findings were inconsistent across the study sites. Interventions that specifically target recently-arrived school-aged youth to prevent behaviors that put health and safety at risk, may result in the best outcomes for immigrant youth. Care should be taken to understand the specific health risks present in different immigrant communities.

    • Health Economics RSS Word feed
      1. Chronic health outcomes and prescription drug copayments in Medicaid
        Kostova D, Fox J.
        Med Care. 2017 Feb 23.
        BACKGROUND: Prescription drug copayments and cost-sharing have been linked to reductions in prescription drug use and expenditures. However, little is known about their effect on specific health outcomes. OBJECTIVE: To evaluate the association between prescription drug copayments and uncontrolled hypertension, uncontrolled hypercholesterolemia, and prescription drug utilization among Medicaid beneficiaries with these conditions. SUBJECTS: Select adults aged 20-64 from NHANES 1999-2012 in 18 states. MEASURES: Uncontrolled hypertension, uncontrolled hypercholesterolemia, and taking medication for each of these conditions. RESEARCH DESIGN: A differencing regression model was used to evaluate health outcomes among Medicaid beneficiaries in 4 states that introduced copayments during the study period, relative to 2 comparison groups-Medicaid beneficiaries in 14 states unaffected by shifts in copayment policy, and a within-state counterfactual group of low-income adults not on Medicaid, while controlling for individual demographic factors and unobserved state-level characteristics. RESULTS: Although uncontrolled hypertension and hypercholesterolemia declined among all low-income persons during the study period, the trend was less pronounced in Medicaid beneficiaries affected by copayments. After netting out concurrent trends in health outcomes of low-income persons unaffected by Medicaid copayment changes, we estimated that introduction of drug copayments in Medicaid was associated with an average rise in uncontrolled hypertension and uncontrolled hypercholesterolemia of 7.7 and 13.2 percentage points, respectively, and with reduced drug utilization for hypercholesterolemia. CONCLUSIONS: As Medicaid programs change in the years following the Affordable Care Act, prescription drug copayments may play a role as a lever for controlling hypertension and hypercholesterolemia at the population level.

    • Healthcare Associated Infections RSS Word feed
      1. Three cases of neurologic syndrome caused by donor-derived microsporidiosis
        Smith RM, Muehlenbachs A, Schaenmann J, Baxi S, Koo S, Blau D, Chin-Hong P, Thorner AR, Kuehnert MJ, Wheeler K, Liakos A, Jackson JW, Benedict T, da Silva AJ, Ritter JM, Rollin D, Metcalfe M, Goldsmith CS, Visvesvara GS, Basavaraju SV, Zaki S.
        Emerg Infect Dis. 2017 Mar;23(3):387-395.
        In April 2014, a kidney transplant recipient in the United States experienced headache, diplopia, and confusion, followed by neurologic decline and death. An investigation to evaluate the possibility of donor-derived infection determined that 3 patients had received 4 organs (kidney, liver, heart/kidney) from the same donor. The liver recipient experienced tremor and gait instability; the heart/kidney and contralateral kidney recipients were hospitalized with encephalitis. None experienced gastrointestinal symptoms. Encephalitozoon cuniculi was detected by tissue PCR in the central nervous system of the deceased kidney recipient and in renal allograft tissue from both kidney recipients. Urine PCR was positive for E. cuniculi in the 2 surviving recipients. Donor serum was positive for E. cuniculi antibodies. E. cuniculi was transmitted to 3 recipients from 1 donor. This rare presentation of disseminated disease resulted in diagnostic delays. Clinicians should consider donor-derived microsporidial infection in organ recipients with unexplained encephalitis, even when gastrointestinal manifestations are absent.

    • Immunity and Immunization RSS Word feed
      1. Risk factors and familial clustering for fever 7-10 days after the first dose of measles vaccines
        Klein NP, Lewis E, McDonald J, Fireman B, Naleway A, Glanz J, Jackson LA, Donahue JG, Jacobsen SJ, Weintraub E, Baxter R.
        Vaccine. 2017 Feb 20.
        BACKGROUND: Seven to ten days after a first dose of a measles-containing vaccine (MCV; i.e., MMR or MMRV), children have elevated fever risk which can be associated with febrile seizures. This study investigated individual and familial factors associated with fever 7-10days after MCV. METHODS: Retrospective cohort study among children who were <36months of age at receipt of MCV in six sites of the Vaccine Safety Datalink from 1/1/2000 to 12/31/2012. We evaluated medically-attended clinic or emergency department visits with a code for fever 7-10days after any MCV ("MCV- associated"). We evaluated factors associated with MCV-associated fever using chi2 and multivariable logistic regression analyses. RESULTS: Among 946,806 children vaccinated with MCV, we identified 7480 (0.8%) MCV-associated fever visits. Compared with children without fever after MCV, children with MCV-associated fever were more likely to have received MMRV than MMR (OR 1.3 95% CI 1.2, 1.5), have had medically attended fever both following previous vaccines (OR 1.3 95% CI 1.1, 1.6) and at any other previous time (OR 1.7 95% CI 1.6, 1.8), have had at least 1 prior seizure (OR 2.2 95% CI 1.7, 2.7), and have had >3 medical visits within the 6months before MCV (OR 1.7 95% CI 1.6, 1.8). In families with multiple MCV-immunized children, after adjusting for healthcare seeking behavior care for fever, those whose siblings had MCV-associated fever were more likely to also have MCV-associated fever (OR 3.5 95% CI 2.5, 4.8). DISCUSSION: Children who received MMRV vaccine or who had prior medically-attended fevers and seizures during the first year of life had increased risk of fever after a first dose of measles vaccine. After adjusting for familial propensity to seek care, MCV-associated fever still clustered within families, suggesting a possible genetic basis for susceptibility to developing fever due to measles vaccines.

      2. Response to a large polio outbreak in a setting of conflict - Middle East, 2013-2015
        Mbaeyi C, Ryan MJ, Smith P, Mahamud A, Farag N, Haithami S, Sharaf M, Jorba JC, Ehrhardt D.
        MMWR Morb Mortal Wkly Rep. 2017 Mar 03;66(8):227-231.
        As the world advances toward the eradication of polio, outbreaks of wild poliovirus (WPV) in polio-free regions pose a substantial risk to the timeline for global eradication. Countries and regions experiencing active conflict, chronic insecurity, and large-scale displacement of persons are particularly vulnerable to outbreaks because of the disruption of health care and immunization services. A polio outbreak occurred in the Middle East, beginning in Syria in 2013 with subsequent spread to Iraq. The outbreak occurred 2 years after the onset of the Syrian civil war, resulted in 38 cases, and was the first time WPV was detected in Syria in approximately a decade. The national governments of eight countries designated the outbreak a public health emergency and collaborated with partners in the Global Polio Eradication Initiative (GPEI) to develop a multiphase outbreak response plan focused on improving the quality of acute flaccid paralysis (AFP) surveillance and administering polio vaccines to >27 million children during multiple rounds of supplementary immunization activities (SIAs). Successful implementation of the response plan led to containment and interruption of the outbreak within 6 months of its identification. The concerted approach adopted in response to this outbreak could serve as a model for responding to polio outbreaks in settings of conflict and political instability.

      3. Shedding of porcine circovirus type 1 DNA and rotavirus RNA by infants vaccinated with Rotarix(R)
        Mijatovic-Rustempasic S, Immergluck LC, Parker TC, Laghaie E, Mohammed A, McFadden T, Parashar UD, Bowen MD, Cortese MM.
        Hum Vaccin Immunother. 2016 Dec 09:0.
        Thirty-three infants aged approximately 2 months had serial stool samples collected after receipt of Rotarix(R) vaccine dose 1, and assessed for shedding of porcine circovirus type 1 DNA and Rotavirus group A RNA by molecular methods. We did not find strong evidence that porcine circovirus type 1 replication occurred. Porcine circovirus type 1 genome with the same sequence as that in Rotarix(R) was detected in a few infants as late as day >/=13; while this timing could suggest there may have been replication and not just transient passage through the gastrointestinal tract, the lack of increase in copy numbers in any infant supports transient passage and there are inherent limitations to the results. We found that 21% of infants did not shed Rotarix(R) RVA RNA beyond the day 3 sample, which may suggest lack of vaccine virus replication. Of the infants in whom Rotarix RVA RNA shedding continued, peak copy numbers were reached on days 3-5 for approximately 40%, and after day 5 in approximately 60%, and shedding can be prolonged (>/=45 days).

      4. Adapting Nepal's polio eradication programme
        Paudel KP, Hampton LM, Gurung S, Bohara R, Rai IK, Anaokar S, Swift RD, Cochi S.
        Bull World Health Organ. 2017 Mar 01;95(3):227-232.
        PROBLEM: Many countries have weak disease surveillance and immunization systems. The elimination of polio creates an opportunity to use staff and assets from the polio eradication programme to control other vaccine-preventable diseases and improve disease surveillance and immunization systems. APPROACH: In 2003, the active surveillance system of Nepal's polio eradication programme began to report on measles and neonatal tetanus cases. Japanese encephalitis and rubella cases were added to the surveillance system in 2004. Staff from the programme aided the development and implementation of government immunization policies, helped launch vaccination campaigns, and trained government staff in reporting practices and vaccine management. LOCAL SETTING: Nepal eliminated indigenous polio in 2000, and controlled outbreaks caused by polio importations between 2005 and 2010. RELEVANT CHANGES: In 2014, the surveillance activities had expanded to 299 sites, with active surveillance for measles, rubella and neonatal tetanus, including weekly visits from 15 surveillance medical officers. Sentinel surveillance for Japanese encephalitis consisted of 132 sites. Since 2002, staff from the eradication programme have helped to introduce six new vaccines and helped to secure funding from Gavi, the Vaccine Alliance. Staff have also assisted in responding to other health events in the country. LESSON LEARNT: By expanding the activities of its polio eradication programme, Nepal has improved its surveillance and immunization systems and increased vaccination coverage of other vaccine-preventable diseases. Continued donor support, a close collaboration with the Expanded Programme on Immunization, and the retention of the polio eradication programme's skilled workforce were important for this expansion.

    • Injury and Violence RSS Word feed
      1. Out-of-hospital triage of older adults with head injury: A retrospective study of the effect of adding "anticoagulation or antiplatelet medication use" as a criterion
        Nishijima DK, Gaona SD, Waechter T, Maloney R, Bair T, Blitz A, Elms AR, Farrales RD, Howard C, Montoya J, Bell JM, Faul M, Vinson DR, Garzon H, Holmes JF, Ballard DW.
        Ann Emerg Med. 2017 Feb 23.
        STUDY OBJECTIVE: Field triage guidelines recommend that emergency medical services (EMS) providers consider transport of head-injured older adults with anticoagulation use to trauma centers. However, the triage patterns and the incidence of intracranial hemorrhage or neurosurgery in these patients are unknown. Our objective is to describe the characteristics and outcomes of older adults with head trauma who are transported by EMS, particularly for patients who do not meet physiologic, anatomic, or mechanism-of-injury (steps 1 to 3) field triage criteria but are receiving anticoagulant or antiplatelet medications. METHODS: This was a retrospective study at 5 EMS agencies and 11 hospitals (4 trauma centers, 7 nontrauma centers). Patients aged 55 years or older with head trauma who were transported by EMS were included. The primary outcome was the presence of intracranial hemorrhage. The secondary outcome was a composite measure of inhospital death or neurosurgery. RESULTS: Of the 2,110 patients included, 131 (6%) had intracranial hemorrhage and 41 (2%) had inhospital death or neurosurgery. There were 162 patients (8%) with steps 1 to 3 criteria. Of the remaining 1,948 patients without steps 1 to 3 criteria, 566 (29%) had anticoagulant or antiplatelet use. Of these patients, 52 (9%) had traumatic intracranial hemorrhage and 15 (3%) died or had neurosurgery. The sensitivity (adjusted for clustering by EMS agency) of steps 1 to 3 criteria was 19.8% (26/131; 95% confidence interval [CI] 5.5% to 51.2%) for identifying traumatic intracranial hemorrhage and 34.1% (14/41; 95% CI 9.9% to 70.1%) for death or neurosurgery. The additional criterion of anticoagulant or antiplatelet use improved the sensitivity for intracranial hemorrhage (78/131; 59.5%; 95% CI 42.9% to 74.2%) and death or neurosurgery (29/41; 70.7%; 95% CI 61.0% to 78.9%). CONCLUSION: Relatively few patients met steps 1 to 3 triage criteria. For individuals who did not have steps 1 to 3 criteria, nearly 30% had anticoagulant or antiplatelet use. A relatively high proportion of these patients had intracranial hemorrhage, but a much smaller proportion died or had neurosurgery during hospitalization. Use of steps 1 to 3 triage criteria alone is not sufficient in identifying intracranial hemorrhage and death or neurosurgery in this patient population. The additional criterion of anticoagulant or antiplatelet use improves the sensitivity of the instrument, with only a modest decrease in specificity.

    • Laboratory Sciences RSS Word feed
      1. Specimen origin, type and testing laboratory are linked to longer turnaround times for HIV viral load testing in Malawi
        Minchella PA, Chipungu G, Kim AA, Sarr A, Ali H, Mwenda R, Nkengasong JN, Singer D.
        PLoS One. 2017 ;12(2):e0173009.
        BACKGROUND: Efforts to reach UNAIDS' treatment and viral suppression targets have increased demand for viral load (VL) testing and strained existing laboratory networks, affecting turnaround time. Longer VL turnaround times delay both initiation of formal adherence counseling and switches to second-line therapy for persons failing treatment and contribute to poorer health outcomes. METHODS: We utilized descriptive statistics and logistic regression to analyze VL testing data collected in Malawi between January 2013 and March 2016. The primary outcomes assessed were greater-than-median pretest phase turnaround time (days elapsed from specimen collection to receipt at the laboratory) and greater-than-median test phase turnaround time (days from receipt to testing). RESULTS: The median number of days between specimen collection and testing increased 3-fold between 2013 (8 days, interquartile range (IQR) = 6-16) and 2015 (24, IQR = 13-39) (p<0.001). Multivariable analysis indicated that the odds of longer pretest phase turnaround time were significantly higher for specimen collection districts without laboratories capable of conducting viral load tests (adjusted odds ratio (aOR) = 5.16; 95% confidence interval (CI) = 5.04-5.27) as well as for Malawi's Northern and Southern regions. Longer test phase turnaround time was significantly associated with use of dried blood spots instead of plasma (aOR = 2.30; 95% CI = 2.23-2.37) and for certain testing months and testing laboratories. CONCLUSION: Increased turnaround time for VL testing appeared to be driven in part by categorical factors specific to the phase of turnaround time assessed. Given the implications of longer turnaround time and the global effort to scale up VL testing, addressing these factors via increasing efficiencies, improving quality management systems and generally strengthening the VL spectrum should be considered essential components of controlling the HIV epidemic.

      2. The use of charcoal in modified cigarette filters for mainstream smoke carbonyl reduction
        Morabito JA, Holman MR, Ding YS, Yan X, Chan M, Chafin D, Perez J, Mendez MI, Cardenas RB, Watson C.
        Regul Toxicol Pharmacol. 2017 Feb 23.
        Carbonyls are harmful and potentially harmful constituents (HPHCs) in mainstream cigarette smoke (MSS). Carbonyls, including formaldehyde and acrolein, are carcinogenic or mutagenic in a dose-dependent manner. Past studies demonstrate significant reduction of HPHCs by charcoal filtration. However, limits of charcoal filtration and cigarette design have not yet been investigated in a systematic manner. Objective data is needed concerning the feasibility of HPHC reduction in combustible filtered cigarettes. This systematic study evaluates the effect of charcoal filtration on carbonyl reduction in MSS. We modified filters of ten popular cigarette products with predetermined quantities (100-400 mg) of charcoal in a plug-space-plug configuration. MSS carbonyls, as well as total particulate matter, tar, nicotine, carbon monoxide (TNCO), and draw resistance were quantified. Significant carbonyl reductions were observed across all cigarette products as charcoal loading increased. At the highest charcoal loadings, carbonyls were reduced by nearly 99%. Tar and nicotine decreased modestly (<20%) compared to reductions in carbonyls. Increased draw resistance was significant at only the highest charcoal loadings. This work addresses information gaps in the science base that can inform the evaluation of charcoal filtration as an available technological adaptation to cigarette design which reduces levels of carbonyls in MSS.

      3. Electroantennogram response of the parasitoid, Microplitis croceipes to host-related odors: The discrepancy between relative abundance and level of antennal responses to volatile compound
        Morawo T, Burrows M, Fadamiro H.
        F1000Res. 2016 ;5:2725.
        Herbivores emit volatile organic compounds (VOCs) after feeding on plants. Parasitoids exploit these VOCs as odor cues to locate their hosts. In nature, host-related odors are emitted as blends of various compounds occurring in different proportions, and minor blend components can sometimes have profound effects on parasitoid responses. In a previous related study, we identified and quantified VOCs emitted by cotton plant-fed Heliothis virescens (Lepidoptera: Noctuidae) larvae, an herbivore host of the parasitoid Microplitis croceipes (Hymenoptera: Braconidae). In the present study, the olfactory response of female M. croceipes to synthetic versions of 15 previously identified compounds was tested in electroantennogram (EAG) bioassays. Using M. croceipes as a model species, we further asked the question: does the relative abundance of a volatile compound match the level of antennal response in parasitoids? Female M. croceipes showed varying EAG responses to test compounds, indicating different levels of bioactivity in the insect antenna. Eight compounds, including decanal, 1-octen-3-ol, 3-octanone, 2-ethylhexanol, tridecane, tetradecane, alpha-farnesene and bisabolene, elicited EAG responses above or equal to the 50 th percentile rank of all responses. Interestingly, decanal, which represented only 1% of the total amount of odors emitted by cotton-fed hosts, elicited the highest (0.82 mV) EAG response in parasitoids. On the other hand, ( E)-beta-caryophyllene, the most abundant (29%) blend component, elicited a relatively low (0.17 mV) EAG response. The results suggest that EAG response to host-related volatiles in parasitoids is probably more influenced by the ecological relevance or functional role of the compound in the blend, rather than its relative abundance.

      4. Burkholderia humptydooensis sp. nov., a new species related to Burkholderia thailandensis and the fifth member of the Burkholderia pseudomallei complex
        Tuanyok A, Mayo M, Scholz H, Hall CM, Allender CJ, Kaestli M, Ginther J, Spring-Pearson S, Bollig MC, Stone JK, Settles EW, Busch JD, Sidak-Loftis L, Sahl JW, Thomas A, Kreutzer L, Georgi E, Gee JE, Bowen RA, Ladner JT, Lovett S, Koroleva G, Palacios G, Wagner DM, Currie BJ, Keim P.
        Appl Environ Microbiol. 2017 Mar 01;83(5).
        During routine screening for Burkholderia pseudomallei from water wells in northern Australia in areas where it is endemic, Gram-negative bacteria (strains MSMB43T, MSMB121, and MSMB122) with a similar morphology and biochemical pattern to B. pseudomallei and B. thailandensis were coisolated with B. pseudomallei on Ashdown's selective agar. To determine the exact taxonomic position of these strains and to distinguish them from B. pseudomallei and B. thailandensis, they were subjected to a series of phenotypic and molecular analyses. Biochemical and fatty acid methyl ester analysis was unable to distinguish B. humptydooensis sp. nov. from closely related species. With matrix-assisted laser desorption ionization-time of flight analysis, all isolates grouped together in a cluster separate from other Burkholderia spp. 16S rRNA and recA sequence analyses demonstrated phylogenetic placement for B. humptydooensis sp. nov. in a novel clade within the B. pseudomallei group. Multilocus sequence typing (MLST) analysis of the three isolates in comparison with MLST data from 3,340 B. pseudomallei strains and related taxa revealed a new sequence type (ST318). Genome-to-genome distance calculations and the average nucleotide identity of all isolates to both B. thailandensis and B. pseudomallei, based on whole-genome sequences, also confirmed B. humptydooensis sp. nov. as a novel Burkholderia species within the B. pseudomallei complex. Molecular analyses clearly demonstrated that strains MSMB43T, MSMB121, and MSMB122 belong to a novel Burkholderia species for which the name Burkholderia humptydooensis sp. nov. is proposed, with the type strain MSMB43T (American Type Culture Collection BAA-2767; Belgian Co-ordinated Collections of Microorganisms LMG 29471; DDBJ accession numbers CP013380 to CP013382).IMPORTANCEBurkholderia pseudomallei is a soil-dwelling bacterium and the causative agent of melioidosis. The genus Burkholderia consists of a diverse group of species, with the closest relatives of B. pseudomallei referred to as the B. pseudomallei complex. A proposed novel species, B. humptydooensis sp. nov., was isolated from a bore water sample from the Northern Territory in Australia. B. humptydooensis sp. nov. is phylogenetically distinct from B. pseudomallei and other members of the B. pseudomallei complex, making it the fifth member of this important group of bacteria.

      5. Recommended test methods and pass/fail criteria for a respirator fit capability test of half-mask air-purifying respirators
        Zhuang Z, Bergman M, Lei Z, Niezgoda G, Shaffer R.
        J Occup Environ Hyg. 2017 :0-0.
        This study assessed key test parameters and pass/fail criteria options for developing a respirator fit capability (RFC) test for half-mask air-purifying particulate respirators. Using a 25-subject test panel, benchmark RFC data were collected for 101 National Institute for Occupational Safety and Health-certified respirator models. These models were further grouped into 61 one-, two- or three-size families. Fit testing was done using a PortaCount Plus with N95-Companion accessory and an Occupational Safety and Health Administration-accepted quantitative fit test protocol. Three repeated tests (donnings) per subject/respirator model combination were performed. The panel passing rate (PPR) (number or percentage of the 25-subject panel achieving acceptable fit) was determined for each model using five different alternative criteria for determining acceptable fit.When the 101 models are evaluated individually (i.e., not grouped by families), the percentages of models capable of fitting > 75% (19/25 subjects) of the panel were 29% and 32% for subjects achieving a fit factor ? 100 for at least one of the first two donnings and at least one of three donnings, respectively. When the models are evaluated grouped into families and using > 75% of panel subjects achieving a fit factor ? 100 for at least one of two donnings as the PPR pass/fail criterion, 48% of all models can pass. When > 50% (13/25 subjects) of panel subjects was the PPR criterion, the percentage of passing models increased to 70%.Testing respirators grouped into families and evaluating the first two donnings for each of two respirator sizes provided the best balance between meeting end user expectations and creating a performance bar for manufacturers. Specifying the test criterion for a subject obtaining acceptable fit as achieving a fit factor ? 100 on at least one out of the two donnings is reasonable because a majority of existing respirator families can achieve an PPR of > 50% using this criterion. The different test criteria can be considered by standards development organizations when developing standards.

    • Maternal and Child Health RSS Word feed
      1. Design of a multisite study assessing the impact of tic disorders on individuals, families, and communities
        Augustine EF, Adams HR, Bitsko RH, van Wijngaarden E, Claussen AH, Thatcher A, Hanks CE, Lewin AB, O'Connor TG, Vierhile A, Danielson ML, Kurlan R, Murphy TK, Mink JW.
        Pediatric Neurology. 2016 .
        Background: Tic disorders, including Tourette syndrome, are complex, multisymptom diseases, yet the impact of these disorders on affected children, families, and communities is not well understood. Methods: To improve the understanding of the impacts of Tourette syndrome, two research groups conducted independent cross-sectional studies using qualitative and quantitative measures. They focused on similar themes, but distinct scientific objectives, and the sites collaborated to align methods of independent research proposals with the aim of increasing the analyzable sample size. Results: Site 1 (University of Rochester) was a Pediatric Neurology referral center. Site 2 (University of South Florida) was a Child Psychiatry referral center. A total of 205 children with tic disorders were enrolled from both studies. The University of Rochester also enrolled 100 control children in order to clearly isolate impacts of Tourette syndrome distinct from those occurring in the general population. The majority of children with tic disorders (n = 191, 93.1%) had Tourette syndrome, the primary population targeted for these studies. Children with Tourette syndrome were similar across sites in terms of tic severity and the occurrence of comorbid conditions. The occurrence of psychiatric comorbidities in the control group was comparable with that in the general pediatric population of the United States, making this a well-justified comparison group. Conclusions: Through collaboration, two sites conducting independent research developed convergent research methods to enable pooling of data, and by extension increased power, for future analyses. This method of collaboration is a novel model for future epidemiological research of tic disorders.

      2. Technological journey from colorimetric to tandem mass spectrometric measurements in the diagnostic investigation for phenylketonuria
        Chace DH, Hannon WH.
        J Inborn Errors Metab Screen. 2016 ;4(no pagination).
        Phenylalanine analysis for phenylketonuria (PKU) detection in newborn screening (NBS) was chosen as the model system to describe how advancements in laboratory technology improved laboratory performance. These advancements have made NBS programs better and have improved the health outcomes of the affected newborn through improvements in accurate early detection over the past 50 years. The most current state-of-the-art technology, tandem mass spectrometry (MS/MS), has proven that it is now the choice in almost all modern NBS facilities because it is a versatile instrument that continues to grow in its application not just for amino acid and acylcarnitine detection but for other metabolites and disorders such as lysosomal storage diseases and second-tier detection of some screen-positive results. The use of MS/MS will continue to expand, even with the anticipated introduction and expansion of molecular screening methods into NBS programs. Regarding technological advancements, the future of NBS will include even newer technologies and approaches that will enhance the detection and treatment of newborns affected by PKU and other inborn errors of metabolism.

      3. Newborn screening quality assurance program for CFTR mutation detection and gene sequencing to identify cystic fibrosis
        Hendrix MM, Foster SL, Cordovado SK.
        J Inborn Errors Metab Screen. 2016 ;4.
        All newborn screening laboratories in the United States and many worldwide screen for cystic fibrosis. Most laboratories use a second-tier genotyping assay to identify a panel of mutations in the CF transmembrane regulator (CFTR) gene. Centers for Disease Control and Prevention's Newborn Screening Quality Assurance Program houses a dried blood spot repository of samples containing CFTR mutations to assist newborn screening laboratories and ensure high-quality mutation detection in a highthroughput environment. Recently, CFTR mutation detection has increased in complexity with expanded genotyping panels and gene sequencing. To accommodate the growing quality assurance needs, the repository samples were characterized with several multiplex genotyping methods, Sanger sequencing, and 3 next-generation sequencing assays using a high-throughput, lowconcentration DNA extraction method. The samples performed well in all of the assays, providing newborn screening laboratories with a resource for complex CFTR mutation detection and next-generation sequencing as they transition to new methods.

      4. Screening and treatment for iron deficiency anemia in women: Results of a survey of obstetrician-gynecologists
        Marcewicz LH, Anderson BL, Byams VR, Grant AM, Schulkin J.
        Matern Child Health J. 2017 Feb 27.
        Objective To better understand the knowledge, attitudes and practices of obstetrician-gynecologists with respect to screening and treatment for iron deficiency anemia (IDA). Methods A total of 1,200 Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists were invited to participate in a survey on blood disorders. Respondents completed a questionnaire regarding their patient population, screening and treatment practices for IDA, and general knowledge about IDA and its risk factors. Results Overall response rate was 42.4%. Thirty-eight percent of respondents screen non-pregnant patients regularly, based on risk factors; 30.5% screen only when symptoms of anemia are present. For pregnant patients, 50.0% of respondents screen patients at their initial visit, while 46.2% screen every trimester. Sixty-one percent of respondents supplement pregnant patients when there is laboratory evidence of anemia; 31.6% supplement all pregnant patients. Forty-two percent of respondents screen post-partum patients based on their risk factors for IDA. However, when asked to identify risk factors for post-partum anemia, slightly more than half of respondents correctly identified young age and income level as risk factors for post-partum anemia; only 18.9% correctly identified pre-pregnancy obesity as a risk factor. Conclusion There are opportunities for increased education on IDA for obstetrician-gynecologists, specifically with respect to risk factors. There also appears to be substantial practice variance regarding screening and supplementation for IDA, which may correspond to variability in professional guidelines. Increased education on IDA, especially the importance of sociodemographic factors, and further research and effort to standardize guidelines is needed.

      5. Cohort study on maternal cytomegalovirus seroprevalence and prevalence and clinical manifestations of congenital infection in China
        Wang S, Wang T, Zhang W, Liu X, Wang X, Wang H, He X, Zhang S, Xu S, Yu Y, Jia X, Wang M, Xu A, Ma W, Amin MM, Bialek SR, Dollard SC, Wang C.
        Medicine (Baltimore). 2017 Feb;96(5):e6007.
        Congenital cytomegalovirus (CMV) infection is the leading viral cause of birth defects and developmental disabilities in developed countries. However, CMV seroprevalence and burden of congenital CMV infection are not well defined in China.Cohort of newborns from 5 birthing hospitals in 2 counties of Shandong Province, China, were enrolled from March 2011 to August 2013. Dried blood spots (DBS) and saliva were collected within 4 days after birth for IgG testing for maternal seroprevalence and real-time PCR testing for congenital CMV infection, respectively.Among 5020 newborns tested for CMV IgG, 4827 were seropositive, resulting in CMV maternal seroprevalence of 96.2% (95% confidence interval [CI]:95.6%-96.7%). Of the 10,933 newborns screened for congenital CMV infection, 75 had CMV detected, resulting in an overall prevalence of 0.7% (95% CI: 0.5%-0.9%), with prevalences of 0.4% (14/3995), 0.6% (66/10,857), and 0.7% (52/7761) for DBS, wet saliva, and dried saliva specimens screened, respectively. Prevalence of congenital CMV infection decreased with increasing maternal age (0.9%, 0.6%, and 0.3% among newborns delivered from mothers aged 16-25, 26-35, and >35 years, respectively; P = 0.03), and was higher among preterm infants than full term infants (1.3% vs 0.6%, P = 0.04), infants with intrauterine growth restriction (IUGR) than those without (1.8% vs 0.7%, P = 0.03), and twins or triplets than singleton pregnancies (2.8% vs 0.7%, P = 0.04). None of the 75 newborns exhibited symptomatic congenital CMV infection, and there was no difference in clinical characteristics and newborn hearing screening results between infants with and without congenital CMV infection at birth.Congenital CMV infection prevalence was lower and the clinical manifestations were milder in this relatively developed region of China compared to populations from other countries with similarly high maternal seroprevalence. Follow-up on children with congenital CMV infection will clarify the burden of disabilities from congenital CMV infection in China.

    • Nutritional Sciences RSS Word feed
      1. Engaging parents to promote children's nutrition and health: Providers' barriers and strategies in Head Start and child care centers
        Dev DA, Byrd-Williams C, Ramsay S, McBride B, Srivastava D, Murriel A, Arcan C, Adachi-Mejia AM.
        Am J Health Promot. 2017 ;31(2):153-162.
        Purpose: Using the Academy of Nutrition and Dietetics benchmarks as a framework, this study examined childcare providers' (Head Start [HS], Child and Adult Care Food Program [CACFP] funded, and non-CACFP) perspectives regarding communicating with parents about nutrition to promote children's health. Design: Qualitative. Setting: State-licensed center-based childcare programs. Participants: Full-time childcare providers (n = 18) caring for children 2 to 5 years old from varying childcare contexts (HS, CACFP funded, and non-CACFP), race, education, and years of experience. Methods: In-person interviews using semi-structured interview protocol until saturation were achieved. Thematic analysis was conducted. Results: Two overarching themes were barriers and strategies to communicate with parents about children's nutrition. Barriers to communication included - (a) parents are too busy to talk with providers, (b) parents offer unhealthy foods, (c) parents prioritize talking about child food issues over nutrition, (d) providers are unsure of how to communicate about nutrition without offending parents, and (e) providers are concerned if parents are receptive to nutrition education materials. Strategies for communication included - (a) recognize the benefits of communicating with parents about nutrition to support child health, (b) build a partnership with parents through education, (c) leverage policy (federal and state) to communicate positively and avoid conflict, (d) implement center-level practices to reinforce policy, and (e) foster a respectful relationship between providers and parents. Conclusion: Policy and environmental changes were recommended for fostering a respectful relationship and building a bridge between providers and parents to improve communication about children's nutrition and health.

    • Occupational Safety and Health RSS Word feed
      1. Noise exposure among federal wildland fire fighters
        Broyles G, Butler CR, Kardous CA.
        J Acoust Soc Am. 2017 ;141(2):EL177-EL183.
        Wildland fire fighters use many tools and equipment that produce noise levels that may be considered hazardous to hearing. This study evaluated 174 personal dosimetry measurements on 156 wildland fire fighters conducting various training and fire suppression tasks. Noise exposures often exceeded occupational exposure limits and suggest that wildland fire fighters may be at risk of developing noise-induced hearing loss, particularly those operating chainsaws, chippers, and masticators. The authors recommend a comprehensive approach to protecting these fire fighters that includes purchasing quieter equipment, noise and administrative controls, and enrolling these fire fighters into a hearing conservation program.

      2. Characterization of exposure to byproducts from firing lead free frangible ammunition in an enclosed, ventilated firing range
        Grabinski CM, Methner MM, Jackson JM, Moore AL, Flory LE, Tilly T, Hussain SM, Ott DK.
        J Occup Environ Hyg. 2017 :00-00.
        U.S. Air Force small arms firing ranges began using copper-based, lead-free frangible ammunition in the early 2000s due to environmental and health concerns related to the use of lead-based ammunition. Exposure assessments at these firing ranges have routinely detected chemicals and metals in amounts much lower than their mass-based occupational exposure limits, yet, instructors report work-related health concerns including respiratory distress, nausea, and headache. The objective of this study at one firing range was to characterize the aerosol emissions produced by weapons during firing events and evaluate the ventilation system's effectiveness in controlling instructor exposure to these emissions. The ventilation system was assessed by measuring the range static air pressure differential and the air velocity at the firing line. Air flow patterns were observed near the firing line. Instructor exposure was sampled using a filter-based air sampling method for metals and a wearable, real-time ultrafine particle counter. Area air sampling was simultaneously performed to characterize the particle size distribution, morphology and composition. In the instructor's breathing zone, the airborne mass concentration of copper was low (range = <1-microg/m3 to 16-microg/m3), yet the ultrafine (nanoscale) particle number concentration increased substantially during each firing event. Ultrafine particles contained some copper and were complex in morphology and composition. The ventilation assessment found that the average velocity across all shooting lanes was acceptable compared to the recommended guideline (20% of the ideal 0.38-m/s (75-ft/min). However, uniform, downrange airflow pattern requirements were not met. These results suggest that the mass-based occupational exposure limits, as applied to this environment, may not be protective enough to eliminate health complaints reported by instructors whose full-time job involves training personnel on weapons that fire lead free frangible ammunition. Using an ultrafine particle counter appears to be an alternative method of assessing ventilation effectiveness in removing ultrafine particulate produced during firing events.

      3. Malignant mesothelioma mortality - United States, 1999-2015
        Mazurek JM, Syamlal G, Wood JM, Hendricks SA, Weston A.
        MMWR Morb Mortal Wkly Rep. 2017 Mar 03;66(8):214-218.
        Malignant mesothelioma is a neoplasm associated with occupational and environmental inhalation exposure to asbestos fibers and other elongate mineral particles (EMPs). Patients have a median survival of approximately 1 year from the time of diagnosis. The latency period from first causative exposure to malignant mesothelioma development typically ranges from 20 to 40 years but can be as long as 71 years. Hazardous occupational exposures to asbestos fibers and other EMPs have occurred in a variety of industrial operations, including mining and milling, manufacturing, shipbuilding and repair, and construction. Current exposures to commercial asbestos in the United States occur predominantly during maintenance operations and remediation of older buildings containing asbestos. To update information on malignant mesothelioma mortality (5), CDC analyzed annual multiple cause-of-death records for 1999-2015, the most recent years for which complete data are available. During 1999-2015, a total of 45,221 deaths with malignant mesothelioma mentioned on the death certificate as the underlying or contributing cause of death were reported in the United States, increasing from 2,479 deaths in 1999 to 2,597 in 2015 (in the same time period the age-adjusted death rates section sign decreased from 13.96 per million in 1999 to 10.93 in 2015). Malignant mesothelioma deaths increased for persons aged >/=85 years, both sexes, persons of white, black, and Asian or Pacific Islander race, and all ethnic groups. Despite regulatory actions and the decline in use of asbestos the annual number of malignant mesothelioma deaths remains substantial. The continuing occurrence of malignant mesothelioma deaths underscores the need for maintaining measures to prevent exposure to asbestos fibers and other causative EMPs and for ongoing surveillance to monitor temporal trends.

      4. Short sleep duration by occupation group - 29 states, 2013-2014
        Shockey TM, Wheaton AG.
        MMWR Morb Mortal Wkly Rep. 2017 Mar 03;66(8):207-213.
        The American Academy of Sleep Medicine and the Sleep Research Society have determined that adults require >/=7 hours of sleep per day to promote optimal health. Short sleep duration (<7 hours per day) has been linked to adverse health outcomes including cardiovascular disease, obesity, diabetes, depression, and anxiety, as well as safety issues related to drowsy driving and injuries. Additional research has found that sleep duration varies by characteristics such as race, education, marital status, obesity, and cigarette smoking. Work-related factors such as job stress, work hours, shift work, and physically demanding work have been found to be associated with sleep duration and quality. All of these work factors vary by industry and occupation of employment, and the prevalence of short sleep duration has been shown to vary by broad industry and occupation category. To provide updated and more detailed information about which occupation groups have the highest prevalences of short sleep duration, CDC analyzed data from currently employed adults surveyed for the 2013 and 2014 Behavioral Risk Factor Surveillance System (BRFSS) in 29 states. Among 22 major occupation groups, the highest prevalences of short sleep duration were among workers in the following five groups: Production (42.9%), Healthcare Support (40.1%), Healthcare Practitioners and Technical (40.0%), Food Preparation and Serving-Related (39.8%), and Protective Service (39.2%). The significant differences among occupation groups in the prevalence of short sleep duration suggest that work-related factors should be further evaluated as they might relate to sleep.

    • Parasitic Diseases RSS Word feed
      1. Bead-based immunoassay allows sub-picogram detection of histidine-rich protein 2 from Plasmodium falciparum and estimates reliability of malaria rapid diagnostic tests
        Rogier E, Plucinski M, Lucchi N, Mace K, Chang M, Lemoine JF, Candrinho B, Colborn J, Dimbu R, Fortes F, Udhayakumar V, Barnwell J.
        PLoS One. 2017 ;12(2):e0172139.
        Detection of histidine-rich protein 2 (HRP2) from the malaria parasite Plasmodium falciparum provides evidence for active or recent infection, and is utilized for both diagnostic and surveillance purposes, but current laboratory immunoassays for HRP2 are hindered by low sensitivities and high costs. Here we present a new HRP2 immunoassay based on antigen capture through a bead-based system capable of detecting HRP2 at sub-picogram levels. The assay is highly specific and cost-effective, allowing fast processing and screening of large numbers of samples. We utilized the assay to assess results of HRP2-based rapid diagnostic tests (RDTs) in different P. falciparum transmission settings, generating estimates for true performance in the field. Through this method of external validation, HRP2 RDTs were found to perform well in the high-endemic areas of Mozambique and Angola with 86.4% and 73.9% of persons with HRP2 in their blood testing positive by RDTs, respectively, and false-positive rates of 4.3% and 0.5%. However, in the low-endemic setting of Haiti, only 14.5% of persons found to be HRP2 positive by the bead assay were RDT positive. Additionally, 62.5% of Haitians showing a positive RDT test had no detectable HRP2 by the bead assay, likely indicating that these were false positive tests. In addition to RDT validation, HRP2 biomass was assessed for the populations in these different settings, and may provide an additional metric by which to estimate P. falciparum transmission intensity and measure the impact of interventions.

      2. Assessment of the utility of a symptom-based algorithm for identifying febrile patients for malaria diagnostic testing in Senegal
        Thwing J, Ba F, Diaby A, Diedhiou Y, Sylla A, Sall G, Diouf MB, Gueye AB, Gaye S, Ndiop M, Cisse M, Ndiaye D, Ba M.
        Malar J. 2017 Mar 01;16(1):95.
        BACKGROUND: Malaria rapid diagnostic tests (RDTs) enable point-of-care testing to be nearly as sensitive and specific as reference microscopy. The Senegal National Malaria Control Programme introduced RDTs in 2007, along with a case management algorithm for uncomplicated febrile illness, in which the first step stipulates that if a febrile patient of any age has symptoms indicative of febrile illness other than malaria (e.g., cough or rash), they would not be tested for malaria, but treated for the apparent illness and receive an RDT for malaria only if they returned in 48 h without improvement. METHODS: A year-long study in 16 health posts was conducted to determine the algorithm's capacity to identify patients with Plasmodium falciparum infection identifiable by RDT. Health post personnel enrolled patients of all ages with fever (>/=37.5 degrees C) or history of fever in the previous 2 days. After clinical assessment, a nurse staffing the health post determined whether a patient should receive an RDT according to the diagnostic algorithm, but performed an RDT for all enrolled patients. RESULTS: Over 1 year, 6039 patients were enrolled and 58% (3483) were determined to require an RDT according to the algorithm. Overall, 23% (1373/6039) had a positive RDT, 34% (1130/3376) during rainy season and 9% (243/2661) during dry season. The first step of the algorithm identified only 78% of patients with a positive RDT, varying by transmission season (rainy 80%, dry 70%), malaria transmission zone (high 75%, low 95%), and age group (under 5 years 68%, 5 years and older 84%). CONCLUSIONS: In all but the lowest malaria transmission zone, use of the algorithm excludes an unacceptably large proportion of patients with malaria from receiving an RDT at their first visit, denying them timely diagnosis and treatment. While the algorithm was adopted within a context of malaria control and scarce resources, with the goal of treating patients with symptomatic malaria, Senegal has now adopted a policy of universal diagnosis of patients with fever or history of fever. In addition, in the current context of malaria elimination, the paradigm of case management needs to shift towards the identification and treatment of all patients with malaria infection.

    • Reproductive Health RSS Word feed
      1. Why we need evidence-based, community-wide approaches for prevention of teen pregnancy
        Barfield WD, Warner L, Kappeler E.
        J Adolesc Health. 2017 Mar;60(3s):S3-s6.
        Teen pregnancy and childbearing have declined over the past two decades to historic lows. The most recent declines have occurred during a time of coordinated national efforts focused on teen pregnancy. This article highlights a federal partnership to reduce teen pregnancy through the implementation of innovative, evidence-based approaches in affected communities, with a focus on reaching African-American and Latino/Hispanic youth. This initiative has the potential to transform the design and implementation of future teen pregnancy prevention efforts and provide a model that can be replicated in communities across the nation.

      2. Strategies to build readiness in community mobilization efforts for implementation in a multi-year teen pregnancy prevention initiative
        Bhuiya N, House LD, Desmarais J, Fletcher E, Conlin M, Perez-McAdoo S, Waggett J, Tendulkar SA.
        J Adolesc Health. 2017 Mar;60(3s):S51-s56.
        PURPOSE: This paper describes an assessment of community readiness to implement a community-wide teen pregnancy prevention initiative, Youth First, and presents strategies used to enhance this readiness as informed by the assessment. METHODS: Twenty-five community stakeholder interviews were conducted to assess four domains of readiness: (1) attitudes, perception, and knowledge of teen pregnancy; (2) perceived level of readiness; (3) resources, existing and current efforts; and (4) leadership. Interview transcripts were coded and analyzed to identify key themes. RESULTS: Stakeholders acknowledged teen pregnancy as an issue but lacked contextual information. They also perceived the community as ready to address the issue and recognized some organizations already championing efforts. However, many key players were not involved, and ongoing data collection to assess teen pregnancy and prevention efforts was limited. Though many stakeholders were ready to engage in teen pregnancy prevention efforts, they required additional information and training to appropriately address the issue. CONCLUSIONS: In response to the assessment findings, several strategies were applied to address readiness and build Youth First partners' capacity to implement the community-wide initiative. Thus, to successfully implement community-wide prevention efforts, it is valuable to assess the level of community readiness to address health issues.

      3. Exploring African-American and Latino teens' perceptions of contraception and access to reproductive health care services
        Galloway CT, Duffy JL, Dixon RP, Fuller TR.
        J Adolesc Health. 2017 Mar;60(3s):S57-s62.
        PURPOSE: Reducing disparities in teen pregnancy and birth rates among African American and Latina teens is a central focus of a community-wide teen pregnancy prevention initiative implemented by the South Carolina Campaign to Prevent Teen Pregnancy. Disparities in teen pregnancy and birth rates are driven, in part, by differential access to contraception and reproductive health care services. The purpose of this qualitative study was to understand African American and Latino teens' 1) preferences for finding health information, 2) perceptions of accessing reproductive health services, and 3) beliefs about contraception. METHODS: As a part of this community-wide initiative, eight focus groups were conducted in the Fall of 2012 with African American and Latino male and female youth from two communities in South Carolina. Among eight focus groups of youth, teens most often reported parents, other trusted relatives, and the Internet as sources of health information. RESULTS: Participants discussed the value of social media and television advertisements for reaching young people and emphasized the importance of privacy, a desire for a teen-only clinic, and the need for friendly clinical staff. Participants' comments often reflected inaccurate beliefs about the reliability and correct usage of contraceptive methods. Female participants also reported side effects of birth control as a potential barrier to use. CONCLUSIONS: Ensuring that teens' beliefs and perceptions are taken into account when developing, marketing, and implementing culturally competent reproductive health care services is important to improve access to care for all teens in Horry and Spartanburg Counties.

      4. Implementing evidence-based teen pregnancy-prevention interventions in a community-wide initiative: Building capacity and reaching youth
        House LD, Tevendale HD, Martinez-Garcia G.
        J Adolesc Health. 2017 Mar;60(3s):S18-s23.
        PURPOSE: To describe efforts to implement evidence-based interventions (EBIs) within multicomponent, community-wide initiatives to reduce teen pregnancy. METHODS: During 2011-2014, we collected information about the capacity (i.e., knowledge, confidence, training, and experience) of state and community-based organizations to support implementation of the following: EBIs, number and characteristics of youth served by EBIs, type of EBIs implemented, EBI settings, hours of training, and technical assistance provided. State and community-based organizations reported these data annually; however, training and technical assistance was reported monthly. We used aggregated data from these annual and monthly reports to describe the implementation of EBIs in the community-wide initiative project. RESULTS: From baseline in 2011-2014, state and community-based organizations increased their capacities to support program partners in delivering EBIs. They provided 5,015 hours of technical assistance and training on topics, including ensuring adequate capacity, process and outcome evaluation, program planning, and continuous quality improvement. Program partners increased the number of youth reached by an EBI in targeted communities by 349%, from 4,304 in the first year of implementation in 2012 to 19,344 in 2014. Most youth in 2014 received sexuality education programs (59%), whereas smaller percentages received abstinence-based, youth development, and clinic-based programs. Most youth were reached through schools (72%) and community-based organizations (16%), and smaller numbers were reached in other settings (e.g., faith-based organizations, health centers). CONCLUSIONS: Building and monitoring the capacity of program partners to deliver EBIs through technical assistance and training is important. In addition, partnering with schools leads to reaching more youth.

      5. Teen pregnancy prevention: Implementation of a multicomponent, community-wide approach
        Mueller T, Tevendale HD, Fuller TR, House LD, Romero LM, Brittain A, Varanasi B.
        J Adolesc Health. 2017 Mar;60(3s):S9-s17.
        This article provides an overview and description of implementation activities of the multicomponent, community-wide initiatives of the Teenage Pregnancy Prevention Program initiated in 2010 by the Office of Adolescent Health and the Centers for Disease Control and Prevention. The community-wide initiatives applied the Interactive Systems Framework for dissemination and implementation through training and technical assistance on the key elements of the initiative: implementation of evidence-based teen pregnancy prevention (TPP) interventions; enhancing quality of and access to youth-friendly reproductive health services; educating stakeholders about TPP; working with youth in communities most at risk of teen pregnancy; and mobilizing the community to garner support. Of nearly 12,000 hours of training and technical assistance provided, the majority was for selecting, implementing, and evaluating an evidence-based TPP program. Real-world implementation of a community-wide approach to TPP takes time and effort. This report describes implementation within each of the components and shares lessons learned during planning and implementation phases of the initiative.

      6. Stakeholder education and community mobilization garner support for sex education
        Plastino K, Quinlan J, Todd J, Tevendale HD.
        J Adolesc Health. 2017 Mar;60(3s):S24-s29.
        PURPOSE: The University of Texas Health Science Center at San Antonio UT Teen Health (UTTH) implemented a community-wide teen pregnancy prevention (TPP) initiative in south San Antonio. This article describes how UTTH staff educated community stakeholders and mobilized community members to support implementation of evidence-based TPP interventions. METHODS: UTTH educated key stakeholders about the need for TPP efforts, strong local support for such efforts, and the value of evidence-based interventions (EBIs). The process of stakeholder education and partnership development leading to implementation of EBIs was lengthy with, for example, an average of 11 meetings and 13.5 months between the initial meeting and formal approval of EBI implementation among school partners. UTTH also mobilized the community by engaging community members on leadership teams that actively supported the initiative efforts. RESULTS: Partnerships to implement EBIs were developed with 16 middle and high schools across five local school districts, two divisions of the juvenile justice system, and five youth-serving organizations. From 2011 to 2015, more than 12,500 youth (51% female) aged 11 to 19 years received EBIs. Of the total served, 95% were served through partnerships with local schools, 4% by juvenile justice, and 1% by youth-serving organizations. CONCLUSIONS: Engaging and educating members of the community require notable time and resource investments up front; however, once strong partnerships are built, there is an ongoing opportunity to reach youth. In south San Antonio, schools provided the opportunity to reach the largest numbers of youth.

      7. Efforts to increase implementation of evidence-based clinical practices to improve adolescent-friendly reproductive health services
        Romero LM, Olaiya O, Hallum-Montes R, Varanasi B, Mueller T, House LD, Schlanger K, Middleton D.
        J Adolesc Health. 2017 Mar;60(3s):S30-s37.
        PURPOSE: The purposes of this study were to describe changes in implementation of evidence-based clinical practices among health center partners as part of a multicomponent, community-wide teen pregnancy prevention initiative; to better understand the barriers to and facilitators of implementation of the evidence-based clinical practices; and to describe the technical assistance and training provided to the health center partners and key lessons learned. METHODS: Health center data from the second and third years (2012 and 2013) of the teen pregnancy prevention community-wide initiative were analyzed from 10 communities (the first year was a planning year; program implementation began in the second year). Data were analyzed from 48 health center partners that contributed data in both years to identify evidence-based clinical practices that were being implemented and opportunities for improvement. In addition, data were analyzed from a purposive sample of 30 health center partners who were asked to describe their experiences in implementing evidence-based clinical practices in adolescent reproductive health care and barriers and facilitators to implementation. RESULTS: Across 48 health centers in the 10 communities, 52% reported an increase in the implementation of evidence-based clinical practices from 2012 to 2013, mostly in providing contraceptive access (23%) and offering Quick Start (19%). Among health centers that reported no change (13%), the majority reported that practices were already being implemented before the initiative. Finally, among health centers that reported a decrease in implementation of evidence-based clinical practices (35%), most reported a decrease in having either hormonal contraception or intrauterine devices available at every visit (15%), having HIV rapid testing available (10%), or participating in the federal 340B Drug Discount Program (2%). In addition, health systems and community-level factors influence health center implementation of evidence-based clinical practices. In particular, support from health center leadership, communication between leadership and staff, and staff attitudes and beliefs were reported as factors that facilitated the implementation of new practices. CONCLUSIONS: To increase adolescent's use of quality, client-centered, affordable and confidential reproductive health services, improvement in the implementation of evidence-based clinical practices is needed. Efforts to identify barriers to and facilitators for implementation of evidence-based clinical practices can inform for health centers of opportunities to build their capacity to ensure that evidence-based clinical practices are being implemented.

      8. Integrated community strategies for linking youth to adolescent reproductive health services: A case study
        Sotolongo J, House LD, Swanson S, Davis SE.
        J Adolesc Health. 2017 Mar;60(3s):S45-s50.
        PURPOSE: This article describes the development and promotion of a full-service adolescent health center at a local health department intended to increase teen access to contraceptive and reproductive health care. This work was conducted as part of a multicomponent, community-based teen pregnancy prevention initiative in Gaston County, North Carolina. METHODS: To increase access to adolescent reproductive health services, we implemented multiple integrated strategies: (1) building community support for adolescent reproductive health services; (2) providing technical assistance to the health department in opening the Teen Wellness Center (TWC), a teen-centered, full-service clinic; (3) strengthening referral partnerships between community organizations and clinical services; and (4) educating teens on how to access reproductive health services. Data were collected to examine the change in the number of adolescent reproductive health clients after the opening of the TWC. RESULTS: In the first year, the TWC was opened, 1,675 adolescent clients received reproductive health services, for a 12.5% increase compared with the prior year. The number of adolescent clients who received more than one type of reproductive health services (e.g., wellness visit and family planning services) increased by 133%. The number of adolescent clients who received family planning services increased by 3.8%. CONCLUSIONS: The project achieved an increase in adolescent reproductive health clients. Establishment of a teen-centered, full-service clinic and working with youth-serving agencies to increase knowledge of the clinic's services are promising approaches to increasing teen access to reproductive health care.

      9. Practical approaches to evaluating progress and outcomes in community-wide teen pregnancy prevention initiatives
        Tevendale HD, Condron DS, Garraza LG, House LD, Romero LM, Brooks MA, Walrath C.
        J Adolesc Health. 2017 Mar;60(3s):S63-s68.
        This paper presents an overview of the key evaluation components for a set of community-wide teen pregnancy prevention initiatives. We first describe the performance measures selected to assess progress toward meeting short-term objectives on the reach and quality of implementation of evidence-based teen pregnancy prevention interventions and adolescent reproductive health services. Next, we describe an evaluation that will compare teen birth rates in intervention communities relative to synthetic control communities. Synthetic controls are developed via a data-driven technique that constructs control communities by combining information from a pool of communities that are similar to the intervention community. Finally, we share lessons learned thus far in the evaluation of the project, with a focus on those lessons that may be valuable for local communities evaluating efforts to reduce teen pregnancy.

      10. Implementation of community-wide teen pregnancy prevention initiatives: Focus on partnerships
        Tevendale HD, Fuller TR, House LD, Dee DL, Koumans EH.
        J Adolesc Health. 2017 Mar;60(3s):S7-s8.
        Seeking to reduce teen pregnancy and births in communities with rates above the national average, the Centers for Disease Control and Prevention, in partnership with the U.S. Department of Health and Human Services Office of Adolescent Health Teen Pregnancy Prevention Program, developed a joint funding opportunity through which grantees worked to implement and test an approach involving community-wide teen pregnancy prevention initiatives. Once these projects had been in the field for 2.5 years, Centers for Disease Control and Prevention staff developed plans for a supplemental issue of the Journal of Adolescent Health to present findings from and lessons learned during implementation of the community-wide initiatives. When the articles included in the supplemental issue are considered together, common themes emerge, particularly those related to initiating, building, and maintaining strong partnerships. Themes seen across articles include the importance of (1) sharing local data with partners to advance initiative implementation, (2) defining partner roles from the beginning of the initiatives, (3) developing teams that include community partners to provide direction to the initiatives, and (4) addressing challenges to maintaining strong partnerships including partner staff turnover and delays in implementation.

    • Substance Use and Abuse RSS Word feed
      1. Effects of workplace generalized and sexual harassment on abusive drinking among first year male and female college students: Does prior drinking experience matter?
        Rospenda KM, Fujishiro K, McGinley M, Wolff JM, Richman JA.
        Subst Use Misuse. 2017 :1-13.
        Background: Workplace harassment, a known risk factor for adult drinking, is understudied in college samples, but may help explain observed gender differences in drinking patterns. Objective: We examine effects of sexual and generalized workplace harassment on changes in drinking behavior over the first semesters of college, and the extent to which these effects differ based on prematriculation drinking for men and women students. Method: Data derive from two waves of a longitudinal study of eight Midwestern colleges and universities. Data were collected from 2080 employed students via a Web-based survey assessing sexual and generalized workplace harassment, stressful life events, drinking to intoxication, and binge drinking prior to freshman year (fall 2011) and approximately one year later (summer to fall 2012). At baseline, lifetime drinking status, frequency of alcohol consumption, and demographics were also assessed. Results: Linear-mixed modeling indicated that employed women students who were frequent drinkers prematriculation were at risk for high levels of drinking associated with workplace harassment, while men who were nondrinkers were most at risk of increasing problem drinking over time when exposed to workplace harassment. Conclusions: Alcohol use prevention efforts directed towards employed students are needed both prior to and during college, to instruct students how to identify workplace harassment and cope in healthier ways with stressful workplace experiences. These efforts might be particularly useful in stemming problematic drinking among women who drink frequently prior to college, and preventing men who are nondrinkers upon college entry from initiating problematic drinking during subsequent enrollment years.

    • Zoonotic and Vectorborne Diseases RSS Word feed
      1. Successful treatment of human plague with oral ciprofloxacin
        Apangu T, Griffith K, Abaru J, Candini G, Apio H, Okoth F, Okello R, Kaggwa J, Acayo S, Ezama G, Yockey B, Sexton C, Schriefer M, Mbidde EK, Mead P.
        Emerg Infect Dis. 2017 Mar;23(3).
        The US Food and Drug Administration recently approved ciprofloxacin for treatment of plague (Yersina pestis infection) based on animal studies. Published evidence of efficacy in humans is sparse. We report 5 cases of culture-confirmed human plague treated successfully with oral ciprofloxacin, including 1 case of pneumonic plague.

      2. Zika virus RNA replication and persistence in brain and placental tissue
        Bhatnagar J, Rabeneck DB, Martines RB, Reagan-Steiner S, Ermias Y, Estetter LB, Suzuki T, Ritter J, Keating MK, Hale G, Gary J, Muehlenbachs A, Lambert A, Lanciotti R, Oduyebo T, Meaney-Delman D, Bolanos F, Saad EA, Shieh WJ, Zaki SR.
        Emerg Infect Dis. 2017 Mar;23(3):405-414.
        Zika virus is causally linked with congenital microcephaly and may be associated with pregnancy loss. However, the mechanisms of Zika virus intrauterine transmission and replication and its tropism and persistence in tissues are poorly understood. We tested tissues from 52 case-patients: 8 infants with microcephaly who died and 44 women suspected of being infected with Zika virus during pregnancy. By reverse transcription PCR, tissues from 32 (62%) case-patients (brains from 8 infants with microcephaly and placental/fetal tissues from 24 women) were positive for Zika virus. In situ hybridization localized replicative Zika virus RNA in brains of 7 infants and in placentas of 9 women who had pregnancy losses during the first or second trimester. These findings demonstrate that Zika virus replicates and persists in fetal brains and placentas, providing direct evidence of its association with microcephaly. Tissue-based reverse transcription PCR extends the time frame of Zika virus detection in congenital and pregnancy-associated infections.

      3. Baseline prevalence of birth defects associated with congenital Zika virus infection - Massachusetts, North Carolina, and Atlanta, Georgia, 2013-2014
        Cragan JD, Mai CT, Petersen EE, Liberman RF, Forestieri NE, Stevens AC, Delaney A, Dawson AL, Ellington SR, Shapiro-Mendoza CK, Dunn JE, Higgins CA, Meyer RE, Williams T, Polen KN, Newsome K, Reynolds M, Isenburg J, Gilboa SM, Meaney-Delman DM, Moore CA, Boyle CA, Honein MA.
        MMWR Morb Mortal Wkly Rep. 2017 Mar 03;66(8):219-222.
        Zika virus infection during pregnancy can cause serious brain abnormalities, but the full range of adverse outcomes is unknown (1). To better understand the impact of birth defects resulting from Zika virus infection, the CDC surveillance case definition established in 2016 for birth defects potentially related to Zika virus infection* (2) was retrospectively applied to population-based birth defects surveillance data collected during 2013-2014 in three areas before the introduction of Zika virus (the pre-Zika years) into the World Health Organization's Region of the Americas (Americas) (3). These data, from Massachusetts (2013), North Carolina (2013), and Atlanta, Georgia (2013-2014), included 747 infants and fetuses with one or more of the birth defects meeting the case definition (pre-Zika prevalence = 2.86 per 1,000 live births). Brain abnormalities or microcephaly were the most frequently recorded (1.50 per 1,000), followed by neural tube defects and other early brain malformationsdagger (0.88), eye abnormalities without mention of a brain abnormality (0.31), and other consequences of central nervous system (CNS) dysfunction without mention of brain or eye abnormalities (0.17). During January 15-September 22, 2016, the U.S. Zika Pregnancy Registry (USZPR) reported 26 infants and fetuses with these same defects among 442 completed pregnancies (58.8 per 1,000) born to mothers with laboratory evidence of possible Zika virus infection during pregnancy (2). Although the ascertainment methods differed, this finding was approximately 20 times higher than the proportion of one or more of the same birth defects among pregnancies during the pre-Zika years. These data demonstrate the importance of population-based surveillance for interpreting data about birth defects potentially related to Zika virus infection.

      4. Chikungunya virus disease outbreak in Yap State, Federated States of Micronesia
        Pastula DM, Hancock WT, Bel M, Biggs H, Marfel M, Lanciotti R, Laven J, Chen TH, Staples JE, Fischer M, Hills SL.
        PLoS Negl Trop Dis. 2017 Mar 01;11(3):e0005410.
        BACKGROUND: Chikungunya virus is a mosquito-borne alphavirus which causes an acute febrile illness associated with polyarthralgia. Beginning in August 2013, clinicians from the Yap State Department of Health in the Federated States of Micronesia (FSM) identified an unusual cluster of illness which was subsequently confirmed to be chikungunya virus disease. Chikungunya virus disease previously had not been recognized in FSM. METHODOLOGY/PRINCIPAL FINDINGS: Information from patients presenting to healthcare facilities was collected and analyzed. During August 11, 2013, to August 10, 2014, a total of 1,761 clinical cases were reported for an attack rate of 155 clinical cases per 1,000 population. Among residents of Yap Main Island, 3% were hospitalized. There were no deaths. The outbreak began on Yap Main Island and rapidly spread throughout Yap Main Island and to three neighboring islands. CONCLUSIONS/SIGNIFICANCE: Chikungunya virus can cause explosive outbreaks with substantial morbidity. Given the increasing globalization of chikungunya virus, strong surveillance systems and access to laboratory testing are essential to detect outbreaks.

      5. A new look at an old disease: Recent insights into the global epidemiology of dengue
        Sharp TM, Tomashek KM, Read JS, Margolis HS, Waterman SH.
        Curr Epidemiol Rep. 2017 ;4(1):11-21.
        PURPOSE OF REVIEW: By all measures, the morbidity and mortality due to dengue are continuing to worsen worldwide. Although both early and recent studies have demonstrated regional differences in how dengue affects local populations, these findings were to varying extents related to disparate surveillance approaches. RECENT FINDINGS: Recent studies have broadened the recognized spectrum of disease resulting from DENV infection, particularly in adults, and have also demonstrated new mechanisms of DENV spread both within and between populations. New results regarding the frequency and duration of homo- and heterotypic anti-DENV antibodies have provided important insights relevant to vaccine design and implementation. SUMMARY: These observations and findings as well as difficulties in comparing the epidemiology of dengue within and between regions of the world underscore the need for population-based dengue surveillance worldwide. Enhanced surveillance should be implemented to complement passive surveillance in countries in the tropics to establish baseline data in order to define affected populations and evaluate the impact of dengue vaccines and novel vector control interventions.

      6. Elimination of dog-mediated human rabies deaths by 2030: Needs assessment and alternatives for progress based on dog vaccination
        Wallace RM, Undurraga EA, Blanton JD, Cleaton J, Franka R.
        Front Vet Sci. 2017 ;4:9.
        BACKGROUND: Rabies imposes a substantial burden to about half of the world population. The World Health Organization (WHO), World Organization for Animal Health, and the Food and Agriculture Organization have set the goal of eliminating dog-mediated human rabies deaths by 2030. This could be achieved largely by massive administration of post-exposure prophylaxis-in perpetuity-, through elimination of dog rabies, or combining both. Here, we focused on the resources needed for the elimination of dog rabies virus by 2030. MATERIALS AND METHODS: Drawing from multiple datasets, including national dog vaccination campaigns, rabies literature, and expert opinion, we developed a model considering country-specific current dog vaccination capacity to estimate the years and resources required to achieve dog rabies elimination by 2030. Resources were determined based on four factors: (a) country development status, (b) dog vaccination costs, (c) dog rabies vaccine availability, and (d) existing animal health workers. Our calculations were based on the WHO's estimate that vaccinating 70% of the dog population for seven consecutive years would eliminate rabies. FINDINGS: If dog rabies vaccine production remains at 2015 levels, we estimate that there will be a cumulative shortage of about 7.5 billion doses to meet expected demand to achieve dog rabies elimination. We estimated a present cost of $6,300 million to eliminate dog rabies in all endemic countries, equivalent to a $3,900 million gap compared to current spending. To eliminate dog rabies, the vaccination workforce may suffice if all public health veterinarians in endemic countries were to dedicate 3 months each year to dog rabies vaccination. We discuss implications of potential technology improvements, including population management, vaccine price reduction, and increases in dog-vaccinating capacities. CONCLUSION: Our results highlight the resources needed to achieve elimination of dog-mediated human rabies deaths by 2030. As exemplified by multiple successful disease elimination efforts, one size does not fit all. We suggest pragmatic and feasible options toward global dog rabies elimination by 2030, while identifying several benefits and drawbacks of specific approaches. We hope that these results help stimulate and inform a necessary discussion on global and regional strategic planning, resource mobilization, and continuous execution of rabies virus elimination.


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DISCLAIMER: Articles listed in the CDC Science Clips are selected by the Stephen B. Thacker CDC Library to provide current awareness of the public health literature. An article's inclusion does not necessarily represent the views of the Centers for Disease Control and Prevention nor does it imply endorsement of the article's methods or findings. CDC and DHHS assume no responsibility for the factual accuracy of the items presented. The selection, omission, or content of items does not imply any endorsement or other position taken by CDC or DHHS. Opinion, findings and conclusions expressed by the original authors of items included in the Clips, or persons quoted therein, are strictly their own and are in no way meant to represent the opinion or views of CDC or DHHS. References to publications, news sources, and non-CDC Websites are provided solely for informational purposes and do not imply endorsement by CDC or DHHS. 

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