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Issue 18, May 9, 2017

CDC Science Clips: Volume 9, Issue 18, May 9, 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. Top Articles of the Week
    • Communicable Diseases RSS Word feed
      1. “We deserve better!”: Perceptions of HIV testing campaigns among black and Latino MSM in New York city
        Drumhiller K, Murray A, Gaul Z, Aholou TM, Sutton MY, Nanin J.
        Arch Sex Behav. 2017 Apr 25.
        In 2014, Black/African-American and Hispanic/Latino men who have sex with men (BLMSM) comprised 64.1% of HIV diagnoses among MSM in the U.S. Routine HIV testing allows earlier diagnosis, linkage to care, and improved health outcomes. HIV testing campaigns may increase HIV awareness and testing behaviors, but perceptions of these campaigns by BLMSM have been understudied. We explored perceptions of HIV testing campaigns with BLMSM in New York City (NYC) to inform campaign strategies that target BLMSM for HIV testing. Using respondent-driven sampling methods, we conducted semi-structured interviews from 2011 to 2012 with BLMSM in NYC who participated in a larger HIV research study. Interview responses from 108 participants were examined for main themes using computer-assisted thematic analyses. The four main themes identified were that HIV testing campaigns should: (1) use non-stereotypical messages and images on the basis of race and sexuality, (2) use non-gay identified images, (3) be maximally inclusive and visible, and (4) raise risk perception of HIV. These findings can inform future campaigns for strengthening HIV testing among BLMSM in support of earlier diagnosis, linkage to care, and reduced disparities.

    • Disease Reservoirs and Vectors RSS Word feed
      1. Conservation of biodiversity as a strategy for improving human health and well-being
        Kilpatrick AM, Salkeld DJ, Titcomb G, Hahn MB.
        Philos Trans R Soc Lond B Biol Sci. 2017 Jun 05;372(1722).
        The Earth’s ecosystems have been altered by anthropogenic processes, including land use, harvesting populations, species introductions and climate change. These anthropogenic processes greatly alter plant and animal communities, thereby changing transmission of the zoonotic pathogens they carry. Biodiversity conservation may be a potential win-win strategy for maintaining ecosystem health and protecting public health, yet the causal evidence to support this strategy is limited. Evaluating conservation as a viable public health intervention requires answering four questions: (i) Is there a general and causal relationship between biodiversity and pathogen transmission, and if so, which direction is it in? (ii) Does increased pathogen diversity with increased host biodiversity result in an increase in total disease burden? (iii) Do the net benefits of biodiversity conservation to human well-being outweigh the benefits that biodiversity-degrading activities, such as agriculture and resource utilization, provide? (iv) Are biodiversity conservation interventions cost-effective when compared to other options employed in standard public health approaches? Here, we summarize current knowledge on biodiversity-zoonotic disease relationships and outline a research plan to address the gaps in our understanding for each of these four questions. Developing practical and self-sustaining biodiversity conservation interventions will require significant investment in disease ecology research to determine when and where they will be effective.This article is part of the themed issue ‘Conservation, biodiversity and infectious disease: scientific evidence and policy implications’.

      2. Unique strain of Rickettsia parkeri associated with the hard tick Dermacentor parumapertus Neumann in the Western United States
        Paddock CD, Allerdice ME, Karpathy SE, Nicholson WL, Levin ML, Smith TC, Becker T, Delph RJ, Knight RN, Ritter JM, Sanders JH, Goddard J.
        Appl Environ Microbiol. 2017 May 01;83(9).
        In 1953, investigators at the Rocky Mountain Laboratories in Hamilton, MT, described the isolation of a spotted fever group Rickettsia (SFGR) species from Dermacentor parumapertus ticks collected from black-tailed jackrabbits (Lepus californicus) in northern Nevada. Several decades later, investigators characterized this SFGR (designated the parumapertus agent) by using mouse serotyping methods and determined that it represented a distinct rickettsial serotype closely related to Rickettsia parkeri; nonetheless, the parumapertus agent was not further characterized or studied. To our knowledge, no isolates of the parumapertus agent remain in any rickettsial culture collection, which precludes contemporary phylogenetic placement of this enigmatic SFGR. To rediscover the parumapertus agent, adult-stage D. parumapertus ticks were collected from black-tailed jackrabbits shot or encountered as roadkills in Arizona, Utah, or Texas from 2011 to 2016. A total of 339 ticks were collected and evaluated for infection with Rickettsia species. Of 112 D. parumapertus ticks collected in south Texas, 16 (14.3%) contained partial ompA sequences with the closest identity (99.6%) to Rickettsia sp. strain Atlantic rainforest Aa46, an SFGR that is closely related or identical to an SFGR species that causes a mild rickettsiosis in several states of Brazil. A pure isolate, designated strain Black Gap, was cultivated in Vero E6 cells, and sequence analysis of the rrs, gltA, sca0, sca5, and sca4 genes also revealed the closest genetic identity to Rickettsia sp. Atlantic rainforest Aa46. Phylogenetic analysis of the five concatenated rickettsial genes place Rickettsia sp. strain Black Gap and Rickettsia sp. Atlantic rainforest Aa46 with R. parkeri in a distinct and well-supported clade.IMPORTANCE We suggest that Rickettsia sp. Black Gap and Rickettsia sp. Atlantic rainforest Aa46 represent nearly identical strains of R. parkeri and that Rickettsia sp. Black Gap or a very similar strain of R. parkeri represents the parumapertus agent. The close genetic relatedness among these taxa, as well as the response of guinea pigs infected with the Black Gap strain, suggests that R. parkeri Black Gap could cause disease in humans. The identification of this organism could also account, at least in part, for the remarkable differences in severity ascribed to Rocky Mountain spotted fever (RMSF) among various regions of the American West during the early 20th century. We suggest that the wide variation in case fatality rates attributed to RMSF could have occurred by the inadvertent inclusion of cases of milder disease caused by R. parkeri Black Gap.

    • Genetics and Genomics RSS Word feed
      1. Draft genome sequence of Bacillus cereus LA2007, a human-pathogenic isolate harboring anthrax-like plasmids
        Pena-Gonzalez A, Marston CK, Rodriguez RL, Kolton CB, Garcia-Diaz J, Theppote A, Frace M, Konstantinidis KT, Hoffmaster AR.
        Genome Announc. 2017 Apr 20;5(16).
        We present the genome sequence of Bacillus cereus LA2007, a strain isolated in 2007 from a fatal pneumonia case in Louisiana. Sequence-based genome analysis revealed that LA2007 carries a plasmid highly similar to Bacillus anthracis pXO1, including the genes responsible for the production and regulation of anthrax toxin.

    • Health Economics RSS Word feed
      1. Medical expenditures associated with diabetes among youth with Medicaid coverage
        Shrestha SS, Zhang P, Thompson TJ, Gregg EW, Albright A, Imperatore G.
        Med Care. 2017 Apr 21.
        BACKGROUND: Information on diabetes-related excess medical expenditures for youth is important to understand the magnitude of financial burden and to plan the health care resources needed for managing diabetes. However, diabetes-related excess medical expenditures for youth covered by Medicaid program have not been investigated recently. OBJECTIVE: To estimate excess diabetes-related medical expenditures among youth aged below 20 years enrolled in Medicaid programs in the United States. METHODS: We analyzed data from 2008 to 2012 MarketScan multistate Medicaid database for 6502 youths with diagnosed diabetes and 6502 propensity score matched youths without diabetes, enrolled in fee-for-service payment plans. We stratified analysis by Medicaid eligibility criteria (poverty or disability). We used 2-part regression models to estimate diabetes-related excess medical expenditures, adjusted for age, sex, race/ethnicity, year of claims, depression status, asthma status, and interaction terms. RESULTS: For poverty-based Medicaid enrollees, estimated annual diabetes-related total medical expenditure was $9046 per person [$3681 (no diabetes) vs. $12,727 (diabetes); P<0001], of which 41.7%, 34.0%, and 24.3% were accounted for by prescription drugs, outpatient, and inpatient care, respectively. For disability-based Medicaid enrollees, the estimated annual diabetes-related total medical expenditure was $9944 per person ($14,149 vs. $24,093; P<0001), of which 41.5% was accounted for by prescription drugs, 31.3% by inpatient, and 27.3% by outpatient care. CONCLUSIONS: The per capita annual diabetes-related medical expenditures in youth covered by publicly financed Medicaid programs are substantial, which is larger among those with disabilities than without disabilities. Identifying cost-effective ways of managing diabetes in this vulnerable segment of the youth population is needed.

    • Immunity and Immunization RSS Word feed
      1. INTRODUCTION: The polio eradication endgame strategic plan calls for the sequential removal of Sabin poliovirus serotypes from the trivalent oral poliovirus vaccine (tOPV), starting with type 2, and the introduction of >/=1 dose of inactivated poliovirus vaccine (IPV), to maintain an immunity base against poliovirus type 2. The global removal of oral poliovirus type 2 was successfully implemented in May 2016. However, IPV supply constraints has prevented introduction in 21 countries and led to complete stock-out in >20 countries. METHODS: We conducted a literature review and contacted corresponding authors of recent studies with fractional-dose IPV (fIPV), one-fifth of intramuscular dose administered intradermally, to conduct additional type 2 immunogenicity analyses of two fIPV doses compared with one full-dose IPV. RESULTS: Four studies were identified that assessed immunogenicity of two fIPV doses compared to one full-dose IPV. Two fractional doses are more immunogenic than 1 full-dose, with type 2 seroconversion rates improving between absolute 19-42% (median: 37%, p<0.001) and relative increase of 53-125% (median: 82%), and antibody titer to type 2 increasing by 2-32-fold (median: 10-fold). Early age of administration and shorter intervals between doses were associated with lower immunogenicity. DISCUSSION: Overall, two fIPV doses are more immunogenic than a single full-dose, associated with significantly increased seroconversion rates and antibody titers. Two fIPV doses together use two-fifth of the vaccine compared to one full-dose IPV. In response to the current IPV shortage, a schedule of two fIPV doses at ages 6 and 14weekshas been endorsed by technical oversight committees and has been introduced in some affected countries.

      2. Effectiveness of rotavirus vaccination: a systematic review of the first decade of global post-licensure data, 2006-2016
        Jonesteller CL, Burnett E, Yen C, Tate JE, Parashar UD.
        Clin Infect Dis. 2017 Apr 21.
        Two rotavirus vaccines, Rotarix (RV1) and RotaTeq (RV5), were licensed for global use in 2006. A systematic review of 48 peer-reviewed articles with post-licensure data from 24 countries showed a median RV1 vaccine effectiveness (VE) of 84%, 75%, and 57% in low, medium, and high child mortality countries, respectively, and RV5 VE of 90% in low and 45% in high child mortality countries. A partial vaccine series provided considerable protection, but not to the same level as a full series. VE tended to decline in the second year of life, particularly in medium and high mortality settings, and tended to be greater against more severe rotavirus disease. Post-licensure data from countries across geographic regions and with different child mortality levels demonstrate that under routine use, both RV1 and RV5 are effective against rotavirus disease, supporting the WHO recommendation that all countries introduce rotavirus vaccine into their national immunization program.

    • Injury and Violence RSS Word feed
      1. Changes in motorcycle-related injuries and deaths after mandatory motorcycle helmet law in a district of Vietnam
        Ha NT, Ederer D, Vo Ha VA, Van Pham A, Mounts A, Nolen L, Sugerman D.
        Traffic Inj Prev. 2017 Apr 27:0.
        OBJECTIVE: Our study measured the change in head injuries and deaths among motorcycle users in Cu Chi district, a suburban district of Ho Chi Minh City. METHODS: Hospital records for road traffic injuries (RTI) were collected from the Cu Chi Trauma Centre and motorcycle-related death records were obtained from mortality registries in commune health offices. Head injury severity was categorised using the Abbreviated Injury Score (AIS). Rate ratios (RR) were used to compare rates pre- and post-law (2005/06-2009/10). Cu Chi’s population, stratified by year, age, and sex was used as the denominator. RESULTS: Of records identifying the transportation mode at the time of injury, motorcyclists accounted for most injuries (3,035, 87%) and deaths (238, 90%). Head injuries accounted for 70% of motorcycle-related hospitalisations. Helmet use was not recorded in any death records and not in 97% of medical records. Males accounted for most injuries (73%) and deaths (88%). The median age was 28 years and 32 years for injuries and deaths, respectively. Compared to the pre-law period, rates of motorcycle injuries (RR 0.53; 95% CI 0.49-0.58), head injuries (RR 0.35; 95% CI 0.31-0.39), severe head injuries (RR 0.47; 95% CI 0.34-0.63) and deaths (RR 0.69; 95% CI 0.53-0.89) significantly decreased in the post-law period. CONCLUSIONS: Rates of head injuries and deaths among motorcycle riders decreased significantly after implementation of the mandatory helmet law in Vietnam. To further examine the impact of the motorcycle helmet law, including compliance and helmet quality, further emphasis should be placed on gathering helmet use data from injured motorcyclists.

    • Laboratory Sciences RSS Word feed
      1. Real-world performance of the new US HIV testing algorithm in medical settings
        Marson KG, Marlin R, Pham P, Cohen SE, Jones D, Roemer M, Peters PJ, Haller B, Pilcher CD.
        J Clin Virol. 2017 Apr 07.
        BACKGROUND: Our medical center laboratory recently adapted its 24/7, two-hourly testing program to use an ARCHITECT-Multispot-viral load (AR-MS-VL) algorithm in place of a previous rapid test-immunofluorescence (RT-IF) algorithm. OBJECTIVES: We evaluated screening test performance, acute case detection, turnaround time and ability to resolve HIV status under the new algorithm. STUDY DESIGN: We considered consecutive HIV tests from January to November 2015. AR-MS-VL results at Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) were compared with RT-IF results at ZSFG and also with AR-MS-VL results in the recently completed CDC Screening Targeted Populations to Interrupt On-going Chains of HIV Transmission with Enhanced Partner Notification (STOP) Study for targeted testing of MSM at publicly funded testing sites in San Francisco. RESULTS: Among 21,985 HIV tests performed at ZSFG, 16,467 were tested by RT-IF and 5518 by AR-MS-VL. There were 321 HIV infections detected, of which 274 (84%) were known HIV+ cases, and 47 were newly identified HIV infections. Considering only patients of HIV-negative or -unknown status, prevalence was 0.22%. Under the AR-MS-VL algorithm, turnaround times for screening results and full algorithm results were 3 and 21h; status-unresolved cases were reduced (from 47% to 22%) compared with the RT-IF algorithm. The positive predictive value (PPV) of a new-positive AR screening test was low (0.44) at ZSFG, where no acute infections were detected. At STOP Study sites where HIV prevalence was higher and acute infection was more common, the AR PPV was higher (0.93). All 24 false-positive AR screening tests at ZSFG had a signal/cutoff (S/CO) ratio of <15 and all 88 true-positive tests had S/CO ratio >15. Of 62 acute infections in the STOP Study, 23 (37%) had an S/CO<15. DISCUSSION: An AR-MS-VL algorithm is feasible and can return rapid results in a large medical center. In this setting, reactive 4th generation assay tests that are negative for HIV antibodies are typically false-positive with low S/CO ratios.

    • Maternal and Child Health RSS Word feed
      1. Preventing alcohol and tobacco exposed pregnancies: CHOICES Plus in primary care
        Velasquez MM, von Sternberg KL, Floyd RL, Parrish D, Kowalchuk A, Stephens NS, Ostermeyer B, Green C, Seale JP, Mullen PD.
        Am J Prev Med. 2017 Apr 17.
        INTRODUCTION: Alcohol and tobacco use are common among U.S. women, yet if used during pregnancy these substances present significant preventable risks to prenatal and perinatal health. Because use of alcohol and tobacco often continue into the first trimester and beyond, especially among women with unintended pregnancies, effective evidence-based approaches are needed to decrease these risk behaviors. This study was designed to test the efficacy of CHOICES Plus, a preconception intervention for reducing the risk of alcohol- and tobacco-exposed pregnancies (AEPs and TEPs). STUDY DESIGN: RCT with two intervention groups: CHOICES Plus (n=131) versus Brief Advice (n=130). Data collected April 2011 to October 2013. Data analysis finalized February 2016. SETTING/PARTICIPANTS: Settings were 12 primary care clinics in a large Texas public healthcare system. Participants were women who were non-sterile, non-pregnant, aged 18-44 years, drinking more than three drinks per day or more than seven drinks per week, sexually active, and not using effective contraception (N=261). Forty-five percent were smokers. INTERVENTION: Interventions were two CHOICES Plus sessions and a contraceptive visit or Brief Advice and referral to community resources. MAIN OUTCOME MEASURES: Primary outcomes were reduced risk of AEP and TEP through 9-month follow-up. RESULTS: In intention-to-treat analyses across 9 months, the CHOICES Plus group was more likely than the Brief Advice group to reduce risk of AEP with an incidence rate ratio of 0.620 (95% CI=0.511, 0.757) and absolute risk reduction of -0.233 (95% CI= -0.239, -0.226). CHOICES Plus group members at risk for both exposures were more likely to reduce TEP risk (incidence rate ratio, 0.597; 95% CI=0.424, 0.840 and absolute risk reduction, -0.233; 95% CI= -0.019, -0.521). CONCLUSIONS: CHOICES Plus significantly reduced AEP and TEP risk. Addressing these commonly co-occurring risk factors in a single preconception program proved both feasible and efficacious in a low-income primary care population. Intervening with women before they become pregnant could shift the focus in clinical practice from treatment of substance-exposed pregnancies to prevention of a costly public health concern. TRIAL REGISTRATION: This study is registered at clinicaltrials.gov NCT01032772.

  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. The limitations of transforming very high body mass indexes into z-scores among 8.7 million 2- to 4-year-old children
        Freedman DS, Butte NF, Taveras EM, Goodman AB, Ogden CL, Blanck HM.
        J Pediatr. 2017 Apr 19.
        OBJECTIVE: To examine the associations among several body mass index (BMI) metrics (z-scores, percent of the 95th percentile (%BMIp95) and BMI minus 95th percentile (DeltaBMIp95) as calculated in the growth charts from the Centers for Disease Control and Prevention (CDC). It is known that the widely used BMI z-scores (BMIz) and percentiles calculated from the growth charts can differ substantially from those that directly observed in the data for BMIs above the 97th percentile (z = 1.88). STUDY DESIGN: Cross-sectional analyses of 8.7 million 2- to 4-year-old children who were examined from 2008 through 2011 in the CDC’s Pediatric Nutrition Surveillance System. RESULTS: Because of the transformation used to calculate z-scores, the theoretical maximum BMIz varied by >3-fold across ages. This results in the conversion of very high BMIs into a narrow range of z-scores that varied by sex and age. Among children with severe obesity, levels of BMIz were only moderately correlated (r ~ 0.5) with %BMIp95 and DeltaBMIp95. Among these children with severe obesity, BMIz levels could differ by more than 1 SD among children who had very similar levels of BMI, %BMIp95 and DeltaBMIp95 due to differences in age or sex. CONCLUSIONS: The effective upper limit of BMIz values calculated from the CDC growth charts, which varies by sex and age, strongly influences the calculation of z-scores for children with severe obesity. Expressing these very high BMIs relative to the CDC 95th percentile, either as a difference or percentage, would be preferable to using BMI-for-age, particularly when assessing the effectiveness of interventions.

      2. Associations between persistent organic pollutants, type 2 diabetes, diabetic nephropathy and mortality
        Grice BA, Nelson RG, Williams DE, Knowler WC, Mason C, Hanson RL, Bullard KM, Pavkov ME.
        Occup Environ Med. 2017 Apr 24.
        OBJECTIVE: Relationships were examined between persistent organic pollutants (POPs) and incident type 2 diabetes, end-stage renal disease (ESRD) and mortality. METHODS: In a nested case-control study, 300 persons without diabetes had baseline examinations between 1969 and 1974; 149 developed diabetes (cases) and 151 remained non-diabetic (controls) during 8.0 and 23.1 years of follow-up, respectively. POPs were measured at baseline. ORs for diabetes were computed by logistic regression analysis. The cases were followed from diabetes onset to ESRD, death or 2013. HRs for ESRD and mortality were computed by cause-specific hazard models. Patterns of association were explored using principal components analysis. RESULTS: PCB151 increased the odds for incident diabetes, whereas hexachlorobenzene (HCB) was protective after adjusting for age, sex, body mass index, sample storage characteristics, glucose and lipid levels. Associations between incident diabetes and polychlorinatedbiphenyl (PCB) or persistent pesticide (PST) components were mostly positive but non-significant. Among the cases, 29 developed ESRD and 48 died without ESRD. PCB28, PCB49 and PCB44 increased the risk of ESRD after adjusting for baseline demographic and clinical characteristics. Several PCBs and PSTs increased the risk of death without ESRD. The principal components analysis identified PCBs with low-chlorine load positively associated with ESRD and death without ESRD, and several PSTs associated with death without ESRD. CONCLUSIONS: Most POPs were positively but not significantly associated with incident diabetes. PCB151 was significantly predictive and HCB was significantly protective for diabetes. Among participants with diabetes, low-chlorine PCBs increase the risk of ESRD and death without ESRD, whereas several PSTs predict death without ESRD.

      3. Diabetes, depressive symptoms, and functional disability in African Americans: the Jackson Heart Study
        Kalyani RR, Ji N, Carnethon M, Bertoni AG, Selvin E, Gregg EW, Sims M, Golden SH.
        J Diabetes Complications. 2017 Mar 09.
        AIMS: To investigate the degree to which comorbid depression contributes to the relationship of diabetes with functional disability in African Americans (AAs), a population at high-risk for complications. METHODS: We examined 2989 African Americans (AAs) in the Jackson Heart Study who had diabetes and depressive symptoms (CES-D) assessed at baseline. Overall functional disability was defined as the inability to perform at least one task of daily living. Multivariable logistic regression models explored the association of diabetes and depressive symptoms with functional disability. RESULTS: Prevalence of overall functional disability was highest with both diabetes and depressive symptoms (54%), similar with diabetes alone (31%) or depressive symptoms alone (33%), and lowest with neither (15%). Adjusting for demographics, smoking, BMI, cardiovascular comorbidities, and hsCRP, the association of depressive symptoms alone (OR=2.30,95% CI 1.75-3.03) and both diabetes and depressive symptoms (OR=2.75,1.88-4.04) with overall functional disability was significant, but not for diabetes alone (OR=1.26,0.95-1.67), compared to neither. In regression analyses including any diabetes and any depressive symptoms together in models, the main effect of depressive symptoms but not diabetes was associated with overall functional disability, and the interaction term was not significant (p-value=0.84). CONCLUSIONS: Functional disability was highest among AAs who have both diabetes and depressive symptoms; the latter was a stronger contributor. Future studies should explore mechanisms underlying functional disability in diabetes, particularly the role of depression.

      4. Diabetes self-management education programs in nonmetropolitan counties – United States, 2016
        Rutledge SA, Masalovich S, Blacher RJ, Saunders MM.
        MMWR Surveill Summ. 2017 Apr 28;66(10):1-6.
        PROBLEM/CONDITION: Diabetes self-management education (DSME) is a clinical practice intended to improve preventive practices and behaviors with a focus on decision-making, problem-solving, and self-care. The distribution and correlates of established DSME programs in nonmetropolitan counties across the United States have not been previously described, nor have the characteristics of the nonmetropolitan counties with DSME programs. REPORTING PERIOD: July 2016. DESCRIPTION OF SYSTEMS: DSME programs recognized by the American Diabetes Association or accredited by the American Association of Diabetes Educators (i.e., active programs) as of July 2016 were shared with CDC by both organizations. The U.S. Census Bureau’s census geocoder was used to identify the county of each DSME program site using documented addresses. County characteristic data originated from the U.S. Census Bureau, compiled by the U.S. Department of Agriculture’s Economic Research Service into the 2013 Atlas of Rural and Small-Town America data set. County levels of diagnosed diabetes prevalence and incidence, as well as the number of persons with diagnosed diabetes, were previously estimated by CDC. This report defined nonmetropolitan counties using the rural-urban continuum code from the 2013 Atlas of Rural and Small-Town America data set. This code included six nonmetropolitan categories of 1,976 urban and rural counties (62% of counties) adjacent to and nonadjacent to metropolitan counties. RESULTS: In 2016, a total of 1,065 DSME programs were located in 38% of the 1,976 nonmetropolitan counties; 62% of nonmetropolitan counties did not have a DSME program. The total number of DSME programs for nonmetropolitan counties with at least one DSME program ranged from 1 to 8, with an average of 1.4 programs. After adjusting for county-level characteristics, the odds of a nonmetropolitan county having at least one DSME program increased as the percentage insured increased (adjusted odds ratio [AOR] = 1.10, 95% confidence interval [CI] = 1.08-1.13), the percentage with a high school education or less decreased (AOR = 1.06, 95% CI = 1.04-1.07), the unemployment rate decreased (AOR = 1.19, 95% CI = 1.11-1.23), and the natural logarithm of the number of persons with diabetes increased (AOR = 3.63, 95% CI = 3.15-4.19). INTERPRETATION: In 2016, there were few DMSE programs in nonmetropolitan, socially disadvantaged counties in the United States. The number of persons with diabetes, percentage insured, percentage with a high school education or less, and the percentage unemployed were significantly associated with whether a DSME program was located in a nonmetropolitan county. PUBLIC HEALTH ACTION: Monitoring the distribution of DSME programs at the county level provides insight needed to strategically address rural disparities in diabetes care and outcomes. These findings provide information needed to assess lack of availability of DSME programs and to explore evidence-based strategies and innovative technologies to deliver DSME programs in underserved rural communities.

    • Communicable Diseases RSS Word feed
      1. Scale-up of collaborative TB/HIV activities in Guyana
        Baker BJ, Peterson B, Mohanlall J, Singh S, Hicks C, Jacobs R, Ramos R, Allen B, Pevzner E.
        Rev Panam Salud Publica. 2017 Apr 20;41:e6.
        Objective: To assess scale-up of recommended tuberculosis (TB)/HIV activities in Guyana and to identify specific strategies for further expansion. Methods: Medical records and clinic registers were reviewed at nine TB clinics and 10 HIV clinics. At TB clinics, data were collected on HIV testing and antiretroviral therapy (ART) for patients with TB/HIV; at HIV clinics, data were collected on intensified case finding (ICF), tuberculin skin test (TST) results, and provision of isoniazid preventive therapy (IPT). Results: At TB clinics, among 461 patients newly diagnosed with TB, 419 (90.9%) had a known HIV status and 121 (28.9%) were HIV-infected. Among the 63 patients with TB/HIV, 33 (52.4%) received ART. Among the 45 patients with TB/HIV for whom dates of HIV diagnosis were available, 38 (84.4%) individuals knew their HIV status prior to TB diagnosis. At HIV clinics, among 127 patients eligible to receive a TST, 87 (68.5%) received a TST, 66 (75.9%) had a TST result, seven (10.6%) had a newly positive result, two had a previously positive result, and six of nine patients with positive results (66.7%) received IPT. ICF could not be assessed because of incomplete or discrepant documentation. Conclusions: An in-depth evaluation of TB/HIV activities successfully identified areas of success and remaining challenges. At TB clinics, HIV testing rates are high; further scale-up of ART for persons with TB/HIV is needed. At HIV clinics, use of TST to focus IPT is a feasible and efficient strategy; improving rates of annual TST screening will allow for further expansion of IPT.

      2. Immunoglobulin-based investigation of spontaneous resolution of chlamydia trachomatis infection
        Bakshi R, Gupta K, Jordan SJ, Brown LT, Press CG, Gorwitz RJ, Papp JR, Morrison SG, Lee JY, Morrison RP, Geisler WM.
        J Infect Dis. 2017 Apr 21.
        Chlamydia trachomatis (CT) elementary body (EB) ELISA was used to investigate serum anti-CT IgG1 (long-lived response) and IgG3 (short-lived response indicating more recent infection) from treatment (enrollment) and 6-month follow-up visits in 77 women previously classified as having spontaneous resolution of chlamydia. 71.4% of women were IgG1+IgG3+, consistent with more recent chlamydia resolution. 15.6% were IgG3- at both visits, suggesting absence of recent chlamydia. Using EB ELISA, we demonstrated about one in six women classified as having spontaneous resolution of chlamydia might have been exposed to CT but not infected. Further, we classified their possible infection stage.

      3. Co-trimoxazole prophylaxis, asymptomatic malaria parasitemia, and infectious morbidity in HIV-exposed uninfected infants in Malawi: The BAN study
        Davis NL, Wiener J, Juliano JJ, Adair L, Chasela CS, Kayira D, Hudgens MG, van der Horst C, Jamieson DJ, Kourtis AP.
        Clin Infect Dis. 2017 Apr 21.
        Background: HIV-exposed infants are disproportionately at risk of morbidity and mortality compared with their HIV-unexposed counterparts. The role of co-trimoxazole preventive therapy (CPT) in reducing leading causes of infectious morbidity is unclear. Methods: We used data from the Breastfeeding, Antiretrovirals and Nutrition (BAN) clinical trial (conducted 2004-2010, Malawi) to assess the association of 1) CPT and 2) asymptomatic malaria parasitemia with respiratory and diarrheal morbidity in infants. In June 2006, all HIV-exposed infants in BAN began receiving CPT (240 mg) from 6-36 weeks of age, or until weaning occurred and HIV infection was ruled out. All HIV-exposed, uninfected infants (HEI) at 8 weeks of age (n=1984) were included when CPT was the exposure. A subset of HEI (n=471) were tested for malarial parasitemia using dried blood spots from 12, 24, and 36 weeks of age. Cox proportional hazards models for recurrent gap-time data were used to examine the association of time-varying exposures on morbidity. Results: CPT was associated with a 36% reduction in respiratory morbidity (hazard ratio (HR) 0.64, 95% confidence interval (CI) 0.60-0.69) and a 41% reduction in diarrheal morbidity (HR 0.59, 95% CI 0.54-0.65). Having asymptomatic malaria parasitemia was associated with a 40% increase in respiratory morbidity (HR 1.40, 95% CI 1.13-1.74) and a 50% increase in diarrheal morbidity (HR 1.50, 95% CI 1.09-2.06), after adjusting for CPT. Conclusion: CPT may have an important role to play in reducing the leading global causes of morbidity and mortality in the growing population of HEIs in malaria-endemic resource-limited settings.

      4. Heightened HIV antibody responses in postpartum women as exemplified by recent infection assays: implications for incidence estimates
        Hargrove J, van Schalkwyk C, Humphrey J, Mutasa K, Ntozini R, Owen M, Masciotra S, Parekh B, Duong YT, Dobbs T, Kilmarx P, Gonese E.
        AIDS Res Hum Retroviruses. 2017 Apr 26.
        BACKGROUND: Laboratory assays that identify recent HIV infections are important for assessing impacts of interventions aimed at reducing HIV incidence. Kinetics of HIV humoral responses can vary with inherent assay properties, and between HIV subtypes, populations and physiological states. They are important in determining mean duration of recent infection (MDRI) for antibody-based assays for detecting recent HIV infections. METHODS: We determined MDRIs for BED-CEIA, LAg and BRAI assays for 101 seroconverting postpartum women, recruited in Harare in 1997- 2000 during the Zimbabwe Vitamin A for Mothers and Babies (ZVITAMBO) Trial, comparing them against published MDRIs estimated from seroconverting cases in the general population. We also compared MDRIs for women who seroconverted either during the first nine months, or at later stages, postpartum. RESULTS: At cut-offs (C) of 0.8 for BED, 1.5 for LAg and 40% for BRAI, estimated MDRIs for postpartum mothers, were 192, 104 and 144 days, 33%, 32-41% and 52% lower than published estimates of 287, 152-177 and 298 days, respectively, for clade C samples from general populations. Point estimates of MDRI values were 7 – 19% shorter for women who seroconverted in the first 9- months postpartum, compared with those seroconverting later. CONCLUSIONS: MDRI values for three HIV incidence biomarkers are longer in the general population than among postpartum women, particularly those who recently gave birth, consistent with heightened immunologic activation soon after birth. Our results provide a caution that MDRI may vary significantly between subjects in different physiological states.

      5. Hospitalization rates among people with HIV/AIDS in New York City, 2013
        Lazar R, Kersanske L, Xia Q, Daskalakis D, Braunstein SL.
        Clin Infect Dis. 2017 Apr 24.
        Background: Hospitalizations are an important indicator of health care quality and access for people with HIV/AIDS. This study assesses hospitalization rates among people with HIV/AIDS in New York City. Methods: We performed a deterministic match between people in the New York City HIV surveillance registry alive as of 1/1/2013 and diagnosed with HIV as of 12/31/2013 and patient-level inpatient hospitalization records during 2013. Event-level data were analyzed to determine characteristics of and reasons for hospitalizations. Primary diagnoses were classified using the International Classification of Diseases, Ninth Revision, Clinical Modification. We estimated hospitalization rates as the number of hospitalizations per 100 person-years for all causes, AIDS-defining illnesses, and non-AIDS-defining infections. Results: Nearly one-fifth of hospitalizations were attributed to non-AIDS-defining infections, while AIDS-defining illness diagnoses were infrequent (3.6% of hospitalizations). Other common causes were cardiovascular (10.9%) and substance use (9.8%). The estimated all-cause hospitalization rate was 36.7 per 100 person-years. Higher all-cause hospitalization rates were observed among females (46.8 per 100 person-years), Black and Latino/Hispanic people (41.8 and 39.5 per 100 person-years, respectively), people living in high poverty neighborhoods (47.4 per 100 person-years), and people with a history of injection drug use (74.9 per 100 person-years). The estimated AIDS-defining-illness and non-AIDS-defining infection hospitalization rates were 1.3 and 7.2 per 100 person-years, respectively. Conclusions: People with HIV in New York City were frequently hospitalized. While AIDS-defining illnesses were relatively rare, non-AIDS-defining infection hospitalizations were more common. Disparities in hospitalization rates indicate a need for targeted improved primary care and comorbid disease management.

      6. Outcomes after antiretroviral therapy during the expansion of HIV services in Haiti
        McNairy ML, Joseph P, Unterbrink M, Galbaud S, Mathon JE, Rivera V, Jannat-Khah D, Reif L, Koenig SP, Domercant JW, Johnson W, Fitzgerald DW, Pape JW.
        PLoS One. 2017 ;12(4):e0175521.
        BACKGROUND: We report patient outcomes after antiretroviral therapy (ART) initiation in a network of HIV facilities in Haiti, including temporal trends and differences across clinics, during the expansion of HIV services in the country. METHODS: We assessed outcomes at 12 months after ART initiation (baseline) using routinely collected data on adults (>/=15 years) in 11 HIV facilities from July 2007-December 2013. Outcomes include death (ascertained from medical records), lost to follow-up (LTF) defined as no visit > 365 days from ART initiation, and retention defined as being alive and attending care >/= 365 days from ART initiation. Outcomes were compared across calendar year of ART initiation and across facilities. Risk factors for death and LTF were assessed using Cox proportional hazards and competing risk regression models. RESULTS: Cumulatively, 9,718 adults initiated ART with median age 37 years (IQR 30-46). Median CD4 count was 254 cells/uL (IQR 139-350). Twelve months after ART initiation, 4.4% (95% CI 4.0-4.8) of patients died, 21.7% (95% CI 20.9-22.6) were LTF, and 73.9% (95% CI 73.0-74.8) were retained in care. Twelve-month mortality decreased from 13.8% among adults who started ART in 2007 to 4.4% in 2013 (p<0.001). Twelve-month LTF after ART start was 29.2% in 2007, 18.7% in 2008, and increased to 30.1% in 2013 (p<0.001). Overall, twelve-month retention after ART start did not change over time but varied widely across facilities from 61.1% to 86.5%. CONCLUSION: Expansion of HIV services across Haiti has been successful with increasing numbers of patients initiating ART and decreasing twelve-month mortality rates. However, overall retention has not improved, despite differences across facilities, suggesting additional strategies to improve engagement in care are needed.

      7. Mumps outbreak among a highly vaccinated university community – New York City, January-April 2014
        Patel LN, Arciuolo RJ, Fu J, Giancotti FR, Zucker JR, Rakeman JL, Rosen JB.
        Clin Infect Dis. 2017 Feb 15;64(4):408-412.
        Background: On 14 January 2014, a vaccinated student presented with parotitis. Mumps immunoglobulin M (IgM) testing was negative and reverse-transcription polymerase chain reaction (RT-PCR) testing was not performed, resulting in a missed diagnosis and the start of an outbreak at a New York City (NYC) university. Methods: Mumps case investigations included patient interviews, medical records review, and laboratory testing including mumps serology and RT-PCR. Case patients were considered linked to the outbreak if they attended or had epidemiologic linkage to the university. Epidemiologic, clinical, and laboratory data for outbreak cases residing in NYC were analyzed. Results: Fifty-six NYC residents with mumps were identified with onset between 12 January and 30 April 2014. Fifty-three cases (95%) were university students, 1 (2%) was a staff member, and 2 (4%) had epidemiologic links to the university. The median age was 20 years (range 18-37 years). All cases had parotitis. Three cases were hospitalized, including 1 of 2 cases with orchitis. Fifty-four (96%) cases had received >/=1 mumps-containing vaccine, 1 (2%) was unvaccinated due to religious exemption, and 1 (2%) had unknown vaccination status. Two of the 44 (5%) cases tested by serology were mumps IgM positive, and 27 of the 40 (68%) tested by RT-PCR were positive. Conclusions.: Mumps outbreaks can occur in highly vaccinated populations. Mumps should be considered in patients with parotitis regardless of vaccination status. RT-PCR is the preferred testing method; providers should not rely on IgM testing alone. High vaccination coverage and control measures likely limited the extent of the outbreak.

      8. Estimation of state-level prevalence of hepatitis C virus infection, US states and District of Columbia, 2010
        Rosenberg ES, Hall EW, Sullivan PS, Sanchez TH, Workowski KA, Ward JW, Holtzman D.
        Clin Infect Dis. 2017 Apr 26.
        Background.: Hepatitis C virus (HCV) infection is the most common chronic blood-borne infection in the United States and a leading cause of morbidity and mortality. Previous analyses of the US National Health and Nutrition Examination Survey (NHANES) indicated approximately 3.6 million noninstitutionalized persons with antibody to HCV (anti-HCV). However, state-level prevalence remains less understood and cannot be estimated reliably from NHANES alone. Methods.: We used 3 publicly available government data sources to estimate anti-HCV prevalence in each US state among noninstitutionalized persons aged >/=18 years. A small-area estimation model combined indirect standardization of NHANES-based prevalence with logistic regression modeling of mortality data, listing acute or chronic HCV infection as a cause of death, from the National Vital Statistics System during 1999-2012. Model results were combined with US Census population sizes to estimate total number and prevalence of persons with antibody to HCV in 2010. Results.: National anti-HCV prevalence was 1.67% (95% confidence interval [CI], 1.53-1.90), or 3 911 800 (95% CI, 3 589 400- 4 447 500) adults in 2010. State-specific prevalence ranged from 0.71% (Illinois) to 3.34% (Oklahoma). The West census region had the highest region-specific prevalence (2.14% [95% CI, 1.96-2.48]); 10 of 13 states had rates above the national average. The South had the highest number of persons with anti-HCV (n = 1561600 [95% CI, 1 427 700-1 768 900]). The Midwest had the lowest region-specific prevalence (1.14% [95% CI, 1.04%-1.30%]). Conclusions.: States in the US West and South have been most impacted by hepatitis C. Estimates of HCV infection burden are essential to guide policy and programs to optimally prevent, detect, and cure infection.

    • Disease Reservoirs and Vectors RSS Word feed
      1. Isolation of the Lyme disease spirochete Borrelia mayonii from naturally infected rodents in Minnesota
        Johnson TL, Graham CB, Hojgaard A, Breuner NE, Maes SE, Boegler KA, Replogle AJ, Kingry LC, Petersen JM, Eisen L, Eisen RJ.
        J Med Entomol. 2017 Apr 24.
        Borrelia mayonii is a newly described member of the Borrelia burgdorferi sensu lato complex that is vectored by the black-legged tick (Ixodes scapularis Say) and a cause of Lyme disease in Minnesota and Wisconsin. Vertebrate reservoir hosts involved in the enzootic maintenance of B. mayonii have not yet been identified. Here, we describe the first isolation of B. mayonii from naturally infected white-footed mice (Peromyscus leucopus Rafinesque) and an American red squirrel (Tamiasciurus hudsonicus Erxleben) from Minnesota, thus implicating these species as potential reservoir hosts for this newly described spirochete.

      2. Vector competence of Amblyomma americanum (Acari: Ixodidae) for Rickettsia rickettsii
        Levin ML, Zemtsova GE, Killmaster LF, Snellgrove A, Schumacher LB.
        Ticks Tick Borne Dis. 2017 Apr 12.
        Rickettsia rickettsii – the etiologic agent of Rocky Mountain spotted fever (RMSF) – is widely spread across the Americas. In the US, Dermacentor spp. ticks are identified as primary vectors of R. rickettsii and Rhipicephalus sanguineus s.l. has been implicated in transmission of this pathogen in several locations in the Southwest. Conversely, ticks of the genus Amblyomma are recognized vectors of RMSF in Central and South America, but not in the US. A. americanum is one of the most aggressive human-biting ticks in the US, whose geographical range overlaps with that of reported RMSF cases. Despite sporadic findings of R. rickettsii DNA in field-collected A. americanum and circumstantial association of this species with human RMSF cases, its vector competence for R. rickettsii has not been appropriately studied. Therefore, we assessed the ability of A. americanum to acquire and transmit two geographically distant isolates of R. rickettsii. The Di-6 isolate of R. rickettsii used in this study originated in Virginia and the AZ-3 isolate originated in Arizona. Under laboratory conditions, A. americanum demonstrated vector competence for both isolates, although the efficiency of acquisition and transovarial transmission was higher for Di-6 than for AZ-3 isolate. Uninfected larvae acquired the pathogen from systemically infected guinea pigs, as well as while feeding side by side with Rickettsia-infected ticks on non-rickettsiemic hosts. Once acquired, R. rickettsii was successfully maintained through the tick molting process and transmitted to susceptible animals during subsequent feedings. Guinea pigs and dogs infested with infected A. americanum developed fever, scrotal edema and dermatitis or macular rash. R. rickettsii DNA was identified in animal blood, skin, and internal organs. The prevalence of infection within tick cohorts gradually increased due to side-by-side feeding of infected and uninfected individuals from 33 to 49% in freshly molted nymphs to 71-98% in engorged females. Moreover, R. rickettsii was transmitted transovarially by approximately 28% and 14% of females infected with Di-6 and AZ-3 isolates, respectively. Hence, A. americanum is capable of acquiring, maintaining and transmitting R. rickettsii isolates originating from two different geographical regions of the US, at least under laboratory conditions. Its role in ecology and epidemiology of RMSF in the US deserves further investigation.

    • Environmental Health RSS Word feed
      1. Associations between blood BTEXS concentrations and hematologic parameters among adult residents of the U.S. Gulf states
        Doherty BT, Kwok RK, Curry MD, Ekenga C, Chambers D, Sandler DP, Engel LS.
        Environ Res. 2017 Apr 24;156:579-587.
        BACKGROUND: Studies of workers exposed to benzene at average air concentrations below one part per million suggest that benzene, a known hematotoxin, causes hematopoietic damage even at low exposure levels. However, evidence of such effects outside of occupational settings and for other volatile organic compounds (VOCs) is limited. OBJECTIVE: To investigate associations between ambient exposures to five VOCs, including benzene, and hematologic parameters among adult residents of the U.S. Gulf Coast. MATERIALS AND METHODS: Blood concentrations of selected VOCs were measured in a sample of adult participants in the Gulf Long-term Follow-up Study (GuLF STUDY) during 2012 and 2013. Complete blood counts with differentials were also performed on a subset of participants (n=406). We used these data together with detailed questionnaire data to estimate adjusted associations between blood BTEXS (benzene, toluene, ethylbenzene, o-xylene, m/p-xylene, and styrene) concentrations and hematologic parameters using generalized linear models. RESULTS: We observed inverse associations between blood benzene concentrations and hemoglobin concentration and mean corpuscular hemoglobin concentration, and a positive association with red cell distribution width among tobacco smoke-unexposed participants (n=146). Among tobacco smoke-exposed participants (n=247), we observed positive associations between blood VOC concentrations and several hematologic parameters, including increased white blood cell and platelet counts, suggestive of hematopoietic stimulation typically associated with tobacco smoke exposure. Most associations were stronger for benzene than for the other VOCs. CONCLUSIONS: Our results suggest that ambient exposure to BTEXS, particularly benzene, may be associated with hematologic effects, including decreased hemoglobin concentration, mean corpuscular hemoglobin concentration, and increased red cell distribution width.

    • Genetics and Genomics RSS Word feed
      1. Ribotypes associated with Clostridium difficile outbreaks in Brazil display distinct surface protein profiles
        Ferreira TG, Moura H, Barr JR, Pilotto Domingues RM, Ferreira EO.
        Anaerobe. 2017 Apr 20.
        Clostridium difficile is a spore-forming anaerobic intestinal pathogen that causes Clostridium difficile infection (CDI). C. difficile is the leading cause of toxin-mediated nosocomial antibiotic-associated diarrhea. The pathogenesis of CDI is attributed to two major virulence factors, TcdA and TcdB toxins, that cause the symptomatic infection. C. difficile also expresses a number of key proteins, including cell wall proteins (CWPs). S-layer proteins (SLPs) are CWPs that form a paracrystalline surface array that coats the surface of the bacterium. SLPs have a role in C. difficile binding to the gastrointestinal tract, but their importance in virulence need to be better elucidated. Here, we describe bottom-up proteomics analysis of surface-enriched proteins fractions obtained through glycine extraction of five C. difficile clinical isolates from Brazil using gel-based and gel-free approaches. We were able to identify approximately 250 proteins for each strain, among them SlpA, Cwp2, Cwp6, CwpV and Cwp84. Identified CWPs presented different amino acid coverage, which might suggest differences in post-translational modifications. Proteomic analysis of SLPs from ribotype 133, agent of C. difficile outbreaks in Brazil, revealed unique proteins and provided additional information towards in depth characterization of the strains causing CDI in Brazil.

    • Health Disparities RSS Word feed
      1. Racial and ethnic differences in a linkage with the National Death Index
        Miller EA, McCarty FA, Parker JD.
        Ethn Dis. 2017 Spring;27(2):77-84.
        OBJECTIVES: Differences in the availability of a Social Security Number (SSN) by race/ethnicity could affect the ability to link with death certificate data in passive follow-up studies and possibly bias mortality disparities reported with linked data. Using 1989-2009 National Health Interview Survey (NHIS) data linked with the National Death Index (NDI) through 2011, we compared the availability of a SSN by race/ethnicity, estimated the percent of links likely missed due to lack of SSNs, and assessed if these estimated missed links affect race/ethnicity disparities reported in the NHIS-linked mortality data. METHODS: We used preventive fraction methods based on race/ethnicity-specific Cox proportional hazards models of the relationship between availability of SSN and mortality based on observed links, adjusted for survey year, sex, age, respondent-rated health, education, and US nativity. RESULTS: Availability of a SSN and observed percent linked were significantly lower for Hispanic and Asian/Pacific Islander (PI) participants compared with White non-Hispanic participants. We estimated that more than 18% of expected links were missed due to lack of SSNs among Hispanic and Asian/PI participants compared with about 10% among White non-Hispanic participants. However, correcting the observed links for expected missed links appeared to only have a modest impact on mortality disparities by race/ethnicity. CONCLUSIONS: Researchers conducting analyses of mortality disparities using the NDI or other linked death records, need to be cognizant of the potential for differential linkage to contribute to their results.

    • Health Economics RSS Word feed
      1. Breast cancer treatment costs in younger, privately insured women
        Allaire BT, Ekwueme DU, Poehler D, Thomas CC, Guy GP, Subramanian S, Trogdon JG.
        Breast Cancer Res Treat. 2017 Apr 21.
        PURPOSE: Younger women (under age 45 years) diagnosed with breast cancer often face more aggressive tumors, higher treatment intensity, lower survival rates, and greater financial hardship. The purpose of this study was to estimate breast cancer costs by stage at diagnosis during the first 18 months of treatment for privately insured younger women. METHODS: We analyzed North Carolina cancer registry data linked to claims data from private insurers from 2003 to 2010. Breast cancer patients were split into two cohorts: a younger and older group aged 21-44 and 45-64 years, respectively. We conducted a cohort study and matched women with and without breast cancer using age, ZIP, and Charlson Comorbidity Index. We calculated mean excess costs between breast cancer and non-breast cancer patients at 6, 12, and 18 months. RESULTS: For younger women, AJCC 6th edition stage II cancer was the most common at diagnosis (40%), followed by stage I (34%). On the other hand, older women had more stage I (46%) cancer followed by stage II (34%). The excess costs for younger and older women at 12 months were $97,486 (95% confidence interval [CI] $93,631-101,341) and $75,737 (95% CI $73,962-77,512), respectively. Younger breast cancer patients had both a higher prevalence of later-stage disease and higher within-stage costs. CONCLUSIONS: The study reports high costs of treatment for both younger and older women than a non-cancer comparison group; however, the estimated excess cost was significantly higher for younger women. The financial implications of breast cancer treatment costs for younger women need to be explored in future studies.

      2. Cost of cancer-related neutropenia or fever hospitalizations, United States, 2012
        Tai E, Guy GP, Dunbar A, Richardson LC.
        J Oncol Pract. 2017 Apr 24:Jop2016019588.
        PURPOSE: Neutropenia and subsequent infections are life-threatening treatment-related toxicities of chemotherapy. Among patients with cancer, hospitalizations related to neutropenic complications result in substantial medical costs, morbidity, and mortality. Previous estimates for the cost of cancer-related neutropenia hospitalizations are based on older and limited data. This study provides nationally representative estimates of the cost of cancer-related neutropenia hospitalizations. METHODS: We examined data from the 2012 National Inpatient Sample and Kids’ Inpatient Database. Hospitalizations for cancer-related neutropenia were defined as those with a primary or secondary diagnosis of cancer and a diagnosis of neutropenia or a fever of unknown origin. We examined characteristics of cancer-related neutropenia hospitalizations among children (age < 18 years) and adults (age >/= 18 years). Adjusted predicted margins were used to estimate length of stay and cost per stay. RESULTS: There were 91,560 and 16,859 cancer-related neutropenia hospitalizations among adults and children, respectively. Total cost of cancer-related neutropenia hospitalizations was $2.3 billion for adults and $439 million for children. Cancer-related neutropenia hospitalizations accounted for 5.2% of all cancer-related hospitalizations and 8.3% of all cancer-related hospitalization costs. For adults, the mean length of stay for cancer-related neutropenia hospitalizations was 9.6 days, with a mean hospital cost of $24,770 per stay. For children, the mean length of stay for cancer-related neutropenia hospitalizations was 8.5 days, with a mean hospital cost of $26,000 per stay. CONCLUSION: We found the costs of cancer-related neutropenia hospitalizations to be substantially high. Efforts to prevent and minimize neutropenia-related complications among patients with cancer may decrease hospitalizations and associated costs.

    • Healthcare Associated Infections RSS Word feed
      1. Future research opportunities in peri-prosthetic joint infection prevention
        Berbari E, Segreti J, Parvizi J, Berrios-Torres SI.
        Surg Infect (Larchmt). 2017 Apr 27.
        Peri-prosthetic joint infection (PJI) is a serious complication of prosthetic joint arthroplasty. A better understanding and reversal of modifiable risk factors may lead to a reduction in the incidence of incisional (superficial and deep) and organ/space (e.g., PJI) surgical site infections (SSI). Recently, the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) published the Guideline for Prevention of Surgical Site Infection. This targeted update applies evidence-based methodology in drafting recommendations for potential strategies to reduce the risk of SSI both across surgical procedures and specifically in prosthetic joint arthroplasty. A panel of PJI content experts identified nine PJI prevention research opportunities based on both evidence gaps identified through the guideline development process (transfusion, immunosuppressive therapy, anticoagulation, orthopedic space suit, and biofilm) and expert opinion (anesthesia, operative room environment, glycemic control, and Staphylococcus aureus nasal screening and decolonization. This article offers a road map for PJI prevention research.

      2. Creutzfeldt-Jakob disease lookback study: 21 years of surveillance for transfusion transmission risk
        Crowder LA, Schonberger LB, Dodd RY, Steele WR.
        Transfusion. 2017 Apr 25.
        BACKGROUND: Transfusion transmission of human prion diseases has been observed for variant Creutzfeldt-Jakob disease (vCJD), but not for the classic forms of prion disease (CJD: sporadic, genetic, and iatrogenic). Although the presence of prions or misfolded prion proteins in blood has been documented in some patients with the most common form of CJD, sporadic CJD, no transfusion-transmitted cases of CJD have been recognized. Since 1995, the American Red Cross has conducted a lookback study of the recipients of blood products from donors who develop CJD to assess the risk of blood-borne CJD transmission in the United States. STUDY DESIGN AND METHODS: Blood donors subsequently diagnosed with confirmed or probable CJD were enrolled and the consignees were asked to identify the recipients of their blood products. These donors’ transfusion recipients are traced annually with the National Death Index to see if they subsequently die of CJD. RESULTS: To date, 65 CJD donors have been enrolled along with 826 of their blood recipients. These recipients have contributed 3934 person-years of follow-up and no transfusion-transmitted cases of CJD have been recognized. CONCLUSION: From this study, as well as other epidemiologic studies, there is no evidence of CJD transfusion transmission; this risk remains theoretical.

      3. The effect of a piperacillin/tazobactam shortage on antimicrobial prescribing and Clostridium difficile risk in 88 U.S. medical centers
        Gross AE, Johannes RS, Gupta V, Tabak YP, Srinivasan A, Bleasdale SC.
        Clin Infect Dis. 2017 Apr 24.
        Background: Anti-infective shortages are a pervasive problem in the U.S. The objective of this study was to identify any associations between changes in antibiotic prescribing during a piperacillin/tazobactam (PIP/TAZO) shortage and hospital-onset Clostridium difficile infection (HO-CDI) risk in 88 U.S medical centers. Methods: We analyzed electronically captured microbiology and antibiotic use data from a network of U.S. hospitals from July 2014 through June 2015. The primary outcome was HO-CDI rate and secondary outcome was changes in antibiotic usage. We fit a Poisson model to estimate the risk of HO-CDI associated with PIP/TAZO shortage that were associated with increased high-risk antibiotic use while controlling for hospital characteristics. Results: A total of 88 hospitals experienced PIP/TAZO shortage and 72 of them experienced a shift towards increased use of high-risk antibiotics during the shortage period. The adjusted relative risk (RR) of HO-CDI for hospitals experiencing a PIP/TAZO shortage was 1.03 (95% CI: 0.85, 1.26; P=0.73). The adjusted RR of HO-CDI for hospitals that both experienced a shortage and also showed a shift toward increased use of high-risk antibiotics was 1.30 (95% CI: 1.03, 1.64; P<0.05). Conclusions: Hospitals that experienced a PIP/TAZO shortage and responded to that shortage by shifting antibiotic usage toward antibiotics traditionally known to place patients at higher risk for CDI experienced higher HO-CDI rates; this highlights an important adverse effect of the PIP/TAZO shortage and the importance of antibiotic stewardship when mitigating drug shortages.

      4. Health care-associated infections studies project: An American Journal of Infection Control and National Healthcare Safety Network data quality collaboration
        Smith H, Brooks JE, Leaptrot D, Allen-Bridson K, Anttila A, Gross C, Hebden JN, Ryan G, Scalise E, Wright MO.
        Am J Infect Control. 2017 Apr 18.
        This case study is part of a series centered on the Centers for Disease Control and Prevention’s National Healthcare Safety Network’s (NHSN) health care-associated infection (HAI) surveillance definitions. The intent of the case study series is to foster standardized application of the NHSN’s HAI surveillance definitions among infection preventionists and accurate determination of HAI events. This specific case study focuses on the definitions found within the surgical site infection (SSI) protocol. It aims to reflect the real life and complex patient scenario surrounding a bloodstream infection that is secondary to an SSI and the application of the Present at the Time of Surgery event detail. An online survey link is provided where participants may confidentially answer questions related to the case study and receive immediate feedback in the form of correct answers and explanations and rationales. Details of the case study, answers, and explanations have been reviewed and approved by NHSN staff. We hope that participants take advantage of this educational offering and thereby gain a greater understanding of the NHSN’s HAI surveillance definitions.

    • Immunity and Immunization RSS Word feed
      1. Monovalent Hepatitis B vaccine (HepB) is heat stable, making it suitable for storage outside cold chain (OCC) at 37 degrees C for 1month. We conducted an OCC project in the Solomon Islands to determine the feasibility of and barriers to national implementation and to evaluate impact on coverage. Healthcare workers at 13 facilities maintained monovalent HepB birth dose (HepB-BD) OCC for up to 28days over 7months. Vaccination data were recorded for children born during the project and those born during 7months before the project. Timely HepB-BD coverage among facility and home births increased from 30% to 68% and from 4% to 24%, respectively. Temperature excursions above 37 degrees C were rare, but vaccine wastage was high and shortages common. Storing HepB OCC can increase HepB-BD coverage in countries with insufficient cold chain capacity or numerous home births. High vaccine wastage and unreliable vaccine supply must be addressed for successful implementation.

      2. Global impact of rotavirus vaccination on childhood hospitalizations and mortality from diarrhea
        Burnett E, Jonesteller CL, Tate JE, Yen C, Parashar UD.
        J Infect Dis. 2017 Apr 18.
        In 2006, two rotavirus vaccines were licensed. We summarize the impact of rotavirus vaccination on hospitalizations and deaths from rotavirus and all-cause acute gastroenteritis (AGE) during the first 10 years since vaccine licensure, including recent evidence from high child mortality countries. We used standardized guidelines (PRISMA) guidelines to identify observational evaluations of rotavirus vaccine impact among children <5 years of age that presented at least 12 months of pre- and post-vaccine introduction surveillance data. We identified 57 articles from 27 countries. Among children <5 years of age, the median percent reduction in AGE hospitalizations was 38% overall and 41%, 30%, 46% in low, medium, and high child mortality countries, respectively. Hospitalizations and ED visits due to rotavirus AGE were reduced by a median of 67% overall and 71%, 59%, and 60% in low, medium and high child mortality countries, respectively. Implementation of rotavirus vaccines has substantially decreased hospitalizations from rotavirus and all-cause AGE.

      3. Time for an immunisation paradigm shift
        Durrheim DN, Goodson JL.
        Trans R Soc Trop Med Hyg. 2017 Apr 21:1-2.

        [No abstract]

      4. Non-specific effects of oral polio vaccine on diarrheal burden and etiology among Bangladeshi infants
        Upfill-Brown A, Taniuchi M, Platts-Mills JA, Kirkpatrick B, Burgess SL, Oberste MS, Weldon W, Houpt E, Haque R, Zaman K, Petri WA.
        Clin Infect Dis. 2017 Apr 24.
        Background: As the global polio eradication initiative prepares to cease use of oral polio vaccine (OPV) in 2020, there is increasing interest in understanding if oral vaccination provides non-specific immunity to other infections so that the consequences of this transition can be effectively planned for and mitigated. Methods: Data was collected from infants in an urban slum in Bangladesh (Mirpur, Dhaka) as part of the PROVIDE study. Following vaccination with tOPV at 6,10, and 14 weeks, infants were randomly assigned to receive tOPV (n=315) or IPV (n=299) at 39 weeks. Episodes of diarrhea were documented through clinic visits and twice-weekly house visits through 52 weeks. 14 pathogens associated with diarrhea were analyzed with TaqMan Array Cards. Results: While the proportion of children experiencing diarrhea was not different between the tOPV and IPV groups (p=0.18), the number of days with diarrhea (p=0.0037) and the number of separate diarrheal episodes (p=0.054) trended lower in the OPV arm. Etiological analysis revealed that male tOPV recipients were less likely to have diarrhea of bacterial etiology (p=0.0099) compared to male IPV recipients, but equally likely to experience diarrhea due to viruses (p=0.57) or protozoa (p=0.14). Among the 6 bacterial enteric pathogens tested, only Campylobacter jejuni/coli detection was significantly reduced in the OPV arm (p=0.0048). Conclusions: Our results suggest that OPV may cause non-specific reductions in mortality, as has been studied elsewhere, by reducing etiology-specific diarrheal burden. This is likely driven by reductions in bacterial diarrhea. Further study of non-specific OPV effects before global cessation is supported.

      5. Case-control vaccine effectiveness studies: Data collection, analysis and reporting results
        Verani JR, Baqui AH, Broome CV, Cherian T, Cohen C, Farrar JL, Feikin DR, Groome MJ, Hajjeh RA, Johnson HL, Madhi SA, Mulholland K, O’Brien KL, Parashar UD, Patel MM, Rodrigues LC, Santosham M, Scott JA, Smith PG, Sommerfelt H, Tate JE, Victor JC, Whitney CG, Zaidi AK, Zell ER.
        Vaccine. 2017 Apr 22.
        The case-control methodology is frequently used to evaluate vaccine effectiveness post-licensure. The results of such studies provide important insight into the level of protection afforded by vaccines in a ‘real world’ context, and are commonly used to guide vaccine policy decisions. However, the potential for bias and confounding are important limitations to this method, and the results of a poorly conducted or incorrectly interpreted case-control study can mislead policies. In 2012, a group of experts met to review recent experience with case-control studies evaluating vaccine effectiveness; we summarize the recommendations of that group regarding best practices for data collection, analysis, and presentation of the results of case-control vaccine effectiveness studies. Vaccination status is the primary exposure of interest, but can be challenging to assess accurately and with minimal bias. Investigators should understand factors associated with vaccination as well as the availability of documented vaccination status in the study context; case-control studies may not be a valid method for evaluating vaccine effectiveness in settings where many children lack a documented immunization history. To avoid bias, it is essential to use the same methods and effort gathering vaccination data from cases and controls. Variables that may confound the association between illness and vaccination are also important to capture as completely as possible, and where relevant, adjust for in the analysis according to the analytic plan. In presenting results from case-control vaccine effectiveness studies, investigators should describe enrollment among eligible cases and controls as well as the proportion with no documented vaccine history. Emphasis should be placed on confidence intervals, rather than point estimates, of vaccine effectiveness. Case-control studies are a useful approach for evaluating vaccine effectiveness; however careful attention must be paid to the collection, analysis and presentation of the data in order to best inform evidence-based vaccine policies.

      6. Case-control vaccine effectiveness studies: Preparation, design, and enrollment of cases and controls
        Verani JR, Baqui AH, Broome CV, Cherian T, Cohen C, Farrar JL, Feikin DR, Groome MJ, Hajjeh RA, Johnson HL, Madhi SA, Mulholland K, O’Brien KL, Parashar UD, Patel MM, Rodrigues LC, Santosham M, Scott JA, Smith PG, Sommerfelt H, Tate JE, Victor JC, Whitney CG, Zaidi AK, Zell ER.
        Vaccine. 2017 Apr 22.
        Case-control studies are commonly used to evaluate effectiveness of licensed vaccines after deployment in public health programs. Such studies can provide policy-relevant data on vaccine performance under ‘real world’ conditions, contributing to the evidence base to support and sustain introduction of new vaccines. However, case-control studies do not measure the impact of vaccine introduction on disease at a population level, and are subject to bias and confounding, which may lead to inaccurate results that can misinform policy decisions. In 2012, a group of experts met to review recent experience with case-control studies evaluating the effectiveness of several vaccines; here we summarize the recommendations of that group regarding best practices for planning, design and enrollment of cases and controls. Rigorous planning and preparation should focus on understanding the study context including healthcare-seeking and vaccination practices. Case-control vaccine effectiveness studies are best carried out soon after vaccine introduction because high coverage creates strong potential for confounding. Endpoints specific to the vaccine target are preferable to non-specific clinical syndromes since the proportion of non-specific outcomes preventable through vaccination may vary over time and place, leading to potentially confusing results. Controls should be representative of the source population from which cases arise, and are generally recruited from the community or health facilities where cases are enrolled. Matching of controls to cases for potential confounding factors is commonly used, although should be reserved for a limited number of key variables believed to be linked to both vaccination and disease. Case-control vaccine effectiveness studies can provide information useful to guide policy decisions and vaccine development, however rigorous preparation and design is essential.

    • Injury and Violence RSS Word feed
      1. Responses from N=60,598 interviews from the 2010 Behavioral Risk Factor Surveillance System (the 10 states and the District of Columbia that included the optional Adverse Childhood Experience (ACE) module) were used to test whether associations between childhood adversity and adult mental health and alcohol behaviors vary by race/ethnicity and sex. ACE items were categorized into two types – household challenges and child abuse. Outcomes were current depression, diagnosed depression, heavy drinking and binge drinking. Logistic regression models found ACEs significantly associated with depression and excessive alcohol use, but sex did not moderate any relationships. Race/ethnicity moderated the relationship between ACEs and heavy drinking. In stratified analyses, compared to those not exposed to ACEs, non-Hispanic blacks who experienced either type of ACE were about 3 times as likely to drink heavily; Non-Hispanic whites who experienced child abuse or both ACE types were 1.5-2 times as likely to drink heavily; and Hispanics who experienced household challenges or both ACE types were 1.2 and 11 times as likely to report heavy drinking. ACEs impact depression and excessive alcohol use similarly across men and women. With the exception of heavy drinking, ACEs appear to have the same association with excessive alcohol use across race/ethnicity. It may be prudent to further investigate why the relationship between ACEs and heavy drinking may differ by race/ethnicity such that prevention strategies can be developed or refined to effectively address the needs of all sub-groups.

    • Laboratory Sciences RSS Word feed
      1. Description of a novel multiplex avidity assay for evaluating HPV antibodies
        Brady AM, Unger ER, Panicker G.
        J Immunol Methods. 2017 Apr 19.
        Limited data exists regarding antibody avidity for human papillomavirus (HPV). We describe development of a multiplex electrochemiluminescent avidity ELISA for four HPV types (HPV 6, 11, 16, 18) by adding a dissociating step to our established multiplex HPV VLP ELISA. Initial experiments exploring ammonium thiocyanate, sodium thiocyanate and guanidine hydrochloride (GuHCl) as dissociating agents identified GuHCl as most promising. Dissociation conditions with GuHCl were varied (concentration, incubation time, temperature) to select conditions with minimal impact on VLP integrity as measured with monoclonal antibodies to conformational epitopes. Avidity index (AI) was calculated based on a standard curve as ratio of bound IgG in GuHCl treated versus untreated sample. To evaluate our assay we determined AI in sera with known HPV titers. We selected 32 residual anonymized sera from individuals with a wide range of titers for HPV6, 11, 16, and 18. AIs were similar across multiple dilutions of serum within the assay’s dynamic range and were reproducible with two plate lots. This assay will aid in understanding HPV antibody avidity and maturation in response to natural infection and varying vaccine schedules. This is the first report of a VLP-based multiplexed avidity ELISA that evaluates assay parameters for all nine HPV vaccine types.

      2. Combating Enhanced intracellular survival (Eis)-mediated kanamycin resistance of Mycobacterium tuberculosis by novel pyrrolo[1,5-a]pyrazine-based Eis inhibitors
        Garzan A, Willby MJ, Ngo HX, Gajadeera CS, Green KD, Holbrook SY, Hou C, Posey JE, Tsodikov OV, Garneau-Tsodikova S.
        ACS Infect Dis. 2017 Apr 14;3(4):302-309.
        Tuberculosis (TB) remains one of the leading causes of mortality worldwide. Hence, the identification of highly effective antitubercular drugs with novel modes of action is crucial. In this paper, we report the discovery and development of pyrrolo[1,5-a]pyrazine-based analogues as highly potent inhibitors of the Mycobacterium tuberculosis (Mtb) acetyltransferase enhanced intracellular survival (Eis), whose up-regulation causes clinically observed resistance to the aminoglycoside (AG) antibiotic kanamycin A (KAN). We performed a structure-activity relationship (SAR) study to optimize these compounds as potent Eis inhibitors both against purified enzyme and in mycobacterial cells. A crystal structure of Eis in complex with one of the most potent inhibitors reveals that the compound is bound to Eis in the AG binding pocket, serving as the structural basis for the SAR. These Eis inhibitors have no observed cytotoxicity to mammalian cells and are promising leads for the development of innovative AG adjuvant therapies against drug-resistant TB.

      3. Influenza A virus (IAV) infection remains a significant cause of morbidity and mortality worldwide. One key transcription factor that is activated upon IAV infection is nuclear factor Kappa B (NF-kappaB). NF-kappaB regulation involves the inhibitor proteins NF-kappaB inhibitor beta (NFKBIB), (also known as IkappaB beta), which form complexes with NF-kappaB to sequester it in the cytoplasm. In this study, microarray data showed differential expression of several microRNAs (miRNAs) on exposure to IAV. Target scan analysis revealed that miR-4776, miR-4514 and miR-4742 potentially target NFKBIB messenger RNA (mRNA). Time-course analysis of primary bronchial epithelial cells (HBEpCs) showed that miR-4776 expression is increased within 1 h of infection, followed by its downregulation 4 h post-exposure to IAV. NFKBIB upregulation of miR-4776 correlated with a decrease in NFKBIB expression within 1 h of infection and a subsequent increase in NFKBIB expression 4 h post-infection. In addition, miRNA ago-immunoprecipitation studies and the three prime untranslated region (3′ UTR) luciferase assay confirmed that miR-4776 targets NFKBIB mRNA. Furthermore, uninfected HBEpCs transfected with miR-4776 mimic showed decreased expression of NFKBIB mRNA. Overexpression of NFKBIB protein in IAV infected cells led to lower levels of IAV. Taken together, our data suggest that miRNA-4776 modulates IAV production in infected cells through NFKBIB expression, possibly through the modulation of NF-kappaB.

    • Maternal and Child Health RSS Word feed
      1. Capture-recapture methodology to study rare conditions using surveillance data for fragile X syndrome and muscular dystrophy
        Smith MG, Royer J, Mann J, McDermott S, Valdez R.
        Orphanet J Rare Dis. 2017 Apr 21;12(1):76.
        BACKGROUND: Rare conditions can be catastrophic for families and the implications for public health can be substantial. Our study compared basic surveillance through active medical record review with a linked administrative data file to assess the number of cases of two rare conditions, fragile X syndrome (FXS) and muscular dystrophy (MD) in a population. METHODS: Two methods of data collection were used to collect information from five counties comprising two standard metropolitan statistical areas of South Carolina. The passive system relied mostly on health claims data using ICD-9 CM diagnostic codes. The active system relied on a nurse abstracting records from a list of all licensed physicians with specialties in neurology, orthopedics, and genetics. RESULTS: There were 141 FXS cases and 348 MD cases that met the case definitions using active surveillance. Additional cases were found for both conditions but they were determined to not be true cases. After linking the actively collected MD and FXS cases to passive datasets, we found that the estimated total numbers of cases were similar to using capture-recapture analysis; the positive predictive values for cases identified in the passive system were 56.6% for MD and 75.7% for FXS. CONCLUSIONS: Applying capture-recapture methods to passively collected surveillance data for rare health conditions produced an estimate of the number of true cases that was similar to that obtained through active data collection.

    • Nutritional Sciences RSS Word feed
      1. Correspondence of folate dietary intake and biomarker data
        Bailey RL, Fulgoni VL, Taylor CL, Pfeiffer CM, Thuppal SV, McCabe GP, Yetley EA.
        Am J Clin Nutr. 2017 Apr 26.
        Background: Public health concerns with regard to both low and high folate status exist in the United States. Recent publications have questioned the utility of self-reported dietary intake data in research and monitoring. Objectives: The purpose of this analysis was to examine the relation between self-reported folate intakes and folate status biomarkers and to evaluate their usefulness for several types of applications. Design: We examined usual dietary intakes of folate by using the National Cancer Institute method to adjust two 24-h dietary recalls (including dietary supplements) for within-person variation and then compared these intakes with serum and red blood cell (RBC) folate among 4878 men and nonpregnant, nonlactating women aged >/=19 y in NHANES 2011-2012, a nationally representative, cross-sectional survey, with respect to consistency across prevalence estimates and rank order comparisons.Results: There was a very low prevalence (<1%) of folate deficiency when serum (<7 nmol/L) and RBC (<305 nmol/L) folate were considered, whereas a higher proportion of the population reported inadequate total dietary folate intakes (6%). Similar patterns of change occurred between intakes and biomarkers of folate status when distributions were examined (i.e., dose response), particularly when diet was expressed in mug. Intakes greater than the Tolerable Upper Intake Level greatly increased the odds of having high serum folate (OR: 17.6; 95% CI: 5.5, 56.0). Conclusions: When assessing folate status in the United States, where fortification and supplement use are common, similar patterns in the distributions of diet and biomarkers suggest that these 2 types of status indicators reflect the same underlying folate status; however, the higher prevalence estimates for inadequate intakes compared with biomarkers suggest, among other factors, a systematic underestimation bias in intake data. Caution is needed in the use of dietary folate data to estimate the prevalence of inadequacy among population groups. The use of dietary data for rank order comparisons or to estimate the potential for dietary excess is likely more reliable.

    • Occupational Safety and Health RSS Word feed
      1. Occupational fatalities resulting from falls in the oil and gas extraction industry, United States, 2005-2014
        Mason KL, Retzer KD, Hill R, Lincoln JM.
        MMWR Morb Mortal Wkly Rep. 2017 Apr 28;66(16):417-421.
        During 2003-2013, fatality rates for oil and gas extraction workers decreased for all causes of death except those associated with fall events, which increased 2% annually during 2003-2013 (1). To better understand risk factors for these events, CDC examined fatal fall events in the oil and gas extraction industry during 2005-2014 using data from case investigations conducted by the Occupational Safety and Health Administration (OSHA). Sixty-three fatal falls were identified, accounting for 15% of all fatal events. Among fatal falls, 33 (52%) workers fell from a height of >30 feet (9 meters), and 22 (35%) fell from the derrick board, the elevated work platform located in the derrick (structure used to support machinery on a drilling rig). Fall fatalities occurred most frequently when drilling rigs were being assembled or disassembled at the well site (rigging up or rigging down) (14; 22%) or when workers were removing or inserting drill pipe into the wellbore (14; 22%). Measures that target derrickmen and workers engaged in assembling and disassembling drilling rigs (rigging up and down) could reduce falls in this industry. Companies should annually update their fall protection plans and ensure effective fall prevention programs are in place for workers at highest risk for falls, including providing trainings on proper use, fit, and inspection of personal protective equipment.

      2. Characterization of chemical contaminants generated by a desktop fused deposition modeling 3-dimensional printer
        Stefaniak AB, LeBouf RF, Yi J, Ham J, Nurkewicz T, Schwegler-Berry DE, Chen BT, Wells JR, Duling MG, Lawrence RB, Martin SB, Johnson AR, Virji MA.
        J Occup Environ Hyg. 2017 Apr 25:0.
        Printing devices are known to emit chemicals into the indoor atmosphere. Understanding factors that influence release of chemical contaminants from printers is necessary to develop effective exposure assessment and control strategies. In this study, a desktop fused deposition modeling (FDM) 3-D printer using acrylonitrile butadiene styrene (ABS) or polylactic acid (PLA) filaments and two monochrome laser printers were evaluated in a 0.5 m3 chamber. During printing, chamber air was monitored for vapors using a real-time photoionization detector (results expressed as isobutylene equivalents) to measure total volatile organic compound (TVOC) concentrations, evacuated canisters to identify specific VOCs by off-line gas chromatography-mass spectrometry (GC-MS) analysis, and liquid bubblers to identify carbonyl compounds by GC-MS. Airborne particles were collected on filters for off-line analysis using scanning electron microscopy with an energy dispersive x-ray detector to identify elemental constituents. For 3-D printing, TVOC emission rates were influenced by a printer malfunction, filament type, and to a lesser extent, by filament color; however, rates were not influenced by the number of printer nozzles used or the manufacturer’s provided cover. TVOC emission rates were significantly lower for the 3-D printer (49 to 3552 microg h-1) compared to the laser printers (5782 to 7735 microg h-1). A total of 14 VOCs were identified during 3-D printing that were not present during laser printing. 3-D printed objects continued to off-gas styrene, indicating potential for continued exposure after the print job is completed. Carbonyl reaction products were likely formed from emissions of the 3-D printer, including 4-oxopentanal. Ultrafine particles generated by the 3-D printer using ABS and a laser printer contained chromium. Consideration of the factors that influenced the release of chemical contaminants (including known and suspected asthmagens such as styrene and 4-oxopentanal) from a FDM 3-D printer should be made when designing exposure assessment and control strategies.

      3. Opportunities and obstacles in translating evidence to policy in occupational asthma
        Tarlo SM, Arif AA, Delclos GL, Henneberger P, Patel J.
        Ann Epidemiol. 2017 Mar 31.
        PURPOSE: Occupational asthma (OA), a common respiratory disorder in Western countries, is caused by exposures at the workplace. It is part of a broader definition of work-related asthma (WRA) that also includes pre-existing asthma aggravated by substances present in the workplace environment, and it is potentially preventable. The purpose of this paper is to illustrate preventive measures for occupational asthma by case studies. METHODS: In three case studies we discuss preventive measures that have been associated with reductions in incidence of occupational asthma from natural rubber latex and from diisocyanates as supported by published literature. We also discuss challenges in relation to asthma from cleaning products in healthcare work. RESULTS AND CONCLUSIONS: Several preventive measures have been associated with reduction in incidence of occupational asthma from natural rubber latex and from diisocyanates, and may provide lessons for prevention of other causes of occupational asthma. Cleaning products remain an unresolved problem at present with respect to asthma risks but potential measures include the use of safer products and safer applications such as avoidance of spray products, use of occupational hygiene methods such as improving local ventilation, and when appropriate, the use of personal protective devices.

    • Occupational Safety and Health – Mining RSS Word feed
      1. Purpose To assess the level of concordance between chest radiographic classifications of A and B Readers in a national surveillance program offered to U.S. coal miners over an approximate 36-year period. Materials and Methods The National Institute for Occupational Safety and Health (NIOSH) Coal Workers’ Health Surveillance Program (CWHSP) is a surveillance program with nonresearch designation and is exempt from Human Subjects Review Board approval (11-DRDS-NR03). Thirty-six years of data (1979-2015) from the CWHSP were analyzed, which included all conventional screen-film radiographs with a classification by at least one A Reader and one B Reader. Agreement was assessed by using kappa statistics; prevalence ratios were used to describe differences between A and B Reader determinations of image technical quality, small opacity profusion, and presence of large opacities and pleural abnormalities. Results The analysis included 79 185 matched A and B Reader chest radiograph classifications. A majority of both A and B Readers were radiologists (74.2% [213 of 287] vs 64.7% [22 of 34]; P = .04). A and B Readers had minimal agreement on technical image quality (kappa = 0.0796; 95% confidence interval [CI]: 0.07, 0.08) and the distribution of small opacity profusion (subcategory kappa, 0.2352; 95% CI: 0.22, 0.25). A Readers classified more images as “good” quality (prevalence ratio, 1.38; 95% CI: 1.35, 1.41) and identified more pneumoconiosis (prevalence ratio, 1.22; 95% CI: 1.20, 1.23). Conclusion A Readers classified substantially more radiographs with evidence of pneumoconiosis and classified higher small opacity profusion compared with B Readers. These observations reinforce the importance of multiple classifications by readers who have demonstrated ongoing competence in the International Labour Office classification system to ensure accurate radiographic classifications.

      2. Strengthening the Coal Workers’ Health Surveillance Program
        Reynolds LE, Wolfe AL, Clark KA, Blackley DJ, Halldin CN, Laney AS, Storey E.
        J Occup Environ Med. 2017 ;59(4):e71.

        [No abstract]

    • Parasitic Diseases RSS Word feed
      1. Molecular profile of malaria drug resistance markers of Plasmodium falciparum in Suriname
        Chenet SM, Akinyi Okoth S, Kelley J, Lucchi N, Huber CS, Vreden S, de Oliveira AM, Barnwell JW, Udhayakumar V, Adhin MR.
        Antimicrob Agents Chemother. 2017 Apr 24.
        In Suriname, an artesunate monotherapy therapeutic efficacy trial was recently conducted to evaluate partial artemisinin resistance emerging in Plasmodium falciparum. We genotyped the PfK13 propeller domain of P. falciparum in forty samples as well as other mutations proposed to be associated with artemisinin resistant mutants. We did not find any mutations previously associated with artemisinin resistance in Southeast Asia but we found fixed resistance mutations for chloroquine and sulfadoxine-pyrimethamine. Additionally, the Pfcrt C350R mutation, associated with reversal of CQ resistance and piperaquine selective pressure was present in 62% of the samples. Our results from neutral microsatellite data also confirmed a high parasite gene flow in the Guiana Shield. Although recruiting participants for therapeutic efficacy studies in very low malaria endemic areas is challenging due to the low number of malaria cases reported, conducting these studies along with molecular surveillance remains essential to monitor artemisinin resistant alleles and to characterize the population structure P. falciparum in areas targeting malaria elimination.

      2. Challenges and persistent questions in the treatment of trichomoniasis
        de Brum Vieira P, Tasca T, Secor WE.
        Curr Top Med Chem. 2017 ;17(11):1249-1265.
        Trichomoniasis is a sexually transmitted disease (STD) caused by infection with the protozoan parasite Trichomonas vaginalis. It is considered the most prevalent non-viral sexually transmitted disease worldwide. Recently, the infection has been associated with adverse outcomes of pregnancy and increased risks of HIV acquisition and transmission, as well as an association with cervical and prostate cancers. The consequences of trichomoniasis are likely much greater than previously recognized, both at the individual and the community level. Since many cases are asymptomatic, and the most common approach used for diagnosis (wet mount) is also one of the least sensitive, millions of T. vaginalis infections remain undiagnosed and therefore untreated. The purpose of this review is to address what is known about the treatment of T. vaginalis infections and what additional approaches could be pursued. The increasing recognition of the potential public health implications of trichomoniasis has resulted in greater attention to improving effectiveness of the interventions for affected individuals. Currently, treatment relies almost solely on one class of drugs, the 5- nitroimidazoles, which causes concern should widespread drug resistance arise. There are also concerns regarding which 5-nitroimidazole to use as not all of them are active against T. vaginalis. Finally, new therapeutic targets and active compounds with treatment potential are considered.

    • Reproductive Health RSS Word feed
      1. Trends in repeat births and use of postpartum contraception among teens – United States, 2004-2015
        Dee DL, Pazol K, Cox S, Smith RA, Bower K, Kapaya M, Fasula A, Harrison A, Kroelinger CD, D’Angelo D, Harrison L, Koumans EH, Mayes N, Barfield WD, Warner L.
        MMWR Morb Mortal Wkly Rep. 2017 Apr 28;66(16):422-426.
        Teen* childbearing (one or more live births before age 20 years) can have negative health, social, and economic consequences for mothers and their children (1). Repeat teen births (two or more live births before age 20 years) can constrain the mother’s ability to take advantage of educational and workforce opportunities (2), and are more likely to be preterm or of low birthweight than first teen births (3). Despite the historic decline in the U.S. teen birth rate during 1991-2015, from 61.8 to 22.3 births per 1,000 females aged 15-19 years (4), many teens continue to have repeat births (3). The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics both recommend that clinicians counsel women (including teens) during prenatal care about birth spacing and postpartum contraceptive use (5), including the safety and effectiveness of long-acting reversible methods that can be initiated immediately postpartum. To expand upon prior research assessing patterns and trends in repeat childbearing and postpartum contraceptive use among teens with a recent live birth (i.e., 2-6 months after delivery) (3), CDC analyzed data from the National Vital Statistics System natality files (2004 and 2015) and the Pregnancy Risk Assessment Monitoring System (PRAMS; 2004-2013). The number and proportion of teen births that were repeat births decreased from 2004 (82,997; 20.1%) to 2015 (38,324; 16.7%); in 2015, the percentage of teen births that were repeat births varied by state from 10.6% to 21.4%. Among sexually active teens with a recent live birth, postpartum use of the most effective contraceptive methods (intrauterine devices and contraceptive implants) increased from 5.3% in 2004 to 25.3% in 2013; however, in 2013, approximately one in three reported using either a least effective method (15.7%) or no method (17.2%). Strategies that comprehensively address the social and health care needs of teen parents can facilitate access to and use of effective methods of contraception and help prevent repeat teen births.

    • Substance Use and Abuse RSS Word feed
      1. Measuring progress in tobacco prevention and control: The role of surveillance
        Ahluwalia IB, Arrazola RA, Graffunder C.
        Salud Publica de Mexico. 2017 ;59:S10-S11.

        [No abstract]

      2. Smokeless tobacco products harbor diverse bacterial microbiota that differ across products and brands
        Smyth EM, Kulkarni P, Claye E, Stanfill S, Tyx R, Maddox C, Mongodin EF, Sapkota AR.
        Appl Microbiol Biotechnol. 2017 Apr 22.
        Smokeless tobacco products contain numerous chemical compounds, including known human carcinogens. Other smokeless tobacco constituents, including bacteria, may also contribute to adverse health effects among smokeless tobacco users. However, there is a lack of data regarding the microbial constituents of smokeless tobacco. Our goal was to characterize the bacterial microbiota of different smokeless tobacco products and evaluate differences across product types and brands. DNA was extracted from 15 brands of smokeless tobacco products (including dry snuff, moist snuff, snus, and Swedish snus) and 6 handmade products (e.g., toombak) using an enzymatic and mechanical lysis approach. Bacterial community profiling was performed using PCR amplification of the V1-V2 hypervariable region of the 16S rRNA gene, followed by 454 pyrosequencing of the resulting amplicons and sequence analysis using the QIIME package. Total viable counts were also determined to estimate the number of viable bacteria present in each product. Average total viable counts ranged from 0 to 9.35 x 107 CFU g-1. Analysis of the 16S rRNA gene sequences revealed high bacterial diversity across the majority of products tested: dry snuff products where characterized by the highest diversity indices compared to other products. The most dominant bacterial phyla across all products were Firmicutes, Proteobacteria, Actinobacteria, and Bacteroidetes. Significant differences in both bacterial community composition and in silico predicted gene content were observed between smokeless tobacco product types and between brands of specific smokeless tobacco products. These data are useful in order to comprehensively address potential health risks associated with the use of smokeless tobacco products.

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CDC Science Clips Production Staff

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  • Onnalee Gomez, MS, Health Scientist
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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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