DSHS Authors: Research Articles by DSHS Staff

(In date order with the most recent first).

Tanksley S, et al. Evidence and recommendation for guanidinoacetate methyltransferase deficiency newborn screening. Pediatrics. 2023 Aug 1;152(2):e2023062100. doi:10.1542/peds.2023-062100
Guanidinoacetate methyltransferase (GAMT) deficiency is an autosomal recessive disorder of creatine biosynthesis due to pathogenic variants in the GAMT gene that lead to cerebral creatine deficiency and neurotoxic levels of guanidinoacetate. Untreated, GAMT deficiency is associated with hypotonia, significant intellectual disability, limited speech development, recurrent seizures, behavior problems, and involuntary movements. The birth prevalence of GAMT deficiency is likely between 0.5 and 2 per million live births. On the basis of small case series and sibling data, presymptomatic treatment with oral supplements of creatine, ornithine, and sodium benzoate, and a protein-restricted diet to reduce arginine intake, appear to substantially improve health and developmental outcomes. Without newborn screening, diagnosis typically happens after the development of significant impairment, when treatment has limited utility. GAMT deficiency newborn screening can be incorporated into the tandem-mass spectrometry screening that is already routinely used for newborn screening, with about 1 per 100,000 newborns screening positive. After a positive screen, diagnosis is established by finding an elevated guanidinoacetate concentration and low creatine concentration in the blood. Although GAMT deficiency is significantly more rare than other conditions included in newborn screening, the feasibility of screening, the low number of positive results, the relative ease of diagnosis, and the expected benefit of presymptomatic dietary therapy led to a recommendation from the Advisory Committee on Heritable Disorders in Newborns and Children to the Secretary of Health and Human Services that GAMT deficiency be added to the Recommended Uniform Screening Panel. This recommendation was accepted in January 2023.

Das T, et al. National Association of Medical Examiners Position paper: recommendations for the documentation and certification of disaster-related deaths. Am J Forensic Med Pathol. 2023;10.1097/PAF.0000000000000859. Epub 2023 Jul 31. doi:10.1097/PAF.0000000000000859
Collecting and reporting accurate disaster mortality data are critical to informing disaster response and recovery efforts. The National Association of Medical Examiners convened an ad hoc committee to provide recommendations for the documentation and certification of disaster-related deaths. This article provides definitions for disasters and direct, indirect, and partially attributable disaster-related deaths; discusses jurisdiction for disaster-related deaths; offers recommendations for medical examiners/coroners (ME/Cs) for indicating the involvement of the disaster on the death certificate; discusses the role of the ME/C and non-ME/C in documenting and certifying disaster-related deaths; identifies existing systems for helping to identify the role of disaster on the death certificate; and describes disaster-related deaths that may require amendments of death certificates. The recommendations provided in this article seek to increase ME/C's understanding of disaster-related deaths and promote uniformity in how to document these deaths on the death certificate.

Langlois PH, Canfield MA, et al. Epidemiology of nonsyndromic, orofacial clefts in Texas: differences by cleft type and presence of additional defects. Cleft Palate Craniofac J. 2023 Jul;60(7):789-803. Epub 2022 Feb 28. doi:10.1177/10556656221080932
To describe the current epidemiology of nonsyndromic cleft palate alone (CP) and cleft lip with or without cleft palate (CL ± P) in Texas and examine differences in the characteristics of infants with CP and CL ± P based on the presence/absence of additional defects.
We used data from the Texas Birth Defects Registry, a statewide active birth defect surveillance system, from 1815 cases with CP and 5066 with CL ± P, without a syndrome diagnosis (1999-2014 deliveries). All live births in Texas were used for comparison. Poisson regression was used to calculate crude and adjusted prevalence ratios (aPR) for each characteristic, separately for each cleft subphenotype.
The prevalence of CL ± P and CP in our study was estimated as 8.3 and 3.0 per 10 000 live births, respectively. After adjusting for several characteristics, several factors were associated with CL ± P, CP, or both, including infant sex and maternal race/ethnicity, age, smoking, and diabetes. There were several differences between infants with isolated versus nonisolated clefts. For example, maternal prepregnancy diabetes was associated with an increased prevalence of CL ± P (aPR 7.91, 95% confidence interval [CI]: 5.53, 11.30) and CP (aPR 3.24, 95% CI: 1.43, 7.36), but only when additional defects were present.
Findings from this study provide a contemporary description of the distribution of orofacial clefts in Texas accounting for differences between isolated and nonisolated clefts. They may contribute to increasing our understanding of the etiology of CP and CL ± P.

Canfield MA, et al. Scientific impact of the National Birth Defects Prevention Network multistate collaborative publications. Birth Defects Res. 2023;10.1002/bdr2.2225. Epub 2023 Jul 26. doi:10.1002/bdr2.2225
Background: Given the lack of a national, population-based birth defects surveillance program in the United States, the National Birth Defects Prevention Network (NBDPN) has facilitated important studies on surveillance, research, and prevention of major birth defects. We sought to summarize NBDPN peer-reviewed publications and their impact.
Methods: We obtained and reviewed a curated list of 49 NBDPN multistate collaborative publications during 2000-2022, as of December 31, 2022. Each publication was reviewed and classified by type (e.g., risk factor association analysis). Key characteristics of study populations and analytic approaches used, along with publication impact (e.g., number of citations), were tabulated
Results: NBDPN publications focused on prevalence estimates (N = 17), surveillance methods (N = 11), risk factor associations (N = 10), mortality and other outcomes among affected individuals (N = 6), and descriptive epidemiology of various birth defects (N = 5). The most cited publications were those that reported on prevalence estimates for a spectrum of defects and those that assessed changes in neural tube defects (NTD) prevalence following mandatory folic acid fortification in the United States.
Conclusions: Results from multistate NBDPN publications have provided critical information not available through other sources, including US prevalence estimates of major birth defects, folic acid fortification and NTD prevention, and improved understanding of defect trends and surveillance efforts. Until a national birth defects surveillance program is established in the United States, NBDPN collaborative publications remain an important resource for investigating birth defects and informing decisions related to health services planning of secondary disabilities prevention and care.

Shumate CJ, et al. Are individual-level risk factors for gastroschisis modified by neighborhood-level socioeconomic factors? Birth Defects Res. 2023;10.1002/bdr2.2224. Epub 2023 Jul 13. doi:10.1002/bdr2.2224
Background: Two strong risk factors for gastroschisis are young maternal age (<20 years) and low/normal pre-pregnancy body mass index (BMI), yet the reasons remain unknown. We explored whether neighborhood-level socioeconomic position (nSEP) during pregnancy modified these associations
Methods: We analyzed data from 1269 gastroschisis cases and 10,217 controls in the National Birth Defects Prevention Study (1997-2011). To characterize nSEP, we applied the neighborhood deprivation index and used generalized estimating equations to calculate odds ratios and relative excess risk due to interaction.
Results: Elevated odds of gastroschisis were consistently associated with young maternal age and low/normal BMI, regardless of nSEP. High-deprivation neighborhoods modified the association with young maternal age. Infants of young mothers in high-deprivation areas had lower odds of gastroschisis (adjusted odds ratio [aOR]: 3.1, 95% confidence interval [CI]: 2.6, 3.8) than young mothers in low-deprivation areas (aOR: 6.6; 95% CI: 4.6, 9.4). Mothers of low/normal BMI had approximately twice the odds of having an infant with gastroschisis compared to mothers with overweight/obese BMI, regardless of nSEP (aOR range: 1.5-2.3).
Conclusion: Our findings suggest nSEP modified the association between gastroschisis and maternal age, but not BMI. Further research could clarify whether the modification is due to unidentified biologic and/or non-biologic factors.

Shumate CJ, et al. Sunspot activity and birth defects among Texas births (1999-2016). Birth Defects Res. 2023 Jul 1;115(12):1120-1139. Epub 2023 May 30. doi:10.1002/bdr2.2206
Background: Building on findings that linked higher levels of sunspot (SS) activity with a range of health and adverse birth outcomes, we sought to understand how SS activity over a 17-year time period may be correlated with the occurrence of birth defects.
Methods: Data from the Texas Birth Defects Registry, vital events from the Texas Center for Health Statistics, and mean monthly numbers of sunspots from the National Oceanic and Atmospheric Administration were utilized. Poisson regression was used to calculate crude/adjusted prevalence ratios (cPRs/aPRs) and 95% confidence intervals for three quartiles (Q) of increasing SS activity (compared to a referent of low activity) and 44 birth defects (31 non-cardiac; 13 cardiac) with estimated dates of conception from 1998 to 2016.Results: We found moderately protective aPRs (range: 0.60-0.89) in a little over half of the case groups examined in our quartiles of higher SS activity (19 non-cardiac; 6 cardiac), after adjusting for maternal age, race/ethnicity, and education. Particularly protective aPRs in the highest SS quartiles (Q3-4) were noted for: anophthalmia, cataract, gastroschisis, trisomy 18, ventricular septal defects, atrial septal defects, and pulmonary valve atresia or stenosis. Conversely, modestly elevated aPRs were noted for two defect groups (agenesis, aplasia, and hypoplasia of the lung and microcephaly [Q2-3]). Following an additional adjustment of year of conception, results remained similar although many of the estimates were attenuated.
Conclusion: The seemingly protective associations between increasing SS activity may be an artifact of increasing spontaneous abortions that occur following conception during these periods of heightened SS activity.

Shumate CJ, et al. Neighborhood-level socioeconomic position during early pregnancy and risk of gastroschisis. Epidemiology. 2023 Jul 1;34(4):576-588. Epub 2023 May 30. doi:10.1097/EDE.0000000000001621
Background: Neighborhood-level socioeconomic position has been shown to influence birth outcomes, including selected birth defects. This study examines the understudied association between neighborhood-level socioeconomic position during early pregnancy and the risk of gastroschisis, an abdominal birth defect of increasing prevalence.
Methods: We conducted a case-control study of 1,269 gastroschisis cases and 10,217 controls using data from the National Birth Defects Prevention Study (1997-2011). To characterize neighborhood-level socioeconomic position, we conducted a principal component analysis to construct two indices-Neighborhood Deprivation Index (NDI) and Neighborhood Socioeconomic Position Index (nSEPI). We created neighborhood-level indices using census socioeconomic indicators corresponding to census tracts associated with addresses where mothers lived the longest during the periconceptional period. We used generalized estimating equations to estimate odds ratios (ORs) and 95% confidence intervals (CIs), with multiple imputations for missing data and adjustment for maternal race-ethnicity, household income, education, birth year, and duration of residence.
Results: Mothers residing in moderate (NDI Tertile 2 aOR = 1.23; 95% CI = 1.03, 1.48 and nSEPI Tertile 2 aOR = 1.24; 95% CI = 1.04, 1.49) or low socioeconomic neighborhoods (NDI Tertile 3 aOR = 1.28; 95% CI = 1.05, 1.55 and nSEPI Tertile 3 aOR = 1.32, 95% CI = 1.09, 1.61) were more likely to deliver an infant with gastroschisis compared with mothers residing in high socioeconomic neighborhoods.
Conclusions: Our findings suggest that lower neighborhood-level socioeconomic position during early pregnancy is associated with elevated odds of gastroschisis. Additional epidemiologic studies may aid in confirming this finding and evaluating potential mechanisms linking neighborhood-level socioeconomic factors and gastroschisis.

Canfield MA, Shumate CJ, et al. Associations between birth defects with neural crest cell origins and pediatric embryonal tumors. Cancer. 2023;10.1002/cncr.34952. Epub 2023 Jul 11. doi:10.1002/cncr.34952
Background: There are few assessments evaluating associations between birth defects with neural crest cell developmental origins (BDNCOs) and embryonal tumors, which are characterized by undifferentiated cells having a molecular profile similar to neural crest cells. The effect of BDNCOs on embryonal tumors was estimated to explore potential shared etiologic pathways and genetic origins.
Methods: With the use of a multistate, registry-linkage cohort study, BDNCO-embryonal tumor associations were evaluated by generating hazard ratios (HRs) and 95% confidence intervals (CIs) with Cox regression models. BDNCOs consisted of ear, face, and neck defects, Hirschsprung disease, and a selection of congenital heart defects. Embryonal tumors included neuroblastoma, nephroblastoma, and hepatoblastoma. Potential HR modification (HRM) was investigated by infant sex, maternal race/ethnicity, maternal age, and maternal education.
Results: The risk of embryonal tumors among those with BDNCOs was 0.09% (co-occurring n = 105) compared to 0.03% (95% CI, 0.03%-0.04%) among those without a birth defect. Children with BDNCOs were 4.2 times (95% CI, 3.5-5.1 times) as likely to be diagnosed with an embryonal tumor compared to children born without a birth defect. BDNCOs were strongly associated with hepatoblastoma (HR, 16.1; 95% CI, 11.3-22.9), and the HRs for neuroblastoma (3.1; 95% CI, 2.3-4.2) and nephroblastoma (2.9; 95% CI, 1.9-4.4) were elevated. There was no notable HRM by the aforementioned factors.Conclusions: Children with BDNCOs are more likely to develop embryonal tumors compared to children without a birth defect. Disruptions of shared developmental pathways may contribute to both phenotypes, which could inform future genomic assessments and cancer surveillance strategies of these conditions.

Bojes HK, et al. Influence of storage conditions and multiple freeze-thaw cycles on N1 SARS-CoV-2, PMMoV, and BCoV signal. Sci Total Environ. 2023;896:165098. Epub 2023 Jun 29. doi:10.1016/j.scitotenv.2023.165098
Wastewater-based epidemiology/wastewater-based surveillance (WBE/WBS) continues to serve as an effective means of monitoring various diseases, including COVID-19 and the emergence of SARS-CoV-2 variants, at the population level. As the use of WBE expands, storage conditions of wastewater samples will play a critical role in ensuring the accuracy and reproducibility of results. In this study, the impacts of water concentration buffer (WCB), storage temperature, and freeze-thaw cycles on the detection of SARS-CoV-2 and other WBE-related gene targets were examined. Freeze-thawing of concentrated samples did not significantly affect (p > 0.05) crossing/cycle threshold (Ct) value for any of the gene targets studied (SARS-CoV-2 N1, PMMoV, and BCoV). However, use of WCB during concentration resulted in a significant (p < 0.05) decrease in Ct for all targets, and storage at -80 °C (in contrast to -20 °C) appeared preferable for wastewater storage signal stability based on decreased Ct values, although this was only significantly different (p < 0.05) for the BCoV target. Interestingly, when Ct values were converted to gene copies per influent sample, no significant differences (p > 0.05) were observed in any of the targets examined. Stability of RNA targets in concentrated wastewater against freeze-thaw degradation supports archiving of concentrated samples for use in retrospective examination of COVID-19 trends and tracing SARS-CoV-2 variants and potentially other viruses, and provides a starting point for establishing a consistent procedure for specimen collection and storage for the WBE/WBS community.

Canfield MA, et al. Associations between birth defects and childhood and adolescent germ cell tumors according to sex, histologic subtype, and site. Cancer. 2023;10.1002/cncr.34906. Epub 2023 Jun 27.  doi:10.1002/cncr.34906
Background: Studies have reported increased rates of birth defects among children with germ cell tumors (GCTs). However, few studies have evaluated associations by sex, type of defect, or tumor characteristics.
Methods: Birth defect-GCT associations were evaluated among pediatric patients (N = 552) with GCTs enrolled in the Germ Cell Tumor Epidemiology Study and population-based controls (N = 6380) without cancer from the Genetic Overlap Between Anomalies and Cancer in Kids Study. The odds ratio (OR) and 95% confidence interval (CI) of GCTs according to birth defects status were estimated by using unconditional logistic regression. All defects were considered collectively and by genetic and chromosomal syndromes and nonsyndromic defects. Stratification was by sex, tumor histology (yolk sac tumor, teratoma, germinoma, and mixed/other), and location (gonadal, extragonadal, and intracranial).
Results: Birth defects and syndromic defects were more common among GCT cases than controls (6.9% vs. 4.0% and 2.7% vs. 0.2%, respectively; both p < .001). In multivariable models, GCT risk was increased among children with birth defects (OR, 1.7; 95% CI, 1.3-2.4) and syndromic defects (OR, 10.4; 95% CI, 4.9-22.1). When stratified by tumor characteristics, birth defects were associated with yolk sac tumors (OR, 2.7; 95% CI, 1.3-5.0) and mixed/other histologies (OR, 2.1; 95% CI, 1.2-3.5) and both gonadal tumors (OR, 1.7; 95% CI, 1.0-2.7) and extragonadal tumors (OR, 3.8; 95% CI, 2.1-6.5). Nonsyndromic defects specifically were not associated with GCTs. In sex-stratified analyses, associations were observed among males but not females
Conclusions: These data suggest that males with syndromic birth defects are at an increased risk of pediatric GCTs, whereas males with nonsyndromic defects and females are not at an increased risk.
Plain language summary: We investigated whether birth defects (such as congenital heart disease or Down syndrome) are linked to childhood germ cell tumors (GCTs), cancers that mainly develop in the ovaries or testes. We studied different types of birth defects (defects that were caused by chromosome changes such as Down syndrome or Klinefelter syndrome and defects that were not) and different types of GCTs. Only chromosome changes such as Down syndrome or Klinefelter syndrome were linked to GCTs. Our study suggests that most children with birth defects are not at an increased risk of GCTs because most birth defects are not caused by chromosome changes.

Canfield MA, et al. Exome-wide assessment of isolated biliary atresia: A report from the National Birth Defects Prevention Study using child-parent trios and a case-control design to identify novel rare variants. Am J Med Genet A. 2023 Jun;191(6):1546-1556. Epub 2023 Mar 21. doi:10.1002/ajmg.a.63185
The etiology of biliary atresia (BA) is unknown, but recent studies suggest a role for rare protein-altering variants (PAVs). Exome sequencing data from the National Birth Defects Prevention Study on 54 child-parent trios, one child-mother duo, and 1513 parents of children with other birth defects were analyzed. Most (91%) cases were isolated BA. We performed (1) a trio-based analysis to identify rare de novo, homozygous, and compound heterozygous PAVs and (2) a case-control analysis using a sequence kernel-based association test to identify genes enriched with rare PAVs. While we replicated previous findings on PKD1L1, our results do not suggest that recurrent de novo PAVs play important roles in BA susceptibility. In fact, our finding in NOTCH2, a disease gene associated with Alagille syndrome, highlights the difficulty in BA diagnosis. Notably, IFRD2 has been implicated in other gastrointestinal conditions and warrants additional study. Overall, our findings strengthen the hypothesis that the etiology of BA is complex.

Chapman LE, Cobb K, Hall E, Seidel S. Creating novel surveillance data products for briefing health department leadership and elected officials during the COVID-19 pandemic in Texas. J Public Health Manag Pract. 2023 May-Jun;29(3):403-410. Epub 2022 Dec 2.  doi:10.1097/PHH.0000000000001675
Beginning in March 2020, the Texas Department of State Health Services (DSHS) developed several internal surveillance tools for briefing state health department leadership and elected officials on the status of the COVID-19 pandemic in Texas. This case study describes the initial conceptualization and daily production of 3 of these internal surveillance tools: (1) a COVID-19 data book displaying daily case, fatality, hospitalization, and testing data by county; (2) graphs and data files displaying new daily COVID-19 fatalities among residents of long-term care facilities in Texas; and (3) graphs and data files comparing COVID-19 cases and hospitalizations between the 4 COVID-19 waves in Texas. In addition, this case study uses qualitative interview data to describe how DSHS leadership used these surveillance products during the pandemic. Finally, details on challenges and lessons learned around creating and maintaining these tools are provided. These surveillance products are easily replicable, and our methods and lessons learned may be helpful for researchers or health department officials working on COVID-19 or other disease surveillance teams.

Shuford JA, Pont SJ, et al. Incidence and predictors of breakthrough and severe breakthrough infections of SARS-CoV-2 after primary series vaccination in adults: a population-based survey of 22,575 participants. J Infect Dis. 2023 May 12;227(10):1164-1172. doi:10.1093/infdis/jiad020
Background: Breakthrough infections of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are well documented. The current study estimates breakthrough incidence across pandemic waves, and evaluates predictors of breakthrough and severe breakthrough infections (defined as those requiring hospitalization).
Methods: In total, 89,762 participants underwent longitudinal antibody surveillance. Incidence rates were calculated using total person-days contributed. Bias-corrected and age-adjusted logistic regression determined multivariable predictors of breakthrough and severe breakthrough infection, respectively.
Results: The incidence was 0.45 (95% confidence interval [CI], .38-.50) during pre-Delta, 2.80 (95% CI, 2.25-3.14) during Delta, and 11.2 (95% CI, 8.80-12.95) during Omicron, per 10,000 person-days. Factors associated with elevated odds of breakthrough included Hispanic ethnicity (vs non-Hispanic white, OR = 1.243; 95% CI, 1.073-1.441), larger household size (OR = 1.251 [95% CI, 1.048-1.494] for 3-5 vs 1 and OR = 1.726 [95% CI, 1.317-2.262] for more than 5 vs 1 person), rural versus urban living (OR = 1.383; 95% CI, 1.122-1.704), receiving Pfizer or Johnson & Johnson versus Moderna, and multiple comorbidities. Of the 1700 breakthrough infections, 1665 reported on severity; 112 (6.73%) were severe. Higher body mass index, Hispanic ethnicity, vaccine type, asthma, and hypertension predicted severe breakthroughs.
Conclusions: Breakthrough infection was 4-25 times more common during the Omicron-dominant wave versus earlier waves. Higher burden of severe breakthrough infections was identified in subgroups.

Patel M, et al. Behavioral health care provider's beliefs, confidence, and knowledge in treating cigarette smoking in relation to their use of the 5A's intervention. Addict Behav Rep. 2023 May 11;17:100493.  doi:10.1016/j.abrep.2023.100493
Introduction: Evidence-based smoking cessation interventions are underused settings where behavioral health treatment is provided, contributing to smoking-related health disparities in this patient group. This study assessed the relationship of provider's beliefs about patients' smoking, perceptions of treatment capability, and knowledge of referral options and their use of the 5A's (Ask, Advise, Assess, Assist, and Arrange) intervention for smoking cessation
Methods: Surveys were collected from providers in healthcare settings in Texas where patients receive behavioral health care (N = 86; 9 federally qualified health centers, 16 Local Mental Health Authorities (LMHAs), 6 substance use treatment programs in LMHAs, and 55 stand-alone substance use treatment centers). Logistic regression analyses were used to assess the association between provider's beliefs about patients' concern and desire to quit smoking; perceptions of their confidence, skills, and effectiveness in treating smoking; their knowledge of referral options; and their use of the 5A's with patients who smoked.
Results: Providers who believed that patients were concerned about smoking and wanted to quit; who perceived themselves as confident in providing cessation care, having the required skills, and being effective in providing advice; and/or who had greater referral knowledge were more likely to use the 5A's with patients who smoked than their (respective) provider counterparts (ps < 0.05).
Conclusion: Provider-level constructs affect their 5A's provision for patients with behavioral health needs. Future work should train providers to correct misconceptions about patients' interest in quitting, bolster their confidence, and provide referral options to support tobacco provision efforts.

Shumate CJ, et al. Prevalence and descriptive epidemiology of Turner syndrome in the United States, 2000-2017: A report from the National Birth Defects Prevention Network. Am J Med Genet A. 2023 May;191(5):1339- 1349. Epub 2023 Mar 15. doi:10.1002/ajmg.a.63181
The lack of United States population-based data on Turner syndrome limits assessments of prevalence and associated characteristics for this sex chromosome abnormality. Therefore, we collated 2000-2017 data from seven birth defects surveillance programs within the National Birth Defects Prevention Network. We estimated the prevalence of karyotype-confirmed Turner syndrome diagnosed within the first year of life. We also calculated the proportion of cases with commonly ascertained birth defects, assessed associations with maternal and infant characteristics using prevalence ratios (PR) with 95% confidence intervals (CI), and estimated survival probability. The prevalence of Turner syndrome of any pregnancy outcome was 3.2 per 10,000 female live births (95% CI = 3.0-3.3, program range: 1.0-10.4), and 1.9 for live birth and stillbirth (≥20 weeks gestation) cases (95% CI = 1.8-2.1, program range: 0.2-3.9). Prevalence was lowest among cases born to non-Hispanic Black women compared to non-Hispanic White women (PR = 0.5, 95% CI = 0.4-0.6). Coarctation of the aorta was the most common defect (11.6% of cases), and across the cohort, individuals without hypoplastic left heart had a five-year survival probability of 94.6%. The findings from this population-based study may inform surveillance practices, prenatal counseling, and diagnosis. We also identified racial and ethnic disparities in prevalence, an observation that warrants further investigation.

Shuford JA, Pont SJ, et al. SARS-CoV-2 serostatus and COVID-19 illness characteristics by variant time period in non-hospitalized children and adolescents. Children (Basel). 2023 Apr 30;10(5):818. doi:10.3390/children10050818
Objective: To describe COVID-19 illness characteristics, risk factors, and SARS-CoV-2 serostatus by variant time period in a large community-based pediatric sample.
Design: Data were collected prospectively over four timepoints between October 2020 and November 2022 from a population-based cohort ages 5 to 19 years old.
Setting: State of Texas, USA.
Participants: Participants ages 5 to 19 years were recruited from large pediatric healthcare systems, Federally Qualified Healthcare Centers, urban and rural clinical practices, health insurance providers, and a social media campaign.
Exposure: SARS-CoV-2 infection.
Main outcome(s) and measure(s): SARS-CoV-2 antibody status was assessed by the Roche Elecsys^® Anti-SARS-CoV-2 Immunoassay for detection of antibodies to the SARS-CoV-2 nucleocapsid protein (Roche N-test). Self-reported antigen or PCR COVID-19 test results and symptom status were also collected.
Results: Over half (57.2%) of the sample (N = 3911) was antibody positive. Symptomatic infection increased over time from 47.09% during the pre-Delta variant time period, to 76.95% during Delta, to 84.73% during Omicron, and to 94.79% during the Omicron BA.2. Those who were not vaccinated were more likely (OR 1.71, 95% CI 1.47, 2.00) to be infected versus those fully vaccinated.
Conclusions: Results show an increase in symptomatic COVID-19 infection among non-hospitalized children with each progressive variant over the past two years. Findings here support the public health guidance that eligible children should remain up to date with COVID-19 vaccinations.

Cantor S, Chaudhary I, et al. COVID-19 outbreaks linked to workplaces, 23 US jurisdictions, August-October 2021. Public Health Rep. 2023 Mar-Apr;138(2):333-340. Epub 2022 Dec 8. doi:10.1177/00333549221138294
Objectives: Early in the COVID-19 pandemic, several outbreaks were linked with facilities employing essential workers, such as long-term care facilities and meat and poultry processing facilities. However, timely national data on which workplace settings were experiencing COVID-19 outbreaks were unavailable through routine surveillance systems. We estimated the number of US workplace outbreaks of COVID-19 and identified the types of workplace settings in which they occurred during August-October 2021.
Methods: The Centers for Disease Control and Prevention collected data from health departments on workplace COVID-19 outbreaks from August through October 2021: the number of workplace outbreaks, by workplace setting, and the total number of cases among workers linked to these outbreaks. Health departments also reported the number of workplaces they assisted for outbreak response, COVID-19 testing, vaccine distribution, or consultation on mitigation strategies.
Results: Twenty-three health departments reported a total of 12 660 workplace COVID-19 outbreaks. Among the 12 470 workplace types that were documented, 35.9% (n = 4474) of outbreaks occurred in health care settings, 33.4% (n = 4170) in educational settings, and 30.7% (n = 3826) in other work settings, including non-food manufacturing, correctional facilities, social services, retail trade, and food and beverage stores. Eleven health departments that reported 3859 workplace outbreaks provided information about workplace assistance: 3090 (80.1%) instances of assistance involved consultation on COVID-19 mitigation strategies, 1912 (49.5%) involved outbreak response, 436 (11.3%) involved COVID-19 testing, and 185 (4.8%) involved COVID-19
vaccine distribution.
Conclusions: These findings underscore the continued impact of COVID-19 among workers, the potential for work-related transmission, and the need to apply layered prevention strategies recommended by public health officials.

Freeland M, et al. Travel history among persons infected with SARS-CoV-2 variants of concern in the United States, December 2020-February 2021. PLOS Glob Public Health. 2023 Mar 29;3(3):e0001252. doi:10.1371/journal.pgph.0001252
The first three SARS-CoV-2 phylogenetic lineages classified as variants of concern (VOCs) in the United States (U.S.) from December 15, 2020 to February 28, 2021, Alpha (B.1.1.7), Beta (B.1.351), and Gamma (P.1) lineages, were initially detected internationally. This investigation examined available travel history of coronavirus disease 2019 (COVID-19) cases reported in the U.S. in whom laboratory testing showed one of these initial VOCs. Travel history, demographics, and health outcomes for a convenience sample of persons infected with a SARS-CoV-2 VOC from December 15, 2020 through February 28, 2021 were provided by 35 state and city health departments, and proportion reporting travel was calculated. Of 1,761 confirmed VOC cases analyzed, 1,368 had available data on travel history. Of those with data on travel history, 1,168 (85%) reported no travel preceding laboratory confirmation of SARS-CoV-2 and only 105 (8%) reported international travel during the 30 days preceding a positive SARS-CoV-2 test or symptom onset. International travel was reported by 92/1,304 (7%) of persons infected with the Alpha variant, 7/55 (22%) with Beta, and 5/9 (56%) with Gamma. Of the first three SARS-CoV-2 lineages designated as VOCs in the U.S., international travel was common only among the few Gamma cases. Most persons infected with Alpha and Beta variant reported no travel history, therefore, community transmission of these VOCs was likely common in the U.S. by March 2021. These findings underscore the importance of global surveillance using whole genome sequencing to detect and inform mitigation strategies for emerging SARS-CoV-2 VOCs.

Gutiérrez Tyler C, Salinas A, Guevara A, Alva H, Ruiz M, Prot EY. Assessing 2019 Hurricane Harvey recovery in Aransas County, Texas through Community Assessment for Public Health Emergency Response (CASPER). Disaster Med Public Health Prep. 2023 Mar 23;17:e366. doi:10.1017/dmp.2023.12
Objectives: The objective of this study was to assess recovery of Aransas County, Texas households 2 years after Category 4 Hurricane Harvey made landfall.
Methods: A 2-stage cluster sampling method used to conduct a Community Assessment for Public Health Emergency Response (CASPER) on May 3 - 4 and May 18 - 19, 2019. A household-based survey was administered through face-to-face interviews, selected through systematic random sampling using weighted analysis of the county population. Field teams collected 175 surveys (83.3% completion rate).
Results: Approximately 57% households experienced repairable damage, 23% had destroyed homes, and 19% had minimal damage. 38% stated having 'no need,' 18% needed financial assistance, 16% needed household repairs, and over 8% had behavioral health needs. 17% experiencing a behavioral health concern were seeking services. Of the 35% of households who did not seek services, 14% felt there was no need, and 4% were not aware of the resources available.
Conclusions: Households reported high levels of preparedness, but gaps remain in evacuation intention and behavioral health care access. CASPERs are effective in assessing long-term recovery of communities impacted by major disasters.

Moore KO, Stuteville HD, et al. A case of primary amebic meningoencephalitis associated with surfing at an artificial surf venue: Environmental investigation. ACS ES T Water. 2023 Mar 15;3(4):1126-1133.  doi:10.1021/acsestwater.2c00592
Naegleria fowleri is a thermophilic ameba found in freshwater that causes primary amebic meningoencephalitis (PAM) when it enters the nose and migrates to the brain. In September 2018, a 29-year-old man died of PAM after traveling to Texas. We conducted an epidemiologic and environmental investigation to identify the water exposure associated with this PAM case. The patient's most probable water exposure occurred while surfing in an artificial surf venue. The surf venue water was not filtered or recirculated; water disinfection and water quality testing were not documented. N. fowleri and thermophilic amebae were detected in recreational water and sediment samples throughout the facility. Codes and standards for treated recreational water venues open to the public could be developed to address these novel venues. Clinicians and public health officials should also consider novel recreational water venues as a potential exposure for this rare amebic infection.

Shumate CJ, Canfield MA, et al. Patterns of co-occurring birth defects in children with anotia and microtia. Am J Med Genet A. 2023 Mar;191(3):805-812. Epub 2022 Dec 21. doi:10.1002/ajmg.a.63081
Many infants with anotia or microtia (A/M) have co-occurring birth defects, although few receive syndromic diagnoses in the perinatal period. Evaluation of co-occurring birth defects in children with A/M could identify patterns indicative of undiagnosed/unrecognized syndromes. We obtained information on co-occurring birth defects among infants with A/M for delivery years 1999-2014 from the Texas Birth Defects Registry. We calculated observed-to-expected ratios (OER) to identify birth defect combinations that occurred more often than expected by chance. We excluded children diagnosed with genetic or chromosomal syndromes from analyses. Birth defects and syndromes/associations diagnosed ≤1 year of age were considered. We identified 1310 infants with non-syndromic A/M, of whom 38% (N = 492) were diagnosed with co-occurring major defects. Top combinations included: hydrocephalus, ventricular septal defect, and spinal anomalies (OER 58.4); microphthalmia and anomalies of the aorta (OER 55.4); and cleft lip with or without cleft palate and rib or sternum anomalies (OER 32.8). Some combinations observed in our study may represent undiagnosed/atypical presentations of known A/M associations or syndromes, or novel syndromes yet to be described in the literature. Careful evaluation of infants with multiple birth defects including A/M is warranted to identify individuals with potential genetic or chromosomal syndromes.

Canfield MA, et al. Prevalence and mortality among children with anorectal malformation: A multi-country analysis. Birth Defects Res. 2023 Feb 1;115(3):390-404. Epub 2022 Nov 19. doi:10.1002/bdr2.2129
We examined the total prevalence, trends in prevalence, and age-specific mortality among individuals with anorectal malformation (ARM) METHODS: We conducted a retrospective cohort study using data from 24 population- and hospital-based birth defects surveillance programs affiliated with the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR) from 18 countries and for births from 1974 to 2014. We estimated pooled and program-specific total prevalence per 10,000 total births. Poisson regression was used to assess time trends in prevalence from 2001 to 2012 when most programs contributed data. We calculated selected age-specific proportions of deaths, stratified by case status RESULTS: The pooled total prevalence of ARM was 3.26 per 10,000 total births (95% Confidence Interval = 3.19, 3.32) for birth years 1974-2014. About 60% of cases were multiple or syndromic. Prevalence of multiple, syndromic, and stillborn cases decreased from 2001 to 2012. The first week mortality proportion was 12.5%, 3.2%, 28.3%, and 18.2% among all, isolated, multiple, and syndromic cases, respectively CONCLUSIONS: ARM is relatively rare, with multiple and syndromic cases showing decreasing prevalence during the study period. Mortality is a concern during the first week of life, and especially among multiple and syndromic cases. Our descriptive epidemiological findings increase our understanding of geographic variation in the prevalence of ARM and can be used to plan needed clinical services. Exploring factors influencing prevalence and mortality among individuals with ARM could inform future studies.

Tanksley S, et al. Evidence and recommendation for mucopolysaccharidosis type II newborn screening in the United States. Genet Med. 2023 Feb;25(2):100330. Epub 2022 Nov 29.
doi:10.1016/j.gim.2022.10.012
Mucopolysaccharidosis type II (MPS II), also known as Hunter syndrome, is an X-linked condition caused by pathogenic variants in the iduronate-2-sulfatase gene. The resulting reduced activity of the enzyme iduronate-2-sulfatase leads to accumulation of glycosaminoglycans that can progressively affect multiple organ systems and impair neurologic development. In 2006, the US Food and Drug Administration approved idursulfase for intravenous enzyme replacement therapy for MPS II. After the data suggesting that early treatment is beneficial became available, 2 states, Illinois and Missouri, implemented MPS II newborn screening. Following a recommendation of the Advisory Committee on Heritable Disorders in Newborns and Children in February 2022, in August 2022, the US Secretary of Health and Human Services added MPS II to the Recommended Uniform Screening Panel, a list of conditions recommended for newborn screening. MPS II was added to the Recommended Uniform Screening Panel after a systematic evidence review reported the accuracy of screening, the benefit of presymptomatic treatment compared with usual case detection, and the feasibility of implementing MPS II newborn screening. This manuscript summarizes the findings of the evidence review that informed the Advisory Committee's decision.

Canfield MA, Marengo LK, et al. Contribution of Preterm Birth to Mortality Among Neonates with Birth Defects. J Pediatr. 2023 Feb;253:270-277.e1. Epub 2022 Oct 10. doi:10.1016/j.jpeds.2022.10.002
Objective: To estimate the proportion of neonatal mortality risk attributable to preterm delivery among neonates with birth defects.
Study design: Using a statewide cohort of live born infants from the Texas Birth Defects Registry (1999-2014 deliveries), we estimated the population attributable fraction and 95% CI of neonatal mortality (death <28 days) attributable to prematurity (birth at <37 weeks vs ≥37 weeks) for 31 specific birth defects. To better understand the overall population burden, analyses were repeated for all birth defects combined.
Results: Our analyses included 169 148 neonates with birth defects, of which 40 872 (24.2%) were delivered preterm. The estimated proportion of neonatal mortality attributable to prematurity varied by birth defect, ranging from 12.5% (95% CI: 8.7-16.1) for hypoplastic left heart syndrome to 71.9% (95% CI: 41.1-86.6) for anotia or microtia. Overall, the proportion was 51.7% (95% CI: 49.4-54.0) for all birth defects combined.
Conclusions: A large proportion of deaths among neonates with birth defects are attributable to preterm delivery. Our results highlight differences in this burden across common birth defects. Our findings may be helpful for prioritizing future work focused on better understanding the etiology of prematurity among neonates with birth defects and the mechanisms by which prematurity contributes to neonatal mortality in this population.

Pont SJ, Shuford JA, et al. Antibody duration after infection from SARS-CoV-2 in the Texas Coronavirus Antibody Response Survey. J Infect Dis. 2023 Jan 11;227(2):193-201. Epub 2022 May 6. doi:10.1093/infdis/jiac167 
Understanding the duration of antibodies to the SARS-CoV-2 virus that causes COVID-19 is important to controlling the current pandemic. Participants from the Texas Coronavirus Antibody Response Survey (Texas CARES) with at least one nucleocapsid protein antibody test were selected for a longitudinal analysis of antibody duration. A linear mixed model was fit to data from participants (n= 4,553) with one to three antibody tests over 11 months (10/1/2020-9/16/2021), and model fit showed that expected antibody response after COVID-19 infection robustly increases for 100 days post-infection, and predicts individuals may remain antibody positive from natural infection beyond 500 days, depending on age, body mass index, smoking or vaping use, and disease severity (hospitalized or not; symptomatic or not).

Cantu V, et al. Listeria monocytogenes illness and deaths associated with ongoing contamination of a multiregional brand of ice cream products, United States, 2010-2015. Clin Infect Dis. 2023 Jan 6;76(1):89-95. doi:10.1093/cid/ciac550
Background: Frozen foods have rarely been linked to Listeria monocytogenes illness. We describe an outbreak investigation prompted by both hospital clustering of illnesses and product testing.
Methods: We identified outbreak-associated listeriosis cases using whole-genome sequencing (WGS), product testing results, and epidemiologic linkage to cases in the same Kansas hospital. We reviewed hospital medical and dietary records, product invoices, and molecular subtyping results. Federal and state officials tested product and environmental samples for L. monocytogenes.Results: Kansas officials were investigating 5 cases of listeriosis at a single hospital when, simultaneously, unrelated sampling for a study in South Carolina identified L. monocytogenes in Company A ice cream products made in Texas. Isolates from 4 patients and Company A products were closely related by WGS, and the 4 patients with known exposures had consumed milkshakes made with Company A ice cream while hospitalized. Further testing identified L. monocytogenes in ice cream produced in a second Company A production facility in Oklahoma; these isolates were closely related by WGS to those from 5 patients in 3 other states. These 10 illnesses, involving 3 deaths, occurred from 2010 through 2015. Company A ultimately recalled all products.
Conclusions: In this US outbreak of listeriosis linked to a widely distributed brand of ice cream, WGS and product sampling helped link cases spanning 5 years to 2 production facilities, indicating longstanding contamination. Comprehensive sanitation controls and environmental and product testing for L. monocytogenes with regulatory oversight should be implemented for ice cream production.

Marengo LK, Archer N, Shumate C, Canfield MA, Drummond-Borg M. Survival of infants and children born with severe microcephaly, Texas, 1999-2015. Birth Defects Res. 2023 Jan 1;115(1):26-42. Epub 2022 Nov 8. doi:10.1002/bdr2.2109
Background: Severe microcephaly is a brain reduction defect where the delivery head circumference is <3rd percentile for gestational age and sex with subsequent lifelong morbidities. Our objective was to evaluate survival among 2,704 Texas infants with severe microcephaly delivered 1999-2015.
Methods: Infants with severe microcephaly from the Texas Birth Defects Registry were linked to death certificates and the national death index. Survival estimates, hazard ratios (HR) and confidence intervals (CI) were calculated using the Kaplan-Meier method and Cox proportional hazards models stratified by presence versus absence of co-occurring defects.
Results: We identified 496 deaths by age 4 years; most (42.9%) occurred in the neonatal period, and another 39.9% died by 1 year of age. Overall infant survival was 84.8%. Lowest infant survival subgroups included those with chromosomal/syndromic conditions (66.1%), very preterm deliveries (63.9%), or co-occurring critical congenital heart defects (44.0%). Among infants with severe microcephaly and a chromosomal/syndromic co-occurring defect, the risk of death was nearly three-fold higher among those with: proportionate microcephaly (i.e., small baby overall), relative to non-proportionate (HR = 2.84, 95% CI = 2.17-3.71); low-birthweight relative to normal (HR = 2.72, 95% CI = 1.92-3.85); critical congenital heart defects (CCHD) relative to no CCHD (HR = 2.90, 95% CI = 2.20-3.80). Trisomies were a leading underlying cause of death (27.5%).
Conclusions: Overall, infants with severe microcephaly had high 4-year survival rates which varied by the presence of co-occurring defects. Infants with co-occurring chromosomal/syndromic anomalies have a higher risk of death by age one than those without any co-occurring birth defects.

Le MT, et al. Assessing associations between residential proximity to greenspace and birth defects in the National Birth Defects Prevention Study. Environ Res. 2023 Jan 1;216(Pt 3):114760. Epub 2022 Nov 7. doi:10.1016/j.envres.2022.114760
Background: Residential proximity to greenspace is associated with various health outcomes.
Objectives: We estimated associations between maternal residential proximity to greenspace (based on an index of vegetation) and selected structural birth defects, including effect modification by neighborhood-level factors.
Methods: Data were from the National Birth Defects Prevention Study (1997-2011) and included 19,065 infants with at least one eligible birth defect (cases) and 8925 without birth defects (controls) from eight Centers throughout the United States. Maternal participants reported their addresses throughout pregnancy. Each address was systematically geocoded and residences around conception were linked to greenspace, US Census, and US Department of Agriculture data. Greenspace was estimated using the normalized difference vegetation index (NDVI); average maximum NDVI was estimated within 100 m and 500 m concentric buffers surrounding geocoded addresses to estimate residential NDVI. We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals comparing those in the highest and lowest quartiles of residential NDVI and stratifying by rural/urban residence and neighborhood median income.
Results: After multivariable adjustment, for the 500 m buffer, inverse associations were observed for tetralogy of Fallot, secundum atrial septal defects, anencephaly, anotia/microtia, cleft lip ± cleft palate, transverse limb deficiency, and omphalocele, (aORs: 0.54-0.86). Results were similar for 100 m buffer analyses and similar patterns were observed for other defects, though results were not significant. Significant heterogeneity was observed after stratification by rural/urban for hypoplastic left heart, coarctation of the aorta, and cleft palate, with inverse associations only among participants residing in rural areas. Stratification by median income showed heterogeneity for atrioventricular and secundum atrial septal defects, anencephaly, and anorectal atresia, with inverse associations only among participants residing in a high-income neighborhood (aORs: 0.45-0.81).
Discussion: Our results suggest that perinatal residential proximity to more greenspace may contribute to a reduced risk of certain birth defects, especially among those living in rural or high-income neighborhoods.

Shumate CJ, Nguyen J, Canfield MA, et al. Factors associated with nonsyndromic anotia and microtia, Texas, 1999-2014. Birth Defects Res. 2023 Jan 1;115(1):67-78. Epub 2022 Nov 17. doi:10.1002/bdr2.2130
Background: Few risk factors have been identified for nonsyndromic anotia/microtia (A/M).
Methods: We obtained data on cases and a reference population of all livebirths in Texas for 1999-2014 from the Texas Birth Defects Registry (TBDR) and Texas vital records. We estimated prevalence ratios (PRs) and 95% confidence intervals (CIs) for A/M (any, isolated, nonisolated, unilateral, and bilateral) using Poisson regression. We evaluated trends in prevalence rates using Joinpoint regression.
Results: We identified 1,322 cases, of whom 982 (74.3%) had isolated and 1,175 (88.9%) had unilateral A/M. Prevalence was increased among males (PR: 1.3, 95% CI: 1.2-1.4), offspring of women with less than high school education (PR: 1.3, 95% CI: 1.1-1.5), diabetes (PR: 2.0, 95% CI: 1.6-2.4), or age 30-39 versus 20-29 years (PR: 1.2, 95% CI: 1.0-1.3). The prevalence was decreased among offspring of non-Hispanic Black versus White women (PR: 0.6, 95% CI: 0.4-0.8) but increased among offspring of Hispanic women (PR: 2.9, 95% CI: 2.5-3.4) and non-Hispanic women of other races (PR: 1.7, 95% CI: 1.3-2.3). We observed similar results among cases with isolated and unilateral A/M. Sex disparities were not evident for nonisolated or bilateral phenotypes, nor did birth prevalence differ between offspring of non-Hispanic Black and non-Hispanic White women. Maternal diabetes was more strongly associated with nonisolated (PR: 4.5, 95% CI: 3.2-6.4) and bilateral A/M (PR: 5.0, 95% CI: 3.3-7.7). Crude prevalence rates increased throughout the study period (annual percent change: 1.82).
Conclusion: We identified differences in the prevalence of nonsyndromic A/M by maternal race/ethnicity, education, and age, which may be indicators of unidentified social/environmental risk factors.

Betancourt D, Canfield MA, Ethen MK, Shumate C, Drummond-Borg M, et al. Connecting children with birth defects to health and social service programs: A collaboration between the Texas Birth Defects Registry and agency social workers. Birth Defects Res. 2023 Jan 1;115(1):110-119. Epub 2022 Nov 14. doi:10.1002/bdr2.2126
Background: Timely referral to services for children born with birth defects can improve health outcomes. Birth defects surveillance registries may be a valuable data source for connecting children to health and social service programs.
Methods: Population-based, state-wide data from the Texas Birth Defects Registry (TBDR) at the Texas Department of State Health Services (DSHS) were used to connect children 9-18 months old, born with select birth defects with DSHS social workers. The social workers reviewed developmental milestones and referred children and their families to various health and social service programs. We tabulated the proportions of children meeting milestones and referral characteristics by referral program type and type of birth defect.
Results: Social workers reached 67% (909/1,362) of identified families. Over half of children (54%, 488/909) were not meeting the developmental milestones for their age. Social workers provided over 3,000 program referrals, including referring 21% (194/909) of children to Early Childhood Intervention (ECI) and 28% (257/909) to case management.
Conclusion: Our results illustrate a method of leveraging a birth defects surveillance system for referral services. Given the large number of referrals made, our findings suggest that birth defects registries can be a valuable source of data for referring children to programs.

Marengo L, Canfield MA, et al. Evaluating the proportion of isolated cases among a spectrum of birth defects in a population-based registry. Birth Defects Res. 2023 Jan 1;10.1002/bdr2.1990. Epub 2022 Feb 26. doi:10.1002/bdr2.1990
Introduction: Because the etiology and outcomes of birth defects may differ by the presence vs. absence of co-occurring anomalies, epidemiologic studies often attempt to classify cases into isolated versus non-isolated groupings. This report describes a computer algorithm for such classification and presents results using data from the Texas Birth Defects Registry (TBDR).
Methods: Each of the 1,041 birth defects coded by the TBDR was classified as chromosomal, syndromic, minor, or "needs review" by a group of three clinical geneticists. A SAS program applied those classifications to each birth defect in a case (child/fetus), and then hierarchically combined them to obtain one summary classification for each case, adding isolated and multiple defect categories. The program was applied to 136,121 cases delivered in 2012-2017.
Results: Of the total cases, 49% were classified by the platform as isolated (having only one major birth defect). This varied widely by birth defect; of those examined, the highest proportion classified as isolated was found in pyloric stenosis (87.6%), whereas several cardiovascular malformations had low proportions, including tricuspid valve atresia/stenosis (2.3%).
Discussion: This is one of the first and largest attempts to identify the proportion of isolated cases across a broad spectrum of birth defects, which can inform future epidemiologic and genomic studies of these phenotypes. Our approach is designed for easy modification for use with any birth defects coding system and category definitions, allowing scalability for different studies or birth defects registries, which often do not have resources for individual clinical review of all case records.

Chaudhary I, et al. Regional outbreak of multidrug-resistant Klebsiella pneumoniae carbapenemase-producing Pseudomonas Aeruginosa. Infect Control Hosp Epidemiol. 2023;44(1):96-98. Epub 2021 Oct 1. doi:10.1017/ice.2021.394
Klebsiella pneumoniae carbapenemase-producing P. aeruginosa (KPC-CRPA) are rare in the United States. An outbreak of KPC-CRPA was investigated in Texas using molecular and epidemiologic methods and 17 cases of KPC-CRPA were identified. The isolates were genetically related and harbored the emerging P. aeruginosa multilocus sequence type 235, the first in the United States.

Canfield MA, Drummond-Borg M, et al. Identifying syndromes in studies of structural birth defects: Guidance on classification and evaluation of potential impact. Am J Med Genet A. 2023;191(1):190-204. Epub 2022 Oct 26. doi:10.1002/ajmg.a.63014
Structural birth defects that occur in infants with syndromes may be etiologically distinct from those that occur in infants in whom there is not a recognized pattern of malformations; however, population-based registries often lack the resources to classify syndromic status via case reviews. We developed criteria to systematically identify infants with suspected syndromes, grouped by syndrome type and level of effort required for syndrome classification (e.g., text search). We applied this algorithm to the Texas Birth Defects Registry (TBDR) to describe the proportion of infants with syndromes delivered during 1999-2014. We also developed a bias analysis tool to estimate the potential percent bias resulting from including infants with syndromes in studies of risk factors. Among 207,880 cases with birth defects in the TBDR, 15% had suspected syndromes and 85% were assumed to be nonsyndromic, with a range across defect types from 28.5% (atrioventricular septal defects) to 98.9% (pyloric stenosis). Across hypothetical scenarios varying expected parameters (e.g., nonsyndromic proportion), the inclusion of syndromic cases in analyses resulted in up to 50.0% bias in prevalence ratios. In summary, we present a framework for identifying infants with syndromic conditions; implementation might harmonize syndromic classification across registries and reduce bias in association estimates.
 

(In date order with the most recent first).

Clark I, et al. Financing benefits and barriers to routine HIV screening in clinical settings in the United States: a scoping review. Int J Environ Res Public Health. 2022 Dec 27;20(1):457. doi:10.3390/ijerph20010457
The Centers for Disease Control and Prevention recommends everyone between 13-64 years be tested for HIV at least once as a routine procedure. Routine HIV screening is reimbursable by Medicare, Medicaid, expanded Medicaid, and most commercial insurance plans. Yet, scaling-up HIV routine screening remains a challenge. We conducted a scoping review for studies on financial benefits and barriers associated with HIV screening in clinical settings in the U.S. to inform an evidence-based strategy to scale-up routine HIV screening. We searched Ovid MEDLINE^®, Cochrane, and Scopus for studies published between 2006-2020 in English. The search identified 383 Citations; we screened 220 and excluded 163 (outside the time limit, irrelevant, or outside the U.S.). Of the 220 screened articles, we included 35 and disqualified 155 (did not meet the eligibility criteria). We organized eligible articles under two themes: financial benefits/barriers of routine HIV screening in healthcare settings (9 articles); and Cost-effectiveness of routine screening in healthcare settings (26 articles). The review concluded drawing recommendations in three areas: (1) Finance: Incentivize healthcare providers/systems for implementing HIV routine screening and/or separate its reimbursement from bundle payments; (2) Personnel: Encourage nurse-initiated HIV screening programs in primary care settings and educate providers on CDC recommendations; and (3) Approach: Use opt-out approach.

Langlois PH, et al. Interaction of maternal medication use with ambient heat exposure on congenital heart defects in the National Birth Defects Prevention Study. Environ Res. 2022 Dec;215(Pt 1):114217. Epub 2022 Aug 28. doi: 10.1016/j.envres.2022.114217.
Background: Maternal exposure to weather-related extreme heat events (EHEs) has been associated with congenital heart defects (CHDs) in offspring. Certain medications may affect an individual's physiologic responses to EHEs. We evaluated whether thermoregulation-related medications modified associations between maternal EHE exposure and CHDs.
Methods: We linked geocoded residence data from the U.S. National Birth Defects Prevention Study, a population-based case-control study, to summertime EHE exposures. An EHE was defined using the 90^th percentile of daily maximum temperature (EHE90) for each of six climate regions during postconceptional weeks 3-8. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between EHE90 and the risk of CHDs were estimated by strata of maternal thermoregulation-related medication use and climate region. Interaction effects were evaluated on multiplicative and additive scales.
Results: Over 45% of participants reported thermoregulation-related medication use during the critical period of cardiogenesis. Overall, these medications did not significantly modify the association between EHEs and CHDs. Still, medications that alter central thermoregulation increased aORs (95% CI) of EHE90 from 0.73 (0.41, 1.30) among non-users to 5.09 (1.20, 21.67) among users in the Southwest region, U.S. This effect modification was statistically significant on the multiplicative (P = 0.03) and additive scales, with an interaction contrast ratio (95% CI) of 1.64 (0.26, 3.02).
Conclusion: No significant interaction was found for the maternal use of thermoregulation-related medications with EHEs on CHDs in general, while medications altering central thermoregulation significantly modified the association between EHEs and CHDs in Southwest U.S. This finding deserves further research.

Chapman LE, Cobb K, Hall E, Seidel S. Creating novel surveillance data products for briefing health department leadership and elected officials during the COVID-19 pandemic in Texas. J Public Health Manag Pract. 2022 May-Jun;10.1097/PHH.0000000000001675. Epub 2022 Dec 2. doi: 10.1097/PHH.0000000000001675.
Beginning in March 2020, the Texas Department of State Health Services (DSHS) developed several internal surveillance tools for briefing state health department leadership and elected officials on the status of the COVID-19 pandemic in Texas. This case study describes the initial conceptualization and daily production of 3 of these internal surveillance tools: (1) a COVID-19 data book displaying daily case, fatality, hospitalization, and testing data by county; (2) graphs and data files displaying new daily COVID-19 fatalities among residents of long-term care facilities in Texas; and (3) graphs and data files comparing COVID-19 cases and hospitalizations between the 4 COVID-19 waves in Texas. In addition, this case study uses qualitative interview data to describe how DSHS leadership used these surveillance products during the pandemic. Finally, details on challenges and lessons learned around creating and maintaining these tools are provided. These surveillance products are easily replicable, and our methods and lessons learned may be helpful for researchers or health department officials working on COVID-19 or other disease surveillance teams.

Broussard KR, et al. Melioidosis in cynomolgus macaques ( Macaca Fascicularis ) Imported to the United States from Cambodia. Comp Med. 2022 Dec 1;72(6):394-402. doi: 10.30802/AALAS-CM-22-000024.
Melioidosis, a potentially fatal infectious disease of humans and animals, including nonhuman primates (NHPs), is caused by the high-consequence pathogen Burkholderia pseudomallei. This environmental bacterium is found in the soil and water of tropical regions, such as Southeast Asia, where melioidosis is endemic. The global movement of humans and animals can introduce B. pseudomallei into nonendemic regions of the United States, where environmental conditions could allow establishment of the organism. Approximately 60% of NHPs imported into the United States originate in countries considered endemic for melioidosis. To prevent the introduction of infectious agents to the United States, the Centers for Disease Control and Prevention (CDC) requires newly imported NHPs to be quarantined for at least 31 d, during which time their health is closely monitored. Most diseases of public health concern that are transmissible from imported NHPs have relatively short incubation periods that fall within the 31-d quarantine period. However, animals infected with B. pseudomallei may appear healthy for months to years before showing signs of illness, during which time they can shed the organism into the environment. Melioidosis presents diagnostic challenges because it causes nonspecific clinical signs, serologic screening can produce unreliable results, and culture isolates are often misidentified on rapid commercial testing systems. Here, we present a case of melioidosis in a cynomolgus macaque (Macaca fascicularis) that developed a subcutaneous abscess after importation from Cambodia to the United States. The bacterial isolate from the abscess was initially misidentified on a commercial test. This case emphasizes the possibility of melioidosis in NHPs imported from endemic countries and its associated diagnostic challenges. If melioidosis is suspected, diagnostic samples and culture isolates should be submitted to a laboratory in the CDC Laboratory Response Network for conclusive identification and characterization of the pathogen.

Mintour J, et al. Blood lead levels among Afghan children in the United States, 2014-2016. Pediatrics. 2022 Nov 1;150(5):e2021054727. doi: 10.1542/peds.2021-054727.
Lead poisoning disproportionately affects children and can result in permanent neurologic damage. Although blood lead levels (BLLs) declined among children in the United States over the past several decades, children resettling to the United States from other countries emerged as a population at risk for BLLs that are higher than the United States blood lead reference value of ≥5 μg/dL at the time of this analysis.  Among children screened for lead shortly after resettlement, children from Afghanistan have a higher prevalence of BLLs ≥5 μg/dL compared with children from other countries, but timely sources of data available for analysis are limited. In 2021, the United States troop withdrawal from Afghanistan prompted the rapid evacuation and resettlement of more than 76 000 Afghans to the United States. We analyzed existing data from domestic medical examinations (DMEs) conducted from 2014 to 2016 for refugees and eligible populations ≤90 days after arrival in multiple states. We described and compared the prevalence of BLL ≥5 μg/dL among Afghan and non-Afghan refugee children screened and evaluated select characteristics associated with BLL ≥5 μg/dL among Afghan children.

Williams M, Ethen MK, Canfield MA, et al. The risks of birth defects and childhood cancer with conception by assisted reproductive technology. Hum Reprod. 2022 Oct 31;37(11):2672-2689. doi:10.1093/humrep/deac196
Study question: Is there an association between fertility status, method of conception and the risks of birth defects and childhood cancer?
Summary answer: The risk of childhood cancer had two independent components: (i) method of conception and (ii) presence, type and number of birth defects.
What is known already: The rarity of the co-occurrence of birth defects, cancer and ART makes studying their association challenging. Prior studies have indicated that infertility and ART are associated with an increased risk of birth defects or cancer but have been limited by small sample size and inadequate statistical power, failure to adjust for or include plurality, differences in definitions and/or methods of ascertainment, lack of information on ART treatment parameters or study periods spanning decades resulting in a substantial historical bias as ART techniques have improved.
Study design, size, duration: This was a population-based cohort study linking ART cycles reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) from 1 January 2004 to 31 December 2017 that resulted in live births in 2004-2018 in Massachusetts and North Carolina and live births in 2004-2017 in Texas and New York. A 10:1 sample of non-ART births were chosen within the same time period as the ART birth. Non-ART siblings were identified through the ART mother's information. Children from non-ART births were classified as being born to women who conceived with ovulation induction or IUI (OI/IUI) when there was an indication of infertility treatment on the birth certificate, and the woman did not link to the SART CORS; all others were classified as being naturally conceived.

Grimm C, Dunham E, Martinez DR, et al. Provider perspectives: identification and follow-up of infants who are deaf or hard of hearing. Am J Perinatol. 2022 Oct 28;10.1055/a-1932-9985. Epub ahead of print. doi:10.1055/a-1932-9985
Objective: Without timely screening, diagnosis, and intervention, hearing loss can cause significant delays in a child's speech, language, social, and emotional development. In 2019, Texas had nearly twice the average rate of loss to follow-up (LFU) or loss to documentation (LTD; i.e., missing documentation of services received) among infants who did not pass their newborn hearing screening compared to the United States overall (51.1 vs. 27.5%). We aimed to identify factors contributing to LFU/LTD among infants who do not pass their newborn hearing screening in Texas.
Study design: Data were collected through semistructured qualitative interviews with 56 providers along the hearing care continuum, including hospital newborn hearing screening program staff, audiologists, primary care physicians, and early intervention (EI) program staff located in three rural and urban public health regions in Texas. Following recording and transcription of the interviews, we used qualitative data analysis software to analyze themes using a conventional content analysis approach.
Results: Frequently cited barriers included problems with family access to care, difficulty contacting patients, problems with communication between providers and referrals, lack of knowledge among providers and parents, and problems using the online reporting system. Providers in rural areas more often mentioned problems with family access to care and contacting families compared to providers in urban areas.
Conclusion: These findings provide insight into strategies that public health professionals and health care providers can use to work together to help further increase the number of children identified early who may benefit from EI services.

Lee R, Reilly B, et al. Missed cystic fibrosis newborn screening cases due to immunoreactive trypsinogen levels below program cutoffs: a national survey of risk factors. Int J Neonatal Screen. 2022 Oct 27;8(4):58. doi:10.3390/ijns8040058
Testing immunoreactive trypsinogen (IRT) is the first step in cystic fibrosis (CF) newborn screening. While high IRT is associated with CF, some cases are missed. This survey aimed to find factors associated with missed CF cases due to IRT levels below program cutoffs. Twenty-nine states responded to a U.S-wide survey and 13 supplied program-related data for low IRT false screen negative cases (CFFN) and CF true screen positive cases (CFTP) for analysis. Rates of missed CF cases and odds ratios were derived for each factor in CFFNs, and two CFFN subgroups, IRT above ("high") and below ("low") the CFFN median (39 ng/mL) compared to CFTPs for this entire sample set. Factors associated with "high" CFFN subgroup were Black race, higher IRT cutoff, fixed IRT cutoff, genotypes without two known CF-causing variants, and meconium ileus. Factors associated with "low" CFFN subgroup were older age at specimen collection, Saturday birth, hotter season of newborn dried blood spot collection, maximum ≥ 3 days laboratories could be closed, preterm birth, and formula feeding newborns. Lowering IRT cutoffs may reduce "high" IRT CFFNs. Addressing hospital and laboratory factors (like training staff in collection of blood spots, using insulated containers during transport and reducing consecutive days screening laboratories are closed) may reduce "low" IRT CFFNs.

Babalola F, et al. The correlation between autistic childhood disorders and the development of anxiety and depression in adults: a systematic review. Cureus. 2022 Oct 9;14(10):e30093. doi:10.7759/cureus.30093
Children with autism spectrum disorder significantly suffer from other mental conditions, including anxiety and depression, compared to the general population. This continues to have a significant effect till adulthood. This study aimed at determining if there is a correlation between autism disorder in childhood and the development of anxiety and depression in adulthood and if behavioral therapy for children with this disorder reduces the likelihood of developing anxiety and depression as an adult. Three major databases were searched: EMBASE, Google Scholar, and PubMed, using specific search terms. Studies were selected according to population, exposure, comparison, condition or outcome(s) of interest, study design, and context. Overall, there are five articles relevant to this systematic review synthesis; all were observational studies. Our study shows psychiatric disorders like anxiety and depression could be related to autism spectrum disorder and early behavioral intervention could be beneficial and reduce the need for anxiety and depression medication.

Babalola F, et al. A comprehensive review on the effects of vegetarian diets on coronary heart disease. Cureus. 2022 Oct 2;14(10):e29843. doi:10.7759/cureus.29843
Coronary heart disease (CHD) is one of the leading causes of morbidity and mortality worldwide. Dietary modifications in the form of a vegetarian diet can perhaps be the key to the prevention and management of cardiovascular diseases. The aims of this review are to determine the association between a vegetarian diet and CHD, to compare the risk of CHD in different types of vegetarian diets, and to assess variability in the biochemical predictors of CHD in the various vegetarian diets. Our study inferred that adherence to a plant-based diet was inversely related to the incidence of heart failure risk. Our research further supports the idea that a vegetarian diet is advantageous for the secondary prevention of CHD since it alters lipid profiles, lowers body mass index (BMI), and increases plasma antioxidant micronutrient concentrations. Additionally, eating a plant-based diet starting in adolescence is linked to a decreased risk of cerebrovascular disease (CVD) by middle age. An increase in sensitization and education efforts is imperative to ensure that people are appropriately informed about this option to significantly improve their quality of life.

Shuford JA, Pont SJ, et al. Comparison of persistent symptoms following SARS-CoV-2 infection by antibody status in nonhospitalized children and adolescents. Pediatr Infect Dis J. 2022 Oct 1;41(10):e409-e417. Epub 2022 Aug 1. doi:10.1097/INF.0000000000003653
Background: The prevalence of long-term symptoms of coronavirus disease 2019 (COVID-19) in nonhospitalized pediatric populations in the United States is not well described. The objective of this analysis was to examine the presence of persistent COVID symptoms in children by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody status.
Methods: Data were collected between October 2020 and May 2022 from the Texas Coronavirus Antibody REsponse Survey, a statewide prospective population-based survey among 5-90 years old. Serostatus was assessed by the Roche Elecsys Anti-SARS-CoV-2 Immunoassay for detection of antibodies to the SARS-CoV-2 nucleocapsid protein. Self-reported antigen/polymerase chain reaction COVID-19 test results and persistent COVID symptom status/type/duration were collected simultaneously. Risk ratios for persistent COVID symptoms were calculated versus adults and by age group, antibody status, symptom presence/severity, variant, body mass index and vaccine status.
Results: A total of 82 (4.5% of the total sample [n = 1813], 8.0% pre-Delta, 3.4% Delta and beyond) participants reported persistent COVID symptoms (n = 27 [1.5%] 4-12 weeks, n = 58 [3.3%] >12 weeks). Compared with adults, all pediatric age groups had a lower risk for persistent COVID symptoms regardless of length of symptoms reported. Additional increased risk for persistent COVID symptoms >12 weeks included severe symptoms with initial infection, not being vaccinated and having unhealthy weight (body mass index ≥85th percentile for age and sex)
Conclusions: These findings highlight the existence of nonhospitalized youth who may also experience persistent COVID symptoms. Children and adolescents are less likely to experience persistent COVID symptoms than adults and more likely to be symptomatic, experience severe symptoms and have unhealthy weight compared with children/adolescents without persistent COVID symptoms.

Koss J, Allen L, Chapman LE, Seidel SE. Association between positive COVID-19 molecular tests and COVID-like illness in Texas during the first year of the pandemic. Texas Public Health Association Journal. 2022;75(1): 25-33.  cdn.ymaws.com/www.texaspha.org/resource/resmgr/journals/2023_journals/TPHJ_Vol_75_Issue_1_Online.pdf
Throughout the COVID-19 pandemic, syndromic surveillance data have complemented authoritative COVID-19 case data by providing preliminary data that are more immediately usable for surveillance. The purpose of this study was to analyze the effectiveness of the United States Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) during COVID-19 by analyzing the association between COVID-like illness (CLI) visits and positive molecular COVID-19 tests in Texas. Additionally, we examined how these associations varied across 22 Trauma Service Areas (TSAs) and over time in Texas. Data were extracted from Texas’ syndromic surveillance database, TxS2, using ESSENCE for the 52 weeks from March 8, 2020, to March 6, 2021. We calculated Pearson’s correlation coefficients to evaluate the association between the number of positive molecular COVID-19 tests and CLI visits for Texas overall and by TSA. We then calculated the ratio of the weekly total number of CLI visits to weekly positive COVID-19 tests and charted this ratio over time to determine how CLI visits reflected the number of positive molecular tests. Pearson’s correlation coefficient analysis revealed a strong correlation between positive COVID-19 molecular tests and CLI throughout Texas as a whole during the study period (r=0.986, p <0.001). Additionally, 16 out of 22 TSAs had correlation coefficients above 0.90. Overall, the ratio of CLI visits to positive molecular tests remained relatively steady (between 10-20 CLI visits for every 100 positive tests), though, for a few TSAs, it was less consistent.
Public Health Significance: Our study provides evidence of the utility and effectiveness of using CLI as a real-time public health surveillance tool to monitor COVID-19 cases in Texas. Our finding that certain TSAs had lower correlations and less consistent ratios of CLI visits to positive molecular tests warrants further investigation of regional characteristics contributing to these variations.

Ethen M, et al. Changes in spina bifida lesion level after folic acid fortification in the US. J Pediatr. 2022 Oct;249:59-66.e1. Epub 2022 Jun 27. doi:10.1016/j.jpeds.2022.06.023
Objective: To assess whether the severity of cases of spina bifida changed after the institution of mandatory folic acid fortification in the US.
Study design: Six active population-based birth defects programs provided data on cases of spina bifida for 1992-1996 (prefortification period) and 1999-2016 (postfortification period). The programs contributed varying years of data. Case information included both a medical record verbatim text description of the spina bifida diagnosis and spina bifida codes (International Classification of Diseases, Clinical Modification, or a modified birth defects surveillance coding system). Comparing the prefortification and postfortification periods, aORs for case severity (upper-level lesions [cervical, thoracic] vs lower-level lesions [lumbar, sacral]) and prevalence ratios (PRs) were estimated.
Results: A total of 2593 cases of spina bifida (out of 7 816 062 live births) met the inclusion criteria, including 573 cases from the prefortification period and 2020 cases from the postfortification period. Case severity decreased by 70% (aOR, 0.30; 95% CI, 0.26-0.35) between the fortification periods. The decrease was most pronounced for non-Hispanic White mothers. Overall spina bifida prevalence declined by 23% (PR, 0.77; 95% CI, 0.71-0.85), with similar reductions seen across the early, mid, and recent postfortification periods. A statistically significant decrease in upper-level lesions occurred in the postfortification period compared with the prefortification period (PR, 0.28; 95% CI, 0.22-0.34), whereas the prevalence of lower-level lesions remained relatively similar (PR, 0.94; 95% CI, 0.84-1.05).
Conclusions: The severity of spina bifida cases decreased after mandatory folic acid fortification in the US. Further examination is warranted to better understand the potential effect of folic acid on spina bifida severity.

Singer R, Rodriguez G, Garcia B, Nutt A, Merengwa E. Remote infection control assessments in long-term care facilities during COVID-19 pandemic in Texas, 2020. Am J Infect Control. 2022 Oct;50(10):1110-1117. doi:10.1016/j.ajic.2022.07.007
Background: The Texas Department of State Health Services (DSHS) Healthcare Safety Unit (HCSU) conducts remote infection control assessments (tele-ICARs) in long-term care facilities (LTCFs) to evaluate COVID-19 infection prevention and control (IPC) knowledge and practices using a standardized assessment tool. Tele-ICARs are used to gauge different IPC measures specific to SARS-CoV-2 and are either proactive--conducted prior to identified cases--or responsive to an outbreak, which is defined as a new SARS-CoV-2 infection in any staff or any facility-onset infection in a resident. State and local partners use findings from the assessments to aid LTCFs by providing targeted and timely resources and support to mitigate identified gaps.
Methods: Data from tele-ICARs conducted between March 1 and October 30, 2020 were analyzed to assess major gaps across LTCF types. A major gap was defined as 10% or more of facilities not satisfying a specific IPC measure, excluding missing data. Gaps were also assessed by tele-ICAR type: proactive or responsive. Fisher's exact tests and univariate logistic regression were used to characterize significant associations between major IPC gaps and LTCF or tele-ICAR type.
Results: DSHS conducted tele-ICARs in 438 LTCFs in Texas during 8 months; 191 were nursing homes/skilled nursing facilities (NH/SNFs), 206 were assisted living facilities (ALFs) and 41 were other settings. Of the assessments, 264 were proactive and 174 responsive. Major gaps identified were: (1) 22% did not have a preference for alcohol-based hand sanitizer (ABHS) over soap and water; (2) 18.1% were not aware of the contact time for disinfectants in use; (3) 17.9% had not stopped resident communal dining; (4) 16.8% did not audit hand hygiene and PPE compliance; and (5) 11.8% had not stopped inter-facility group activities and extra-facility field trips. When restricting analyses to proactive tele-ICARs, one additional gap was identified: 11.1% of facilities lacked a dedicated space to care for or cohort residents with confirmed SARS-CoV-2 infection. Significantly more ALFs than NH/SNFs had not suspended resident communal dining (P < .001) nor identified a dedicated space to cohort residents with confirmed SARS-CoV-2 infection (P < .001). Significantly more LTCFs that received a responsive ICAR compared to a proactive ICAR reported a preference for ABHS over soap and water (P = .008) and reported suspending communal dining (P < .001) and group activities (P < .001). Also, significantly more LTCFs that received a responsive ICAR compared to a proactive ICAR had identified a dedicated space to cohort residents with confirmed SARS-CoV-2 (P = .009).
Conclusions: Increased facility education and awareness of federal and state guidelines for group activities and communal dining is warranted in Texas, emphasizing the importance of social distancing for preventing the transmission of SARS-CoV-2 in LTCFs, particularly ALFs. CDC recommendations for ABHS versus hand washing should be emphasized, as well as the importance of monitoring and auditing HCP hand hygiene and PPE compliance. Facilities may benefit from additional education and resources about disinfection, to ensure proper selection of disinfectants and understanding of the contact time required for efficacy. Analysis by tele-ICAR type suggests facilities may benefit from identifying space for dedicated COVID-19 units in advance of an outbreak in their facility. Conducting tele-ICARs in LTCFs enables public health agencies to provide direct and individualized feedback to facilities and identify state-wide opportunities for effective interventions in response to SARS-CoV-2.

Babalola F, et al. Molecular markers of pancreatic cancer: A 10-year retrospective review of molecular advances. Cureus. 2022 Sept 23;14(9):e29485. doi:10.7759/cureus.29485
Pancreatic cancer remains the third leading cause of death amongst men and women in the United States. Pancreatic ductal adenocarcinoma (PDAC), the most common type of pancreatic cancer maintains its reputation of being the most aggressive with a poor prognosis. One of the contributing factors to the high mortality of PDAC is the absence of biomarkers for early detection of disease and the complexity of tumor biology and genomics. In this review, we explored the current understanding of epigenetics and diagnostic biomarkers in PDAC and summarized recent advances in molecular biology. We discussed current guidelines on diagnosis, prognosis, and treatment, especially in high-risk individuals. We also reviewed studies that have touched on identifying biomarkers and the role they play in making early diagnosis although there are currently no screening tools for PDAC. We explored the recent understanding of epigenetic alterations of PDAC and the future implications for early detection and prognosis. In conclusion, the new and emerging advances in the detection and treatment of PDAC can lead to an improvement in the current outcome of PDAC.

Buendia J, Sears S, et al. Prevalence and risk factors of high cholesterol and triglycerides among people with HIV in Texas. AIDS Res Ther. 2022 Sep 19;19(1):43. doi:10.1186/s12981-022-00467-y
Background: People with HIV (PWH) commonly have elevated cholesterol and triglycerides levels that have been linked to medications. However, healthy behaviors including lifestyle changes can lower high cholesterol (CHOL) or high triglycerides (TG), thereby reducing individual risk for cardiovascular diseases. This study aimed to determine the prevalence and risk factors associated with high CHOL or TG among PWH in Texas.
Methods: Cross-sectional data of 981 PWH from the 2015-2017 Texas and Houston Medical Monitoring Projects were examined. High CHOL or TG was identified by medical chart diagnosis, CHOL or TG medication use, or most recent fasting lab ≥ 200 mg/dl (total CHOL) or ≥ 150 mg/dl (TG). High CHOL or TG associations with sociodemographic and clinical characteristics were assessed using Rao-Scott chi-square tests. Prevalence of high CHOL or TG development was calculated using multivariable logistic regression model.
Results: High CHOL or TG prevalence was 41% with participants being mostly male (73%), ≥ 40 years (68%), with overweight (31%) or obesity (28%), and virally suppressed (62%). Compared with PWH < 40 years of age, PWH in their 40s, 50s, and ≥ 60s were 57%, 64%, and 62% more likely to have high CHOL or TG, respectively. Participants with overweight and obesity were 41% and 30% more likely to have high CHOL or TG than those with normal weight (BMI: 18.5- < 25), respectively.
Conclusion: Since high CHOL and TG are modifiable CVD risk factors, increased education and lifestyle modification interventions are warranted to prevent the development of high CHOL or TG among PWH.

Babalola F,  et al. A comprehensive review on the effects of humor in patients with depression. Cureus. 2022 Sep 17;14(9):e29263. doi:10.7759/cureus.29263
Depression is a leading cause of disability worldwide and a major contributor to the overall global burden of disease. Although there are known, effective treatments for depression, people in low- and middle-income areas experience multiple barriers which limit their ability to receive adequate treatment. Some known barriers to effective care include a lack of resources, lack of trained healthcare providers, and social stigma associated with mental disorders and this creates gaps in mental health care and the need for more treatment modalities and adjuvant therapies to address these gaps. This review article was conducted using the scale for the assessment of non-systematic review articles (SANRA). We searched three databases; EMBASE, PubMed (MEDLINE), and Google Scholar using specified search terms. We had a total of nine articles with sample sizes ranging from 37 to 1551, and the age of participants ranged from 23 to 93 years. Articles were diverse in race and geographical locations. The articles were derived from cross-sectional studies, randomized studies, and experimental studies, and they focused on the relationship between humor and depression, and the reduced risk of depression in the study population. The articles identified different aspects of the relationship between humor and depression. The willingness of patients with depression to recognize or participate in humor could be defective resulting in abnormal social interactions such as withdrawal. However, there was some significant influence of humor or its styles on patients with depression either mitigating depressive symptoms or having no impact at all.

Shuford JA, Pont SJ, et al. Methodology to estimate natural- and vaccine-induced antibodies to SARS-CoV-2 in a large geographic region. PLoS One. 2022 Sep 9;17(9):e0273694. doi:10.1371/journal.pone.0273694
Accurate estimates of natural and/or vaccine-induced antibodies to SARS-CoV-2 are difficult to obtain. Although model-based estimates of seroprevalence have been proposed, they require inputting unknown parameters including viral reproduction number, longevity of immune response, and other dynamic factors. In contrast to a model-based approach, the current study presents a data-driven detailed statistical procedure for estimating total seroprevalence (defined as antibodies from natural infection or from full vaccination) in a region using prospectively collected serological data and state-level vaccination data. Specifically, we conducted a longitudinal statewide serological survey with 88,605 participants 5 years or older with 3 prospective blood draws beginning September 30, 2020. Along with state vaccination data, as of October 31, 2021, the estimated percentage of those 5 years or older with naturally occurring antibodies to SARS-CoV-2 in Texas is 35.0% (95% CI = (33.1%, 36.9%)). This is 3× higher than, state-confirmed COVID-19 cases (11.83%) for all ages. The percentage with naturally occurring or vaccine-induced antibodies (total seroprevalence) is 77.42%. This methodology is integral to pandemic preparedness as accurate estimates of seroprevalence can inform policy-making decisions relevant to SARS-CoV-2.

Babalola F, et al. The role of cognitive behavioral therapy in the management of psychosis. Cureus. 2022 Sep 7;14(9):e28884. doi:10.7759/cureus.28884
Cognitive behavioral therapy for psychosis (CBTp) as a modality of treatment is gaining attention. A number of authors have reported their experiences, including challenges, in administering CBTp for psychotic patients. With CBTp still evolving a lot more research is ongoing to fine-tune its benefits while mitigating the limitations to its use. The objectives of this review are to determine the role of CBTp in the overall improvement of a patient's quality of life, ascertain the number of hospitalizations with acute symptoms after the start of CBTp; and address the common drawbacks to CBTp in the management of psychosis. It was found that cognitive behavioral therapy (CBT) use can prevent the first episode of psychosis in ultra-high risk (UHR) and is effective in improving depression, self-esteem, and psychological well-being. Its use was associated with positive changes in thinking and mood, and sleep quality leading to improved everyday life. Patients who underwent CBT had fewer hospitalizations with a higher number of voluntary hospitalizations as compared to patients with usual care, who underwent a higher number of involuntary hospitalizations. Drawbacks included cost-ineffectiveness and resource limitation.

Canfield M, et al. Associations between maternal reports of periconceptional fever from miscellaneous causes and structural birth defects. Birth Defects Res. 2022 Sep 1;114(15):885-894. Epub 2022 Aug 6. doi:10.1002/bdr2.2068
Background: Associations between birth defects and fevers attributed to colds, influenza, and urinary tract infections (UTIs) have been observed in previous studies. Our aim was to study associations between birth defects and fevers attributed to other causes.
Methods: We analyzed data from 34,862 participants in the National Birth Defects Prevention Study, a multistate case-control study of major structural birth defects. Using multivariable logistic regression, we assessed the association between maternal report of fever during early pregnancy due to causes other than colds, influenza, or UTI and 36 categories of birth defects.
Results: Maternal reports of fever due to other causes were associated with significantly elevated odds ratios ranging from 1.93 to 10.60 for 8 of 36 birth defects, primarily involving the spine, limbs, and heart (spina bifida, intestinal atresia, intercalary limb deficiency, transverse limb deficiency, congenital heart defect with heterotaxy, tetralogy of Fallot, pulmonary atresia and atrial septal defect, not otherwise specified).
Conclusion: Our data suggests fever itself or other physiologic changes associated with many infections are associated with some birth defects. Women who are pregnant or planning to become pregnant may want to consider speaking with their healthcare provider about the best ways to avoid infections that may cause fever and for guidance on how to treat fevers during pregnancy.

Gill M, et al. Associations between variety of fruits and vegetables consumed, diet quality, and sociodemographic factors among 8^th and 11^th grade adolescents in Texas Public Health Nutr. 2022;1-25. Epub 2022 Aug 18. doi:10.1017/S1368980022001690
Objective: To examine demographic and dietary correlates of consumption of a variety of fruits and vegetables (FV) among Texas adolescents. Different types of FV are needed for adequate dietary intake of vitamins and phytochemicals for proper development and functioning throughout the lifespan.
Design: Cross-sectional analysis from the Texas Surveillance of Physical Activity and Nutrition (Texas SPAN) data comparing consumption of a variety of fruit and vegetables by gender, race/ethnicity, and region (Texas-Mexico border/non-border).
Setting: Middle, high schools in Texas.
Participants: 8^th, 11^th grade Texas adolescents (n=9,056 representing N=659,288) mean age 14.8 years.
Results: Within this sample, mean fruit and vegetable variety scores (0-7) ranged from 2.47-2.65. Boys consumed a significantly greater variety of fruit than girls (m=1.12 compared to 1.04). Adolescents in non-border regions consumed a greater variety of vegetables and FV compared to those in border regions. FV variety was associated with healthier eating in the full sample, particularly in the highest Socioeconomic Status (SES) tertile. Within the highest SES tertile, a one-unit increase in variety of fruit, vegetable, and FV was associated with significant increases (p<0.001) in a healthy eating measure, the SPAN Healthy Eating Index: Fruit variety (β=1.33, SE=.29), Vegetable variety (β=0.90, SE=0.28), and FV Variety (β=.81, SE=0.19).
Conclusions: Consumption of a greater variety of FV appears to be associated with a healthier overall diet. Associations of FV variety with healthy eating were most significant in the highest SES tertile. These findings support the need to further examine consuming a variety of FV within healthy eating behavior.

Cantu Y, et al. Successes and challenges of latent TB screening and treatment in a high-prevalence US region. Int J Tuberc Lung Dis. 2022 Aug 1;26(8):720-726. doi:10.5588/ijtld.21.0454
Background: South Texas has higher TB disease incidence than much of the United States. We evaluated a multi-site South Texas interferon-gamma release assay (IGRA)-based testing and latent TB infection (LTBI) treatment program targeting high-risk populations.
Methods: Number of IGRA tests, test results, LTBI confirmation, and treatment outcomes were collected over 2.5 years. Sixteen semi-structured patient interviews and 10 site-based focus groups were conducted with providers, nurses, and administrators. Grounded theory identified themes associated with successful outcomes.
Results: Of 9,050 IGRA tests, 687 (8%) were positive; 340 (49%) confirmed as LTBI; 191 initiated LTBI treatment; and 130 (68% of initiators) completed treatment. Patient barriers to treatment completion included lack of knowledge, misconceptions, and treatment toxicities. Clinic staff concurred that toxicity was a barrier to treatment and requiring new processes with limited resources were implementation barriers.
Conclusions: Over 9,000 patients were screened with a high prevalence of IGRA positivity, but confirming LTBI, initiating, and completing treatment were challenging. Qualitative evaluation supports low literacy patient education on LTBI and toxicities and expanded support for process implementation and provider training. These findings highlight challenges at all levels of the LTBI care cascade and provide patient, staff, and provider perspectives on implementation of these programs.

Cantu C, Surita K, Buendia J. Factors that increase risk of an HIV diagnosis following a diagnosis of syphilis: A population-based analysis of Texas men. AIDS Behav. 2022 Aug;10.1007/s10461-022-03593-w. Epub 2022 Feb 2. doi:10.1007/s10461-022-03593-w
Studies have consistently shown that diagnosis of a syphilis infection increases the risk of human immunodeficiency virus (HIV) infection. This study examines patterns in HIV incidence among men following a Primary and Secondary (P&S) syphilis diagnosis. P&S syphilis cases among men reported to the Texas Department of State Health Services between January 2010 and June 2018 were linked to the Enhanced HIV/AIDS Reporting System. Risk factors for HIV diagnosis were identified using univariate and multivariate extended Cox proportional hazards models. The 9113 men with syphilis without a concurrent or prior HIV diagnosis contributed a cumulative 35,674 person-years with a mean follow-up time of 3.9 years. The multivariate model showed that among men with a P&S syphilis diagnosis, age, race/ethnicity, transmission risk, comorbid STDs, subsequent STDs, and syphilis diagnosing facility were independently associated with a new HIV diagnosis. The results highlight disparities in HIV diagnoses, despite current prevention recommendations. Reducing these disparities will require multi-level, comprehensive interventions that are appropriate for the diverse populations around the state.

Maness T, Stewart J, Sidwa T, et al. Low risk of acquiring melioidosis from the environment in the continental United States. PLoS One. 2022 Jul 29;17(7):e0270997. doi:10.1371/journal.pone.0270997
Melioidosis is an underreported human disease of tropical and sub-tropical regions caused by the saprophyte Burkholderia pseudomallei. Although most global melioidosis cases are reported from tropical regions in Southeast Asia and northern Australia, there are multiple occurrences from sub-tropical regions, including the United States (U.S.). Most melioidosis cases reported from the continental U.S. are the result of acquiring the disease during travel to endemic regions or from contaminated imported materials. Only two human melioidosis cases from the continental U.S. have likely acquired B. pseudomallei directly from local environments and these cases lived only ~7 km from each other in rural Texas. In this study, we assessed the risk of acquiring melioidosis from the environment within the continental U.S. by surveying for B. pseudomallei in the environment in Texas where these two human melioidosis cases likely acquired their infections. We sampled the environment near the homes of the two cases and at additional sampling locations in surrounding counties in Texas that were selected based on ecological niche modeling. B. pseudomallei was not detected at the residences of these two cases or in the surrounding region. These negative data are important to demonstrate that B. pseudomallei is rare in the environment in the U.S. even at locations where locally acquired human cases likely have occurred, documenting the low risk of acquiring B. pseudomallei infection from the environment in the continental U.S.

Garza E, et al. Changes to timeliness and completeness of infectious disease reporting in Texas after implementation of an epidemiologic capacity program. Public Health Reports. 2022 Jul-Aug;137(4):679-686. Epub 2021 Apr 30. doi:10.1177/00333549211009490
Objectives: The objective of this study was to characterize the changes in timeliness and completeness of disease case reporting in Texas in response to an increasing number of foodborne illnesses and high-consequence infectious disease investigations and the Texas Department of State Health Services’ new state-funded epidemiologist (SFE) program.
Methods: We extracted electronic disease case reporting data on 42 conditions from 2012 through 2016 in all local health department (LHD) jurisdictions. We analyzed data on median time for processing reports and percentage of complete reports across time and between SFE and non-SFE jurisdictions using Mann–Whitney t tests and z scores.
Results: The median time of processing improved from 13 days to 10 days from 2012 to 2016, and the percentage of disease case reports that were complete improved from 19.6% to 27.7%. Most reports were for foodborne illnesses; both timeliness (11 to 7 days) and completeness (20.9% to 23.5%) improved for these reports.
Conclusions: Disease reporting improvements in timeliness and completeness were associated with the SFE program and its enhancement of epidemiologic capacity. SFEs were shown to improve surveillance metrics in LHDs, even in jurisdictions with a high volume of case reports. Adding epidemiologist positions in LHDs produces a tangible outcome of improved disease surveillance.

Chapman LE, Hu J, Seidel SE. Factors associated with COVID-19 vaccine hesitancy among Texas households. Texas Public Health Journal. 2022; 74(3):14-21.
COVID-19 vaccinations are an important tool for alleviating the effects of the pandemic. However, many Americans, including many Texans, are hesitant to receive a COVID-19 vaccine. This study examined who, among Texans, is most likely to experience COVID-19 vaccine hesitancy and determined the reasons behind COVID-19 vaccine hesitancy among Texans. To address our objectives, we used six weeks of repeated cross-sectional data from January 6, 2021, through March 29, 2021, from the United States Census Bureau’s Household Pulse Survey. An average of 4,145 Texas households responded to the survey each week. We found that 52 percent of Texans who had not yet received a COVID-19 vaccine (as of January - March 2021) reported vaccine hesitancy. Female and black Texans had the highest odds of reporting COVID-19 vaccine hesitancy, while Texans of Asian descent, Texans who have college degrees or higher, and Texans 40 years and older had lower odds of reporting hesitancy. The most common reasons for vaccine hesitancy among Texans were: they plan to wait and see if the vaccine is safe, and they may get it later; they are concerned about possible side effects of a COVID-19 vaccine; and they think other people need the vaccine more than they do at the present moment. Efforts to promote COVID-19 vaccination in Texas may benefit from a focus on black, female, and younger (<40 years) Texans. Additionally, to increase COVID-19 vaccination rates, public health messages could address the two most commonly reported reasons for Texans’ vaccine hesitancy: (1) I plan to wait and see if it is safe and may get it later, and (2) I am concerned about possible side effects of a COVID-19 vaccine.

Seidel SE, Archer N, Lawrence E, Bojes HK, et al. (2022). Quantitative reverse transcription PCR surveillance of SARS-CoV-2 variants of concern in wastewater of two counties in Texas, United States. ACS EST Water. 2022 Jul 6:2(1):2211-2224. doi.org/10.1021/acsestwater.2c00103
After its emergence in late November/December 2019, the severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2) rapidly spread globally. Recognizing that this virus is shed in the feces of individuals and that viral RNA is detectable in wastewater, testing for SARS-CoV-2 in sewage collection systems has allowed for the monitoring of a community’s viral burden. Over 9 months, the influents of two regional wastewater treatment facilities were concurrently examined for wild-type SARS-CoV-2 along with variants B.1.1.7 and B.1.617.2 incorporated as they emerged. Epidemiological data including new confirmed COVID-19 cases and associated hospitalizations and fatalities were tabulated within each location. RNA from SARS-CoV-2 was detectable in 100% of the wastewater samples, while variant detection was more variable. Quantitative reverse transcription PCR (RT-qPCR) results align with clinical trends for COVID-19 cases and increases in COVID-19 cases were positively related to increases in SARS-CoV-2 RNA load in wastewater, although the strength of this relationship was location specific. Our observations demonstrate that clinical and wastewater surveillance of SARS-CoV-2 wild type and constantly emerging variants of concern can be combined using RT-qPCR to characterize population infection dynamics. This may provide an early warning for at-risk communities and increase COVID-19-related hospitalizations.

Pont SJ, Shuford JA, et al. Antibody duration after infection from SARS-CoV-2 in the Texas Coronavirus Antibody Response Survey. J Infect Dis. 2022. Epub 2022 May 6. doi:10.1093/infdis/jiac167 
Understanding the duration of antibodies to the SARS-CoV-2 virus that causes COVID-19 is important to controlling the current pandemic. Participants from the Texas Coronavirus Antibody Response Survey (Texas CARES) with at least one nucleocapsid protein antibody test were selected for a longitudinal analysis of antibody duration. A linear mixed model was fit to data from participants (n= 4,553) with one to three antibody tests over 11 months (10/1/2020-9/16/2021), and model fit showed that expected antibody response after COVID-19 infection robustly increases for 100 days post-infection, and predicts individuals may remain antibody positive from natural infection beyond 500 days, depending on age, body mass index, smoking or vaping use, and disease severity (hospitalized or not; symptomatic or not).

Lee R, Keehn A, et al. COVID-19 pandemic-related impacts on newborn screening public health surveillance. Int J Neonatal Screen. 2022 Apr 15;8(2):28. doi:10.3390/ijns8020028
Newborn screening (NBS) is an essential public health service that performs screening to identify those newborns at increased risk for a panel of disorders, most of which are genetic. The goal of screening is to link those newborns at the highest risk to timely intervention and potentially life-saving treatment. The global COVID-19 pandemic led to disruptions within the United States public health system, revealing implications for the continuity of newborn screening laboratories and follow-up operations. The impacts of COVID-19 across different states at various time points meant that NBS programs impacted by the pandemic later could benefit from the immediate experiences of the earlier impacted programs. This article will review the collection, analysis, and dissemination of information during the COVID-19 pandemic facilitated by a national, centralized technical assistance and resource center for NBS programs.

Surita K, et al. The organization, content, and case-finding effectiveness of HIV-assisted partner services in high HIV morbidity areas of the United States. J Acquir Immune Defic Syndr. 2022 Apr 15;89(5):498-504. doi:10.1097/QAI.0000000000002904
Background: The contemporary effectiveness of assisted partner notification services (APS) in the United States is uncertain.
Setting: State and local jurisdictions in the United States that reported ≥300 new HIV diagnoses in 2018 and were participating in the Ending the Epidemic Initiative.
Methods: The study surveyed health departments to collect data on the content and organization of APS and aggregate data on APS outcomes for 2019. Analyses defined contact and case-finding indices (i.e., sex partners named and newly diagnosed per index case receiving APS) and estimated staff case-finding productivity.
Results: Sixteen (84%) of 19 jurisdictions responded to the survey, providing APS outcome data for 14 areas (74%). Most health departments routinely integrated APS with the linkage of cases and partners to HIV care (88%) and pre-exposure prophylaxis (88%). A total of 19,164 persons were newly diagnosed with HIV in the 14 areas. Staff initiated APS investigations on 14,203 cases (74%) and provided APS to 9937 cases (52%). Cases named 6799 partners (contact index = 0.68), of whom 1841 (27%) had previously been diagnosed with HIV, 2202 (32%) tested HIV negative, 541 (8% of named and 20% of tested partners) were newly diagnosed with HIV, and 2215 (33%) were not known to have tested. Across jurisdictions, the case-finding index was 0.054 (median = 0.05, range 0.015-0.12). Health departments employed 292 full-time equivalent staff to provide APS. These staff identified a median of 2.0 new HIV infections per staff per year. APS accounted for 2.8% of new diagnoses in 2019.
Conclusions: HIV case-finding resulting from APS in the United States is low.

Drumgoole R, et al. Ecological niche model of Bacillus cereus group isolates containing a homologue of the pXO1 anthrax toxin genes infecting metalworkers in the United States. Pathogens. 2022 Apr 14;11(4):470. doi:10.3390/pathogens11040470
While Bacillus cereus typically causes opportunistic infections in humans, within the last three decades, severe and fatal infections caused by isolates of the B. cereus group harboring anthrax toxin genes have been reported in the United States. From 1994 to 2020, seven cases of anthrax-like illness resulting from these isolates have been identified. With one exception, the cases have occurred in the Gulf States region of the United States among metalworkers. We aimed to develop an ecological niche model (ENM) to estimate a spatial area conducive to the survival of these organisms based on the presence of known human infections and environmental variables. The estimated ecological niche for B. cereus was modeled with the maximum entropy algorithm (Maxent). Environmental variables contributing most to the model were soil characteristics (cation exchange capacity, carbon content, soil pH), temperature, enhanced vegetation index (EVI), and land surface temperature (LST). Much of the suitable environments were located throughout the Gulf Coast Plain, Texas Backland Prairies, East Central Texas Plains, Edwards Plateau, Cross Timbers, Mississippi Alluvial Plain, and Central Great Plains. These findings may provide additional guidance to narrow potential risk areas to efficiently communicate messages to metalworkers and potentially identify individuals who may benefit from the anthrax vaccine.

Massey J, et al. Monkeypox in a traveler returning from Nigeria - Dallas, Texas, July 2021. MMWR Morb Mortal Wkly Rep. 2022 Apr 8;71(14):509-516. doi:10.15585/mmwr.mm7114a1
Monkeypox is a rare, sometimes life-threatening zoonotic infection that occurs in West and Central Africa. It is caused by the Monkeypox virus, an orthopoxvirus similar to the Variola virus (the causative agent of smallpox) and Vaccinia virus (the live virus component of orthopoxvirus vaccines) and can spread to humans. After 39 years without detection of human disease in Nigeria, an outbreak involving 118 confirmed cases was identified during 2017-2018 (1); sporadic cases continue to occur. During September 2018-May 2021, six unrelated persons traveling from Nigeria received diagnoses of monkeypox in non-African countries: four in the United Kingdom and one each in Israel and Singapore. In July 2021, a man who traveled from Lagos, Nigeria, to Dallas, Texas, became the seventh traveler to a non-African country with diagnosed monkeypox. Among 194 monitored contacts, 144 (74%) were flight contacts. The patient received tecovirimat, an antiviral for the treatment of orthopoxvirus infections, and his home required large-scale decontamination. Whole genome sequencing showed that the virus was consistent with a strain of the Monkeypox virus known to circulate in Nigeria, but the specific source of the patient's infection was not identified. No epidemiologically linked cases were reported in Nigeria; no contact received postexposure prophylaxis (PEP) with the orthopoxvirus vaccine ACAM2000.

Langlois PH, Canfield MA, et al. Association between maternal smoking and survival among infants with trisomy 21. Birth Defects Res. 2022 Apr;114(7):249-258. Epub 2022 Feb 24. doi:10.1002/bdr2.1993
Background: Trisomy 21 (T21) is common, with affected infants having an increased risk of infant mortality (5.9-7.1%). Maternal smoking is associated with infant mortality in the general population, and we evaluated if similar associations were present among infants with T21.
Methods: We identified infants with T21 from the Texas Birth Defects Registry, and maternal smoking and infant vital status were obtained from linked birth and death certificate data, respectively. Cox proportional hazards regression models were used to calculate hazard ratios between maternal smoking and death between 0 to ≤ 364 days, 28-364 days, and 0-27 days.
Results: We found a significant association between maternal smoking and death between 0 to ≤ 364 (unadjusted HR 1.72, 95% CI 1.07, 2.77), which was no longer statistically significant after adjustment for covariates (adjusted HR 1.55, 95% CI 0.94, 2.56). A similar pattern was observed for death between 28-364 days (adjusted HR: 1.68, 95% CI 0.93, 3.03), whereas the association for 0-27 days (adjusted HR: 1.30, 95% CI 0.51, 3.29) was not statistically significant before and after adjustment.
Conclusions: The observed magnitudes of associations were similar to previous estimates among the general population. Further work considering the role of other maternal and infant risk factors and social determinants of health is necessary to better understand the observed results.

Langlois PH, Canfield MA, et al. Birth defect co-occurrence patterns among infants with cleft lip and/or palate. Cleft Palate Craniofac J. 2022 Apr;59(4):417-426. Epub 2021 Apr 28. doi:10.1177/10556656211010060
Objective: To investigate 2- to 5-way patterns of defects co-occurring with orofacial clefts using data from a population-based registry.
Design: We used data from the Texas Birth Defects Registry for deliveries between 1999 and 2014 to Texas residents, including 1884 cases with cleft palate (CP) and 5289 cases with cleft lip with or without cleft palate (CL±P) without a known syndrome. We identified patterns of defects co-occurring with CP and with CL±P observed more frequently than would be expected if these defects occurred independently. We calculated adjusted observed-to-expected (O/E) ratios to account for the known tendency of birth defects to cluster nonspecifically.
Results: Among infants without a syndrome, 23% with CP and 21% with CL±P had at least 1 additional congenital anomaly. Several combinations of defects were observed much more often than expected. For example, the combination of CL±P, congenital hydrocephaly, anophthalmia, and other nose anomalies had an O/E ratio of 605. For both CP and CL±P, co-occurrence patterns with the highest O/E ratios involved craniofacial and brain abnormalities, and many included the skeletal, cardiovascular, and renal systems.
Conclusions: The patterns of defects we observed co-occurring with clefts more often than expected may help improve our understanding of the relationships between multiple defects. Further work to better understand some of the top defect combinations could reveal new phenotypic subgroups and increase our knowledge of the developmental mechanisms that underlie the respective defects.

Langlois PH, Canfield MA, et al. The epidemiology of biliary atresia: Exploring the role of developmental factors on birth prevalence. J Pediatr. 2022 Jul;S0022-3476(22)00288-8. Epub 2022 Mar 29. doi:10.1016/j.jpeds.2022.03.038
Objectives: To identify key epidemiological factors relevant to fetal development that are associated with biliary atresia.
Study design: This population-based registry study examined infants born in Texas between 1999 and 2014. Epidemiological data relevant to fetal development was compared between cases of biliary atresia identified in the Texas Birth Defects Registry (n=305) versus all live births (n=4,689,920), and Poisson regression was used to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs).
Results: The prevalence of BA was 0.65 per 10,000 live births over the study period. BA was positively associated with female sex (adjusted PR 1.68, 95% CI: 1.33-2.12), delivery before 32-37 weeks gestation (adjusted PR 1.64, 95%CI 1.18-2.29), delivery before 32 weeks gestation (adjusted PR 3.85, 95%CI 2.38-6.22), and non-Hispanic Black versus non-Hispanic White maternal race/ethnicity (adjusted PR 1.54, 95%CI 1.06-2.24), and BA was inversely associated with season of conception in the fall relative to spring (adjusted PR 0.62, 95%CI 0.45-0.86). In addition, BA was associated with maternal diabetes (adjusted PR 2.34, 95%CI 1.57-3.48), with a stronger association with pre-gestational compared with gestational diabetes. In sub-group analyses, these associations were present in isolated BA cases which do not have any additional birth defects.
Conclusions: BA is associated with multiple factors related to fetal development, including pre-gestational maternal diabetes, female sex, and preterm birth. These associations were also observed in isolated cases of biliary atresia without other malformations or laterality defects. Our results are consistent with early life events influencing the pathogenesis of biliary atresia and support further studies investigating in-utero events to better understand the etiology and time of onset.

Fegan-Bohm K, et al. Peer-support intervention for African American and Latino parents to improve the glycemic control trajectory among school-aged children with type 1 diabetes: A pilot and feasibility protocol. Contemp Clin Trials. 2022 May;116:106739. Epub 2022 Mar 25. doi:10.1016/j.cct.2022.106739
Background: Type 1 diabetes (T1D) is a common, chronic pediatric health condition with complicated management demands. African American and Latino children with T1D have troubling disparities in glycemic outcomes and acute complications. While there are empirically supported behavioral interventions to support disease management in youth with T1D, there are few that specifically aim to reduce health disparities in this population. While collaborative parent involvement with the child with T1D management tasks is important to promote optimal glycemic outcomes during childhood, our formative research identified multiple individuals, family, and broader system factors that impede or facilitate collaborative parental involvement among African American and Latino parents of children with T1D.
Methods: This paper describes the development, design, and study protocol for the Type 1 Diabetes Empowerment And Management (TEAM) pilot trial. The TEAM intervention is a novel, group-based behavioral intervention designed to enhance collaborative involvement in T1D management for African American and Latino parents of children aged 5-10. This randomized pilot trial's primary aim is to evaluate the TEAM intervention's feasibility and acceptability. The secondary aim is to examine preliminary intervention outcomes (i.e., children's HbA1c, treatment adherence, collaborative parent involvement in T1D management, parent/child quality of life, and parent's diabetes-related distress, depressive symptoms, and self-efficacy) compared to usual T1D care.
Discussion: The trial will provide preliminary information about whether optimizing appropriate parent involvement during the school-age years may increase T1D treatment adherence and stabilize or improve glycemic control in African American and Latino school-aged children.

Broussard KR, et al. Tick-borne encephalitis among US travelers, 2010-20. J Travel Med. 2022 Mar 21;29(2):taab167. doi:10.1093/jtm/taab167
Background: Tick-borne encephalitis (TBE) is an arboviral disease that is focally endemic in parts of Europe and Asia. TBE cases among US travelers are rare, with previous reports of only six cases among civilian travelers through 2009 and nine military-related cases through 2020. A TBE vaccine was licensed in the USA in August 2021. Understanding TBE epidemiology and risks among US travelers can help with the counseling of travelers going to TBE-endemic areas.
Methods: Diagnostic testing for TBE in the USA is typically performed at the Centers for Disease Control and Prevention (CDC) because no commercial testing is available. Diagnostic testing for TBE at CDC since 2010 was reviewed. For individuals with evidence of TBE virus infection, information was gathered on demographics, clinical presentations, and risk factors for infection.
Results: From 2010-20, six patients with TBE were identified. Cases occurred among both pediatric and adult travelers and all were male. Patients were diagnosed with meningitis (n = 2) or encephalitis (n = 4); none died. Cases had traveled to various countries in Europe or Russia. Three cases reported visiting friends or relatives. Activities reported included hiking, camping, trail running, or working outdoors, and two cases had a recognized tick bite.
Conclusions: TBE cases among US travelers are uncommon, with these six cases being the only known TBE cases among civilian travelers during these 11 years. Nonetheless, given potential disease severity, pre-travel counseling for travelers to TBE-endemic areas should include information on measures to reduce the risk for TBE and other tick-borne diseases, including possible TBE vaccine use if a traveler's itinerary puts them at higher risk for infection. Clinicians should consider the diagnosis of TBE in a patient with a neurologic or febrile illness recently returned from a TBE-endemic country, particularly if a tick bite or possible tick exposure is reported.

Shuford JA, Pont SJ, et al. The durability of SARS-CoV-2 antibodies from natural infection in children and adolescents. Pediatrics. 2022 Jun 1;10.1542/peds.2021-055505. Epub 2022 Mar 18. doi:10.1542/peds.2021-055505
As of January 27, 2022, over 11.4 million children in the United States (US) have tested positive for COVID-19.1 COVID-19 cases among US children have seen an exponential increase in December 2021 and January 2022, a very short period that far exceeds previous peaks of infection.1 These recent data suggest the omicron (B.1.1.529) variant is more transmissible compared to the delta (B.1.617.2) and alpha (B.1.1.7) variants.1 These data are particularly troubling as they coincide with school re-openings after the 2021-22 holiday break across the country. Information about the durability of SARS-CoV-2-specific natural immune responses in children is important to inform community-based transmission mitigation and pediatric vaccination strategies, for both current and potential future variants. However, the true incidence and longitudinal presence of natural (not-vaccine induced) antibody response to SARS-CoV-2 infection is not known in the pediatric population due to the high proportion of asymptomatic infection2 and prioritization of testing for adults and those with severe illness early in the pandemic. This is important information for the field as not all parents can or will choose to vaccinate their children.

Monterosso A, et al. Epidemiology of cervical adenocarcinoma and squamous cell carcinoma among women living with human immunodeficiency virus compared with the general population in the United States. Clin Infect Dis. 2022 Mar 9;74(5):814-820. doi:10.1093/cid/ciab561
Background: Although cervical cancer risk overall is elevated among women living with human immunodeficiency virus (HIV; WLH), it is unclear whether risks are similarly elevated across histologic subtypes.
Methods: Data from the HIV/AIDS Cancer Match Study, a linkage of 12 US HIV and cancer registries during 1996 -2016, were used. Cervical cancers were categorized as adenocarcinoma (AC), squamous cell carcinoma (SCC), or other histologic subtype. Standardized incidence ratios compared rates of AC and SCC in WLH to those in the general population. For WLH, risk factors for AC and SCC were evaluated using Poisson regression. Five-year survival was estimated by HIV status and histology.
Results: Overall, 62 615 cervical cancers were identified, including 609 in WLH. Compared with the general population, the incidence of AC was 1.47 times higher (95% confidence interval [CI]: 1.03-2.05) and SCC was 3.62 times higher among WLH (95% CI: 3.31-3.94). Among WLH, there was no difference in AC rates by race/ethnicity or HIV transmission group, although SCC rates were lower among White women (vs Black) and higher among women who inject drugs (vs heterosexual transmission). Among WLH, 5-year overall survival was similar for AC (46.2%) and SCC (43.8%) but notably lower than for women not living with HIV.
Conclusions: Among WLH, AC rates were modestly elevated, whereas SCC rates were greatly elevated compared with the general population. These findings suggest there may be differences in the impact of immunosuppression and HIV in the development of AC versus SCC, given their common etiology in human papillomavirus infection.

Gee JE, Bower WA, Kunkel A, et al. Multistate outbreak of melioidosis associated with imported aromatherapy spray. N Engl J Med. 2022 Mar 3;386(9):861-868. doi:10.1056/NEJMoa2116130
Melioidosis, caused by the bacterium Burkholderia pseudomallei, is an uncommon infection that is typically associated with exposure to soil and water in tropical and subtropical environments. It is rarely diagnosed in the continental United States. Patients with melioidosis in the United States commonly report travel to regions where melioidosis is endemic. We report a cluster of four non-travel-associated cases of melioidosis in Georgia, Kansas, Minnesota, and Texas. These cases were caused by the same strain of B. pseudomallei that was linked to an aromatherapy spray product imported from a melioidosis-endemic area.

Saxton DL, Archer NP. The effect of postpartum depressive symptoms (PDS) on maternal health practices after childbirth, Texas pregnancy risk assessment monitoring system, 2012-2015. Matern Child Health J. 2022 Mar;26(3):537-544. Epub 2022 Jan 10. doi:10.1007/s10995-021-03304-2
Objectives: This study examined the contribution of postpartum depressive symptoms (PDS) on select maternal health practices among Texas women, using 2012-2015 survey data from the Pregnancy Risk Assessment Monitoring System.
Methods: Multiple logistic regression was used to assess the effect of PDS on postpartum checkups, postpartum dental visits, and the use of postpartum birth control. Covariates included maternal age, race/ethnicity, marital status, education, and depression before birth.
Results: Data from 4679 respondents were used in analyses, and the prevalence of women reporting PDS was 13.8 percent. Women without PDS were more likely to attend a postpartum checkup (adjusted OR = 1.5; 95% CI 1.1-2.1) or have a postpartum dental visit (adjusted OR = 1.4, 95% CI 1.0-1.8) than women with PDS. There was insufficient evidence to conclude any association between PDS and the use of postpartum birth control.
Conclusions: These findings highlight the adverse effects of PDS on maternal health practices not previously studied. Results stress the importance of healthcare professionals monitoring the moods and actions of women of childbearing age to provide early interventions for women experiencing PDS, and emphasizing positive maternal health practices after childbirth.

Langlois PH, Marengo L, Canfield MA, et al. Evaluating the proportion of isolated cases among a spectrum of birth defects in a population-based registry. Birth Defects Res. 2023 Jan 1;10.1002/bdr2.1990. Epub 2022 Feb 26. doi:10.1002/bdr2.1990
Introduction: Because the etiology and outcomes of birth defects may differ by the presence vs. absence of co-occurring anomalies, epidemiologic studies often attempt to classify cases into isolated versus non-isolated groupings. This report describes a computer algorithm for such classification and presents results using data from the Texas Birth Defects Registry (TBDR).
Methods: Each of the 1,041 birth defects coded by the TBDR was classified as chromosomal, syndromic, minor, or "needs review" by a group of three clinical geneticists. A SAS program applied those classifications to each birth defect in a case (child/fetus), and then hierarchically combined them to obtain one summary classification for each case, adding isolated and multiple defect categories. The program was applied to 136,121 cases delivered in 2012-2017.
Results: Of the total cases, 49% were classified by the platform as isolated (having only one major birth defect). This varied widely by birth defect; of those examined, the highest proportion classified as isolated was found in pyloric stenosis (87.6%), whereas several cardiovascular malformations had low proportions, including tricuspid valve atresia/stenosis (2.3%).
Discussion: This is one of the first and largest attempts to identify the proportion of isolated cases across a broad spectrum of birth defects, which can inform future epidemiologic and genomic studies of these phenotypes. Our approach is designed for easy modification for use with any birth defects coding system and category definitions, allowing scalability for different studies or birth defects registries, which often do not have resources for individual clinical review of all case records.

Nunley KA, et al. Neural correlates of slower gait in middle-aged persons with childhood-onset type 1 diabetes mellitus: the impact of accelerated brain aging. J Diabetes Complications. 2022 Feb;36(2):108084. Epub 2021 Nov 14. doi:10.1016/j.jdiacomp.2021.108084
Aims: We aimed to determine if neuroimaging characteristics of gray and white matter are associated with gait speed in middle-aged individuals with childhood-onset type 1 diabetes (T1D), and whether associations are independent of diabetic peripheral neuropathy (DPN) status.
Methods: In a cohort of 100 middle-aged adults with childhood-onset T1D (aged 49.2 ± 7.0 years, 50F/50M), we assessed cross-sectional associations of DPN, severity of white matter hyperintensities (WMH; Fazekas score), and regional gray matter volume (GMV) with gait speed. Associations were tested separately and combined in linear regression models adjusted for diabetes duration and locomotor risk factors.
Results: Average gait speed was 1.3 m/s, with 52% of participants walking below the age-appropriate range of 1.3-1.5 m/s. In separate models, higher WMH severity (β = -0.27, p = 0.01) and smaller caudate GMV (β = -0.21, p = 0.04), but not DPN (β = -0.20, p = 0.08) were associated with slower gait speed. When combined, only WMH severity remained significant (β = -0.22, p = 0.04).
Conclusions: More than half of the participants walked more slowly than expected based on age. Gait speed was slower among those with more severe WMH independent of locomotor risk factors. Gait slowing in middle-aged persons with T1D may reflect brain changes, and thus, deserve further attention.

Franco G, et al. Knowledge, attitudes, behavior, and practices of self-breast examination in Nicaragua. Cureus. 2022 Jan 17;14(1):e21317. doi:10.7759/cureus.21317
Self-breast examination (SBE) has been recommended as an important preventative practice for the early identification of breast cancer in women. However, our understanding of women's knowledge, attitudes, and practices of self-breast examination in Nicaragua is limited. In the present study, we conducted a cross-sectional study of women aged 18 years and over (n=500) living in selected urban and rural areas of Nicaragua. Measures included in the survey reflected knowledge, attitudes, behaviors, and practices related to self-breast examination. We compared these measures between women living in urban and rural areas and women aged 18-39 years and 40+ years. Using a t-test, we tested the significance of these differentials. Results indicate widespread and significant differentials in basic knowledge and behaviors on self-breast examination practices among women living in rural and urban locations in Nicaragua. Further, while younger women reported significant and lower overall knowledge about breast cancer (BC), purpose and reasons for SBE, characteristics of women who tend to be at higher risk for BC, and strategies and steps women take performing SBE compared to women who were in the 40+ age group. Study results call for location and population-specific programs and policies addressing disparities in breast cancer prevention efforts in the country.

Sanchez MLN, et al. Prevalence of critical congenital heart defects and selected co-occurring congenital anomalies, 2014-2018: a U.S. population-based study. Birth Defects Res. 2022 Jan 15;114(2):45-56. Epub 2022 Jan 19. doi:10.1002/bdr2.1980
Background: Critical congenital heart defects (CCHDs) are one of the most common types of birth defects and can lead to significant morbidity and mortality along with surgical or catheter interventions within the first year of life. This report updates previously published estimates of CCHD prevalence with the latest population-based surveillance data from 19 birth defect surveillance programs.
Methods: The U.S. population-based surveillance programs submitted data on identified cases of 12 CCHDs and co-occurring cardiovascular and chromosomal birth defects from 2014 to 2018. We estimated prevalence by program type and maternal and infant characteristics. Among nine programs with active case ascertainment that collect more than live births, we estimated the percentage of co-occurring cardiovascular and chromosomal birth defects for the 12 CCHDs.
Results: We identified 18,587 cases of CCHD among all participating programs. Overall CCHD prevalence was 19.6 per 10,000 live births among all 19 programs and 20.2 per 10,000 live births among active programs. Among maternal racial/ethnic groups, infants/fetuses born to American Indian/Alaska Native mothers showed the highest overall prevalence for all CCHDs (28.3 per 10,000) along with eight of the 12 individual CCHDs. Among 7,726 infants/fetuses with CCHD from active case ascertainment programs, 15.8% had at least one co-occurring chromosomal birth defect.
Conclusion: Our study provides prevalence estimates for CCHDs by maternal and infant characteristics along with co-occurrence with cardiovascular and chromosomal birth defects among infants/fetuses with CCHD using one of the largest and most recent cohorts since the implementation of widespread CCHD screening. These data can provide a basis for future research to better understand risk factors for these defects.

Ethen MK, et al. Interpregnancy interval and prevalence of selected birth defects: a multistate study. Birth Defects Res. 2022 Jan 15;114(2):69-79. Epub 2021 Oct 21. doi.org/10.1002/bdr2.1960
Background: Both short and long interpregnancy intervals (IPIs) have been associated with adverse birth outcomes. We undertook a multistate study to describe the prevalence of selected birth defects by IPI. 
Methods: We obtained data from nine population-based state birth defects registries for singleton live births in 2000-2009 among mothers with a previous live birth identified through birth certificates. IPI was calculated as the difference between the prior birthdate and the start of the current pregnancy (conception date). We estimated the prevalence of selected defects per 10,000 live births and prevalence ratios (PRs) with 95% confidence intervals (CIs) overall and stratified by maternal age at previous birth and race/ethnicity. Primary analyses focused on short IPI < 6 months and long IPI ≥ 60 months compared to 18-23 months (referent). Sensitivity analyses are limited to active-surveillance states and those with<10% missing IPI.
Results: Among 5,147,962 eligible births, 6.3% had short IPI while 19.8% had long IPI. Compared to referent, prevalence with short IPI was elevated for gastroschisis (3.7, CI: 3.0-4.5 vs. 2.0, CI: 1.6-2.4) and with both short and long IPI for tetralogy of Fallot (short: 3.4, 2.8-4.2 long: 3.8, 3.4-4.3 vs. 2.7, 2.3-3.2) and cleft lip ± palate (short: 9.9, 8.8-11.2 long: 9.2, 8.5-9.8 vs. 8.4, 7.6-9.2). Stratified analyses identified additional associations, including the elevated prevalence of anencephaly with short IPI in younger mothers and limb defects with long IPI in those ages 25-34 at prior birth. Sensitivity
analyses showed similar results.
Conclusion: In this population-based study, we observed an increased prevalence of several birth defects with short and long IPI.

(In date order with the most recent first):

Pont SJ, Shuford JA, et al. Strategies to estimate prevalence of SARS-CoV-2 antibodies in a Texas vulnerable population: Results from Phase I of the Texas Coronavirus Antibody Response Survey. Front Public Health. 2021;9:753487. Published 2021 Dec 14. doi.org/10.3389/fpubh.2021.753487
Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and immunity remain uncertain in populations. The state of Texas ranks 2nd in infection with over 2.71 million cases and has seen a disproportionate rate of death across the state. The Texas CARES project was funded by the state of Texas to estimate the prevalence of SARS-CoV-2 antibody status in children and adults. Identifying strategies to understand natural as well as vaccine-induced antibody responses to COVID-19 is critical. 
Materials and Methods: The Texas CARES (Texas Coronavirus Antibody Response Survey) is an ongoing prospective population-based convenience sample from the Texas general population that commenced in October 2020. Volunteer participants are recruited across the state to participate in a 3-time point data collection Texas CARES to assess antibody response over time. We use the Roche Elecsys® Anti-SARS-CoV-2 Immunoassay to determine SARS-CoV-2 antibody status.0
Results: The crude antibody positivity prevalence in Phase I was 26.1% (80/307). The fully adjusted seroprevalence of the sample was 31.5%. Specifically, 41.1% of males and 21.9% of females were seropositive. For age categories, 33.5% of those 18-34; 24.4% of those 35-44; 33.2% of those 45-54; and 32.8% of those 55+ were seropositive. In this sample, 42.2% (89/211) of those negative for the antibody test reported having had a COVID-19 test. 
Conclusions: In this survey we enrolled and analyzed data for 307 participants, demonstrating a high survey and antibody test completion rate, and ability to implement a questionnaire and SARS-CoV-2 antibody testing within clinical settings. We were also able to determine our capability to estimate the cross-sectional seroprevalence within Texas's federally qualified community centers (FQHCs). The crude positivity prevalence for SARS-CoV-2 antibodies in this sample was 26.1% indicating potentially high exposure to COVID-19 for clinic employees and patients. Data will also allow us to understand sex, age and chronic illness variation in seroprevalence by natural and vaccine-induced. These methods are being used to guide the completion of a large longitudinal survey in the state of Texas with implications for practice and population health.

Hughes MJ, Birhane MG, Dorough L, et al. Extensively drug-resistant typhoid fever in the United States. Open Forum Infect Dis. 2021;8(12):ofab572. Published 2021 Nov 16. doi.org/10.1093/ofid/ofab572
Cases of extensively drug-resistant (XDR) typhoid fever have been reported in the United States among patients who did not travel internationally. Clinicians should consider if and where the patient traveled when selecting empiric treatment for typhoid fever. XDR typhoid fever should be treated with a carbapenem, azithromycin, or both.

Mutebi JP, Godsey M, Rose D, et al. Entomological investigation following a Zika outbreak in Brownsville, Texas. J Am Mosq Control Assoc. 2021;37(4):286-290. doi.org/10.2987/21-6980
In November and December 2016, an outbreak of locally transmitted Zika occurred in Brownsville, TX. The Texas Department of State Health Services requested for a Centers for Disease Control and Prevention (CDC) Epi Aid, and as part of that Epi Aid a team of CDC entomologists was deployed in January 2017. The mission was to improve mosquito-based arbovirus surveillance and evaluate the possibility of continuing local Zika virus (ZIKV) transmission in the city. The mosquito-based arbovirus surveillance program was expanded from 4 to 40 BG-Sentinel traps evenly distributed throughout the city. Over a 2-wk period, 15 mosquito species were detected; the most abundant species were Culex quinquefasciatus, Aedes aegypti, and Ae. albopictus, which accounted for 66.7%, 16.2%, and 5.7% of the total mosquito collection, respectively. The relative abundance of Ae. aegypti (1.0 mosquitoes/trap/day) and Ae. albopictus (0.4 mosquitoes/trap/day) was very low and unlikely to initiate and/or sustain ZIKV transmission. Zika virus was not detected in the mosquitoes collected, suggesting no or extremely low ZIKV transmission at that time.

Wendel KA, Mauk K, Amsterdam L, et al. Enhancing gonococcal antimicrobial resistance surveillance in cisgender women, strengthening the US response to resistant gonorrhea, 2018 to 2019. Sex Transm Dis. 2021;48(12S Suppl 2):S104-S110. doi.org/10.1097/OLQ.0000000000001554
Background: Cisgender women have been underrepresented in antibiotic-resistant gonorrhea (ARGC) surveillance systems. Three of 8 project sites (City of Milwaukee [MIL], Guilford County [GRB], Denver County [DEN]), funded under the Centers for Disease Control and Prevention's Strengthening the US Response to Resistant Gonorrhea (SURRG), focused efforts to better include cisgender women in ARGC surveillance.
Methods: MIL, GRB, and DEN partnered with diverse health care settings and developed gonorrhea culture criteria to facilitate urogenital specimen collection in cisgender women and men. Regional laboratories within the Antibiotic Resistance Laboratory Network performed agar dilution antibiotic susceptibility testing (AST) of gonococcal isolates. Data from 2018 and 2019 were analyzed.
Results: In SURRG, 90.5% (11,464 of 12,667) of the cisgender women from whom urogenital culture specimens were collected were from MIL, GRB, and DEN. Of women in SURRG whose gonococcal isolates underwent AST, 70% were from these 3 sites. In these 3 sites, a substantial proportion of cisgender women with positive urogenital cultures and AST were from health care settings other than sexually transmitted disease (STD) clinics (non-STD clinics; MIL, 56.0%; GRB, 80.4%; and DEN, 23.5%). Isolates with AST were obtained from 5.1%, 10.2%, and 2.4% of all diagnosed gonorrhea cases among cisgender women in MIL, GRB, and DEN, respectively, and were more often susceptible to all antibiotics than those from cisgender men from each of these sites.
Conclusions: With focused efforts and partnerships with non-STD clinics, 3 SURRG sites were able to include robust ARGC surveillance from cisgender women. These findings may guide further efforts to improve gender equity in ARGC surveillance.

Ihongbe TO, Olayinka PO, Curry S. Association between bully victimization and vaping among Texas high school students. Am J Prev Med. 2021;61(6):910-918. doi.org/10.1016/j.amepre.2021.06.004
Introduction: Bullying and vaping among adolescents in Texas is a major public health concern. Bully victimization has been associated with substance use in adolescents; however, research examining the association between bully victimization and vaping in adolescents is sparse. This study aims to examine the independent association between bully victimization and vaping among Texas high school students.
Methods: Pooled data from the 2017 and 2019 Texas Youth Risk Behavior Survey (N=3,486) were analyzed in July 2020. Past-year bully victimization was categorized into 4 mutually exclusive groups: no bully victimization, school bully victimization only, cyberbully victimization only, and both school bully and cyberbully victimization. Current vape use was measured as a binary variable. Multivariable logistic regression was used to examine the association.
Results: In the total sample, the past-year prevalence of school bully victimization only, cyberbully victimization only, and both school bully and cyberbully victimization was 8.3%, 4.6%, and 7.7%, respectively. Approximately 1 in 7 students (14.5%) reported vaping during the past 30 days. Female students who experienced both school bullying and cyberbullying had 68% greater odds of vaping than female students who did not experience bullying (AOR=1.68, 95% CI=1.02, 3.41). Bully victimization was not significantly associated with vaping in male students.
Conclusions: Female Texas high school students who are victims of both school bullying and cyberbullying have a greater likelihood of vaping. Healthcare providers, school counselors, and educators should be aware of the association and sex differences that exist while developing intervention programs to address bullying and vaping in high school students.

Pont SJ, Kolsin J, McCormick DW, et al. Deaths in children and adolescents associated with COVID-19 and MIS-C in the United States. Pediatrics. 2021;148(5):e2021052273. doi.org/10.1542/peds.2021-052273
Objectives: To describe the demographics, clinical characteristics, and hospital course among persons <21 years of age with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated death.
Methods: We conducted a retrospective case series of suspected SARS-CoV-2-associated deaths in the United States in persons <21 years of age during February 12 to July 31, 2020. All states and territories were invited to participate. We abstracted demographic and clinical data, including laboratory and treatment details, from medical records.
Results: We included 112 SARS-CoV-2-associated deaths from 25 participating jurisdictions. The median age was 17 years (IQR 8.5-19 years). Most decedents were male (71, 63%), 31 (28%) were Black (non-Hispanic) persons, and 52 (46%) were Hispanic persons. Ninety-six decedents (86%) had at least 1 underlying condition; obesity (42%), asthma (29%), and developmental disorders (22%) were most commonly documented. Among 69 hospitalized decedents, common complications included mechanical ventilation (75%) and acute respiratory failure (82%). The sixteen (14%) decedents who met multisystem inflammatory syndrome in children (MIS-C) criteria were similar in age, sex, and race and/or ethnicity to decedents without MIS-C; 11 of 16 (69%) had at least 1 underlying condition.
Conclusions: SARS-CoV-2-associated deaths among persons <21 years of age occurred predominantly among Black (non-Hispanic) and Hispanic persons, male patients, and older adolescents. The most commonly reported underlying conditions were obesity, asthma, and developmental disorders. Decedents with coronavirus disease 2019 were more likely than those with MIS-C to have underlying medical conditions.

Erickson TA, Mayes B, Murray KO, Gunter SM. The epidemiology of human ehrlichiosis in Texas, 2008-2017. Ticks Tick Borne Dis. 2021;12(6):101788. doi.org/10.1016/j.ttbdis.2021.101788
Tick-borne diseases in the United States, including ehrlichiosis, represent a growing public health problem. The purpose of this study was to examine the contemporary epidemiology of human ehrlichiosis in Texas by analyzing cases reported to the Texas Department of State Health Services. In Texas, 101 cases of ehrlichiosis were reported during 2008-2017. We observed geographic grouping of cases as well as an increasing trend of reported cases occurring annually from 2009 to 2017. Notably, 27 cases occurred in 2008 in south Texas with unique patient characteristics in that they were younger, less likely to be hospitalized, and presented with disease earlier in the year than typically seen. Our findings highlight the importance of disease awareness and prevention of tick bites as well as further investigation into transmission risk and future disease patterns.

Washburn DJ, Callaghan T, Schmit C, Thompson E, Martinez D, Lafleur M. Community health worker roles and their evolving interprofessional relationships in the United States [published online ahead of print, 2021 Oct 15]. J Interprof Care. 2021;1-7. doi.org/10.1080/13561820.2021.1974362
In the United States, growing attention to the cost of care, the social determinants of health, prevention, and population health, signals a refocusing f efforts on value-based care. Just as Accountable Care Organizations and alternative payment models exemplify this shift in attention, so does the increasing integration of Community Health Workers (CHWs) into the US health are system. CHWs are often referred to as "bridge figures," helping clients to navigate what are oftentimes complicated pathways to access a variety of needed services. The integration of CHWs into interprofessional care teams is a process that takes time, and can lead to conflict as traditional care models are disrupted. Through focus groups with CHWs in rural and urban areas of four states, this work identifies and describes three early stages in the evolving interprofessional relationships between CHWs and other care providers. These stages are characterized by: (1) a lack of knowledge and understanding of CHW roles, (2) conflict and competition, and (3) engagement and integration of CHWs into patient care teams. A better understanding of the evolving process of CHW integration is critical to facilitate education and training that will more quickly encourage the development and efficacy of modern models of interprofessional care that include CHWs.

Tadese BK, Nutt A, Chaudhary I, Offiong C, Darkoh C. Regional outbreak of multidrug-resistant Klebsiella pneumoniae carbapenemase-producing Pseudomonas Aeruginosa [published online ahead of print, 2021 Oct 1]. Infect Control Hosp Epidemiol. 2021;1-3. doi.org/10.1017/ice.2021.394
Klebsiella pneumoniae carbapenemase-producing P. aeruginosa (KPC-CRPA) are rare in the United States. An outbreak of KPC-CRPA was investigated in Texas using molecular and epidemiologic methods and 17 cases of KPC-CRPA were identified. The isolates were genetically related and harbored the emerging P. aeruginosa multilocus sequence type 235, the first in the United States.

Dunn M, Peterson Johnson E, Smith B, Cooper M, Bhakta N. Perspectives on workforce development needs for community health workers (CHWs): Results from a statewide survey of CHW employers. J Community Health. 2021;46(5):1020-1028. doi.org/10.1007/s10900-021-00986-1
We conducted a survey of community health worker (CHW) employers in Texas to understand the employment context and workforce development needs of Texas CHWs. An electronic, mixed-methods survey was emailed to 841 CHW employers across Texas in Spring 2020. The survey consisted of 51 questions. The response rate was 22% (n = 182). Responses were analyzed using SPSS, Microsoft Excel, and N.Vivo. We found that most CHW employers directly employ their CHWs, and CHWs are typically part of a multidisciplinary healthcare team. Most respondents required their CHWs be certified by the state's health department and have at least a high school diploma or GED. The most common services that CHWs provide are health education/promotion and information referral. The main health issues that CHWs address are diabetes, hypertension, and mental/behavioral health. Current CHW workforce development needs include continued training on topics including chronic disease self-management and health promotion. CHW employers differ in their capacity to implement workforce development activities. There is significant variety in the employment context and workforce development needs of CHWs across Texas. Results reinforce previous findings on the need for specialized, continuing training for CHWs and the development of pathways, resources, and opportunities that could advance the CHW profession even more. These results can inform those interested in employing CHWs in their CHW program development. Findings from this study can be used to guide development of tailored curriculum for continuing education units, specialized certifications, or other professional development resources for CHWs.

Langlois PH, Canfield MA, et al. A comprehensive assessment of co-occurring birth defects among infants with non-syndromic anophthalmia or microphthalmia. Ophthalmic Epidemiol. 2021;28(5):428-435. doi.org/10.1080/09286586.2020.1862244
Purpose: Infants with anophthalmia or microphthalmia frequently have co-occurring birth defects. Nonetheless, there have been few investigations of birth defect patterns among these children. Such studies may identify novel multiple malformation syndromes, which could inform future research into the developmental processes that lead to anophthalmia/microphthalmia and assist physicians in determining whether further testing is appropriate.
Methods: This study includes cases with anophthalmia/microphthalmia identified by the Texas Birth Defects Registry from 1999 to 2014 without clinical or chromosomal diagnoses of recognized syndromes. We calculated adjusted observed-to-expected ratios for two - through five-way birth defect combinations involving anophthalmia/microphthalmia to estimate whether these combinations co-occur more often than would be expected if they were independent. We report combinations observed in ≥5 cases.
Results: We identified 653 eligible cases with anophthalmia/microphthalmia (514 [79%] with co-occurring birth defects), and 111 birth defect combinations, of which 44 were two-way combinations, 61 were three-way combinations, six were four-way combinations and none were five-way combinations. Combinations with the largest observed-to-expected ratios were those involving central nervous system (CNS) defects, head/neck defects, and orofacial clefts. We also observed multiple combinations involving cardiovascular and musculoskeletal defects.
Conclusion: Consistent with previous reports, we observed that a large proportion of children diagnosed with anophthalmia/microphthalmia have co-occurring birth defects. While some of these defects may be part of a sequence involving anophthalmia/microphthalmia (e.g., CNS defects), other combinations could point to as yet undescribed susceptibility patterns (e.g., musculoskeletal defects). Data from population-based birth defect registries may be useful for accelerating the discovery of previously uncharacterized malformation syndromes.

Shuford, JA, Neuman BW, Brashear WA, et al. Case report: Paucisymptomatic college-age population as a reservoir for potentially neutralization-resistant severe acute respiratory syndrome coronavirus 2 variants. Am J Trop Med Hyg. 2021;105(5):1227-1229. Published 2021 Sep 20. doi:10.4269/ajtmh.21-0542
To better understand the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant lineage distribution in a college campus population, we carried out viral genome surveillance over a 7-week period from January to March 2021. Among the sequences were three novel viral variants: BV-1 with a B.1.1.7/20I genetic background and an additional spike mutation Q493R, associated with a mild but longer-than-usual COVID-19 case in a college-age person, BV-2 with a T478K mutation on a 20B genetic background, and BV-3, an apparent recombinant lineage. This work highlights the potential of an undervaccinated younger population as a reservoir for the spread and generation of novel variants. This also demonstrates the value of whole genome sequencing as a routine disease surveillance tool.

Peprah S, Engels EA, Horner MJ, et al. Kaposi sarcoma incidence, burden, and prevalence in United States people with HIV, 2000-2015. Cancer Epidemiol Biomarkers Prev. 2021;30(9):1627-1633. doi:10.1158/1055-9965.EPI-21-0008
Background: The introduction of combination antiretroviral therapy (cART) has led to a significant reduction in Kaposi sarcoma (KS) incidence among people with HIV (PWH). However, it is unclear if incidence has declined similarly across key demographic and HIV transmission groups and the annual number of incident and prevalent KS cases remains unquantified.
Methods: Using population-based registry linkage data, we evaluated temporal trends in KS incidence using adjusted Poisson regression. Incidence and prevalence estimates were applied to CDC HIV surveillance data, to obtain the number of incident (2008-2015) and prevalent (2015) cases in the United States.
Results: Among PWH, KS rates were elevated 521-fold [95% confidence intervals (CI), 498-536] compared with the general population and declined from 109 per 100,000 person-years in 2000 to 47 per 100,000 person-years in 2015, at an annual percentage change of -6%. Rates declined substantially (P trend < 0.005) across all demographic and HIV transmission groups. Of the 5,306 new cases estimated between 2008 and 2015, 89% occurred among men who have sex with men. At the end of 2015, 1,904 PWH (0.20%) had been diagnosed with KS in the previous 5 years.
Conclusions: A consistent gradual decline in KS incidence has occurred among PWH in the United States during the current cART era. This decrease is uniform across key demographic and HIV transmission groups, though rates remain elevated relative to the general population.
Impact: Continued efforts to control HIV through early cART initiation and retention in care need to be maintained and possibly expanded to sustain declines.

Benavides E, Lupo PJ, Sosa M, et al. Urban-rural residence and birth defects prevalence in Texas: A phenome-wide association study. [published online ahead of print, 2021 Aug 16] [published correction appears in Pediatr Res. 2021 Oct 28;:]. Pediatr Res. 2021;10.1038/s41390-021-01700-6. doi.org/10.1038/s41390-021-01700-6
Background: Some assessments indicate the prevalence of certain birth defects varies by urban-rural status. We evaluated associations between urban-rural residence and a spectrum of birth defects, using a phenome-wide association study approach in Texas, a state with large urban centers and expansive rural areas.
Methods: Data for birth defects and livebirths during 1999-2015 were obtained from the Texas Birth Defects Registry and the Center for Health Statistics. Maternal residence was classified as urban or rural, and prevalence ratios (PR) and 95% confidence intervals (CI) were calculated for any defect and 140 specific defects by Poisson regression.
Results: Overall, birth defects were less frequent in rural compared to urban counties (PR = 0.88, 95% CI: 0.87-0.89). Twelve specific defects were less prevalent in rural counties, including ventricular septal defects (VSDs; PR = 0.76, 95% CI: 0.73-0.79) and hypospadias (PR = 0.86, 95% CI: 0.82-0.89). For some birth defects, including VSDs, there was evidence of decreasing prevalence with decreasing population size.
Conclusions: In our large population-based assessment, we demonstrated that several birth defects were less prevalent in rural counties, suggesting that characteristics of urban settings may be relevant to their etiologies, diagnosis, or surveillance. Further research is needed to identify specific exposures underlying these associations.
Impact: There are few studies of birth defects prevalence in urban versus rural settings. To address this, we investigated a comprehensive range of birth defects, including several rare defects that have not been previously studied, in a large and diverse population. We identified 12 structural birth defects that were less prevalent in rural areas. Findings suggest possible differential exposures among urban and rural women, and/or possible underdiagnosis of certain birth defects in rural areas. Findings highlight the need for further study of geographically referenced risk factors for birth defects, and of the completeness of birth defects ascertainment in rural areas.

Bollling, BG, Qualls WA, Tyler R, et al. Increasing public health mosquito surveillance in Hidalgo County, Texas to monitor vector and arboviral presence. Pathogens. 2021 Aug 13;10(8):1022. doi: 10.3390/pathogens10081022
From 2016 to 2018, Hidalgo County observed the emergence of Zika virus (ZIKV) infections along with sporadic cases of Dengue virus (DENV) and West Nile virus (WNV). Due to the emergence of ZIKV and the historical presence of other mosquito-borne illnesses, Hidalgo County obtained funding to enhance mosquito surveillance and educate residents on arboviruses and travel risks. During this time period, Hidalgo County mosquito surveillance efforts increased by 1.275%. This increase resulted in >8000 mosquitoes collected, and 28 mosquito species identified. Aedes aegypti, Ae albopictus, and Culex quinquefasciatus made up approximately two-thirds of the mosquitoes collected in 2018 (4122/6171). Spatiotemporal shifts in vector species composition were observed as the collection period progressed. Significantly, temperature variations (p < 0.05) accounted for associated variations in vector abundance, whereas all other climate variables were not significant.

Belay ED, Abrams J, et al. Trends in geographic and temporal distribution of US children with multisystem inflammatory syndrome during the COVID-19 pandemic. JAMA Pediatr. 2021 Aug 1;175(8):837-845. doi.org/10.1001/jamapediatrics.2021.0630
Importance: Multiple inflammatory syndrome in children (MIS-C) occurs in association with the COVID-19 pandemic.
Objective: To describe the clinical characteristics and geographic and temporal distribution of the largest cohort of patients with MIS-C in the United States to date.
Design, setting, and participants: Cross-sectional analysis was conducted on clinical and laboratory data collected from patients with MIS-C. The analysis included patients with illness onset from March 2020 to January 2021 and met MIS-C case definition.
Main outcomes and measures: Geographic and temporal distribution of MIS-C was compared with that of COVID-19 nationally, by region, and level of urbanicity by county. Clinical and laboratory findings and changes over time were described by age group and by presence or absence of preceding COVID-19.
Results: A total of 1733 patients with MIS-C were identified; 994 (57.6%) were male and 1117 (71.3%) were Hispanic or non-Hispanic Black. Gastrointestinal symptoms, rash, and conjunctival hyperemia were reported by 53% (n = 931) to 67% (n = 1153) of patients. A total of 937 patients (54%) had hypotension or shock, and 1009 (58.2%) were admitted for intensive care. Cardiac dysfunction was reported in 484 patients (31.0%), pericardial effusion in 365 (23.4%), myocarditis in 300 (17.3%), and coronary artery dilatation or aneurysms in 258 (16.5%). Patients aged 0 to 4 years had the lowest proportion of severe manifestations, although 171 patients (38.4%) had hypotension or shock and 197 (44.3%) were admitted for intensive care. Patients aged 18 to 20 years had the highest proportions with myocarditis (17 [30.9%]), pneumonia (20 [36.4%]), acute respiratory distress syndrome (10 [18.2%]), and polymerase chain reaction positivity (39 [70.9%]). These older adolescents also had the highest proportion reporting preceding COVID-19-like illness (63%). Nationally, the first 2 MIS-C peaks followed the COVID-19 peaks by 2 to 5 weeks. The cumulative MIS-C incidence per 100 000 persons younger than 21 years was 2.1 and varied from 0.2 to 6.3 by state. Twenty-four patients (1.4%) died.
Conclusions and relevance: In this cross-sectional study of a large cohort of patients with MIS-C, 2 peaks that followed COVID-19 peaks by 2 to 5 weeks were identified. The geographic and temporal association of MIS-C with the COVID-19 pandemic suggested that MIS-C resulted from delayed immunologic responses to SARS-CoV-2 infection. The clinical manifestations varied by age and by presence or absence of preceding COVID-19.

Norkin SK, Benson S, et al. Inadequate engagement in HIV care among people with HIV newly diagnosed with a sexually transmitted disease: A multijurisdictional analysis. Sex Transm Dis. 2021 Aug 1;48(8):601-605. doi: 10.1097/OLQ.0000000000001381
Background: Esophageal atresia (EA) affects around 2.3-2.6 per 10,000 births world-wide. Infants born with this condition require surgical correction soon after birth. Most survival studies of infants with EA are locally or regionally based. We aimed to describe survival across multiple world regions.
Methods: We included infants diagnosed with EA between 1980 and 2015 from 24 birth defects surveillance programs that are members of the International Clearinghouse for Birth Defects Surveillance and Research. We calculated survival as the proportion of liveborn infants alive at 1 month, 1- and 5-years, among all infants with EA, those with isolated EA, those with EA and additional anomalies or EA and a chromosomal anomaly or genetic syndrome. We also investigated trends in survival over the decades, 1980s-2010s.
Results: We included 6,466 liveborn infants with EA. Survival was 89.4% (95% CI 88.1-90.5) at 1-month, 84.5% (95% CI 83.0-85.9) at 1-year and 82.7% (95% CI 81.2-84.2) at 5-years. One-month survival for infants with isolated EA (97.1%) was higher than for infants with additional anomalies (89.7%) or infants with chromosomal or genetic syndrome diagnoses (57.3%) with little change at 1- and 5-years. Survival at 1 month improved from the 1980s to the 2010s, by 6.5% for infants with isolated EA and by 21.5% for infants with EA and additional anomalies.
Conclusions: Almost all infants with isolated EA survived to 5 years. Mortality was higher for infants with EA and an additional anomaly, including chromosomal or genetic syndromes. Survival improved from the 1980s, particularly for those with additional anomalies.

Shuford JA, et al. Use of Drug-level Testing and Single-genome Sequencing to Unravel a Case of Human Immunodeficiency Virus Seroconversion on Pre-exposure Prophylaxis. Clin Infect Dis. 2021;72(11):2025-2028. doi.org/10.1093/cid/ciaa1011
Cases of seroconversion on pre-exposure prophylaxis (PrEP) should be carefully investigated, given their public health implications and rarity. We report a case of transmitted drug resistance causing seroconversion on PrEP in spite of high adherence, confirmed with dried blood spot and segmental hair drug-level testing and single-genome sequencing.

Canfield MA, et al. Survival of infants born with esophageal atresia among 24 international birth defects surveillance programs. Birth Defects Res. 2021 Jul 15;113(12):945-957. Epub 2021 Mar 18. doi: 10.1002/bdr2.1891
Background: Esophageal atresia (EA) affects around 2.3-2.6 per 10,000 births worldwide. Infants born with this condition require surgical correction soon after birth. Most survival studies of infants with EA are locally or regionally based. We aimed to describe survival across multiple world regions.
Methods: We included infants diagnosed with EA between 1980 and 2015 from 24 birth defects surveillance programs that are members of the International Clearinghouse for Birth Defects Surveillance and Research. We calculated survival as the proportion of liveborn infants alive at 1 month, 1- and 5 years, among all infants with EA, those with isolated EA, those with EA and additional anomalies or EA, and a chromosomal anomaly or genetic syndrome. We also investigated trends in survival over the decades, from the 1980s-2010s.
Results: We included 6,466 liveborn infants with EA. Survival was 89.4% (95% CI 88.1-90.5) at 1 month, 84.5% (95% CI 83.0-85.9) at 1 year, and 82.7% (95% CI 81.2-84.2) at 5 years. One-month survival for infants with isolated EA (97.1%) was higher than for infants with additional anomalies (89.7%) or infants with chromosomal or genetic syndrome diagnoses (57.3%) with little change at 1- and 5 years. Survival at 1 month improved from the 1980s to the 2010s, by 6.5% for infants with isolated EA and by 21.5% for infants with EA and additional anomalies.
Conclusions: Almost all infants with isolated EA survived to 5 years. Mortality was higher for infants with EA and an additional anomaly, including chromosomal or genetic syndromes. Survival improved from the 1980s, particularly for those with additional anomalies.

Langlois PH, Canfield MA, et al. Birth defect co-occurrence patterns in the Texas Birth Defects Registry. Pediatr Res. 2021 Jun 30. [published online ahead of print]. doi: 10.1038/s41390-021-01629-w
Background: The population-level landscape of co-occurring birth defects among infants without a syndromic diagnosis is not well understood.
Methods: We analyzed data from 40,771 infants with two or more major birth defects in the Texas Birth Defects Registry (TBDR; 1999-2014). We calculated adjusted observed-to-expected (O/E) ratios for all two, three, four, and five-way combinations of 138 major defects.
Results: Among 530 patterns with the highest adjusted O/E ratios (top 5% of 10,595 patterns), 66% included only defects co-occurring within one organ system and 28% were suggestive of known patterns (e.g., midline developmental defects). Of the remaining patterns, the combination of defects with the highest O/E ratio (193.8) encompassed the diaphragm, spine, spleen, and heart defects. Fourteen patterns involved heart and spine defects with or without rib defects. Ten additional patterns primarily involved two hallmark components of VACTERL association (specifically, vertebral defects, anal atresia, cardiac defects, renal, or limb defects, but not tracheoesophageal fistula).
Conclusions: Our analyses provide a description of the birth defect co-occurrence patterns in a multi-ethnic, population-based sample, and revealed several patterns of interest. This work complements prior work that has suggested etiologic connections between select defects (e.g., diaphragmatic hernia and heart and spleen anomalies; heart and spine defects).
Impact: In this large-scale, population-based study of birth defect co-occurrence patterns, we found several birth defect combinations of potential interest that warrant further investigation: congenital diaphragmatic hernia, heart, spine, and spleen defects and scimitar syndrome with vertebral defects. The majority of patterns of co-occurring defects observed more frequently than expected involved multiple defects within the same system and combinations suggestive of known associations. Nearly all of the top patterns (beyond the same system and those suggestive of known associations) involved organ systems that are components of the VACTERL association, with heart, spine, and rib defect patterns being the most common.

Rositch AF, Levinson K, et al. Epidemiology of cervical adenocarcinoma and squamous cell carcinoma among women living with HIV compared to the general population in the United States. Clin Infect Dis. 2021 Jun 18:ciab561. [published online ahead of print]. doi: 10.1093/cid/ciab561
Objectives: Cervical cancer risk overall is elevated among women living with HIV (WLH). However, it is unclear whether risks of cervical cancer are similarly elevated across histologic subtypes.
Methods: Data were utilized from the HIV/AIDS Cancer Match Study, a linkage of 12 US HIV and cancer registries during 1996-2016. Cervical cancers were categorized as adenocarcinoma (AC), squamous cell carcinoma (SCC) or other histologic type. Standardized incidence ratios were estimated to compare rates of AC and SCC in WLH compared to the general population. For WLH, risk factors for AC and SCC were evaluated using Poisson regression. All-cause 5-year survival was estimated by HIV status and histology.
Results: Overall, 62,615 cervical cancers were identified, including 609 in WLH. Compared to the general population, incidence of AC was 1.47-times higher (95%CI: 1.03-2.05) and incidence of SCC was 3.62-times higher among WLH (95%CI: 3.31-3.94). Among WLH, there was no difference in AC rates by race/ethnicity or HIV transmission group, although SCC rates were lower among White women (vs. Black, adjusted rate ratio (aRR)=0.53; 95%CI: 0.38-0.73) and higher among women who inject drugs (vs. heterosexual transmission; aRR=1.44; 95%CI: 1.17-1.78). Among WLH, 5-year overall survival was similar for AC (46.2%) and SCC (43.8%), but notably lower than women without HIV.
Conclusions: Among WLH, AC rates were modestly elevated whereas SCC rates were greatly elevated compared to the general population. These findings suggest that there may be differences in the impact of immunosuppression and HIV status in the development of AC compared to SCC, given their common etiology in HPV infection.

Canfield MA, et al. Sixth grade academic achievement among children conceived with IVF: a population-based study in Texas, USA. J Assist Reprod Genet. 2021 Jun;38(6):1481-1492. Epub 2021 Apr 2. doi: 10.1007/s10815-021-02170-9
Purpose: To compare academic achievement in reading and mathematics at the end of sixth grade and progress from third to sixth grade by children conceived with in vitro fertilization (IVF) to those conceived naturally.
Methods: This was a retrospective population-based cohort study of IVF-conceived singleton and twin children who took the 3rd grade and 6th grade public school standardized reading and mathematics testing in Texas.
Results: There were 6,623 children with reading scores in both the third and sixth grades and 6,374 children with mathematics scores in both the third and sixth grades. Mean (± SE) scaled test scores for IVF and control singleton children for reading were 1544.6 ± 3.4 and 1527.7 ± 1.9, respectively, in third grade and 1701.2 ± 3.6 and 1681.0 ± 2.0, respectively, in sixth grade; for mathematics, the scores were 1564.4 ± 3.7 and 1548.9 ± 2.1, respectively, in third grade and 1774.0 ± 4.2 and 1752.0 ± 2.3, respectively, in sixth grade. In multivariate models, singleton IVF children scored significantly higher than control children in reading and mathematics, averaging 17.7 ± 4.0 points and 20.1 ± 4.1 points higher, respectively, in reading in third and sixth grades and 17.8 ± 4.4 points and 25.0 ± 4.8 points higher, respectively, in mathematics in third and sixth grades.
Conclusions: Children conceived with IVF and aged 8-9 years and aged 10-12 years performed as well on third and sixth grade reading and mathematics assessments as their counterparts conceived naturally.

Langlois PH, Canfield MA, et al. Patterns of congenital anomalies among individuals with trisomy 13 in Texas. Am J Med Genet A. 2021 Jun;185(6):1787-1793. Epub 2021 Mar 22. doi: 10.1002/ajmg.a.62175
Few population-based studies have analyzed patterns of co-occurring birth defects among those with trisomy 13. We evaluated the frequency of all possible combinations of any one, two, three, or four additional co-occurring birth defects among 736 individuals with trisomy 13 using data from the Texas Birth Defects Registry for deliveries during 1999-2014. We calculated the observed-to-expected ratio for each combination, adjusting for the known tendency for birth defects to cluster non-specifically. To address potential ascertainment differences among live births and non-live births, we repeated analyses specifically among live births. The combination of defects with the largest observed-to-expected ratio was microcephalus, reduction deformities of brain (e.g., holoprosencephaly), anomalies of nose, and polydactyly. As expected, most of the highest 30 observed-to-expected ratios involved combinations with documented features of trisomy 13, including defects of the scalp (e.g., aplasia cutis) and heart. Results were similar among sensitivity analyses restricted to live births. Our findings may help further delineate the phenotypic spectrum for trisomy 13 and may inform future research related to improving screening and counseling for the condition.

Vallabhaneni S, Huang JY, et al. Antimicrobial susceptibility profiles to predict the presence of carbapenemase genes among carbapenem-resistant Pseudomonas aeruginosa isolates. J Clin Microbiol. 2021 May 19;59(6):e02874-20. doi: 10.1128/JCM.02874-20
Detection of carbapenem-resistant Pseudomonas aeruginosa (CRPA) with carbapenemase-producing (CP) genes is critical for preventing transmission. Our objective was to assess whether certain antimicrobial susceptibility testing (AST) profiles can efficiently identify CP-CRPA. We defined CRPA as P. aeruginosa with imipenem or meropenem MICs of ≥8 μg/ml; CP-CRPA was CRPA with CP genes (bla KPC/bla IMP/bla NDM/bla OXA-48/bla VIM). We assessed the sensitivity and specificity of AST profiles to detect CP-CRPA among CRPA isolates collected by CDC's Antibiotic Resistance Laboratory Network (AR Lab Network) and the Emerging Infections Program (EIP) during 2017 to 2019. Three percent (195/6,192) of AR Lab Network CRPA isolates were CP-CRPA. Among CRPA isolates, adding not susceptible (NS) to cefepime or ceftazidime to the definition had 91% sensitivity and 50% specificity for identifying CP-CRPA; adding NS to ceftolozane-tazobactam had 100% sensitivity and 86% specificity. Of 965 EIP CRPA isolates evaluated for CP genes, 7 were identified as CP-CRPA; 6 of the 7 were NS to cefepime and ceftazidime, and all 7 were NS to ceftolozane-tazobactam. Among 4,182 EIP isolates, clinical laboratory AST results were available for 96% of them for cefepime, 80% for ceftazidime, and 4% for ceftolozane-tazobactam. The number of CRPA isolates needed to test (NNT) to identify one CP-CRPA isolate decreased from 138 to 64 if the definition of NS to cefepime or ceftazidime was used and to 7 with NS to ceftolozane-tazobactam. Adding not susceptible to cefepime or ceftazidime to CRPA carbapenemase testing criteria would reduce the NNT by half and can be implemented in most clinical laboratories; adding not susceptible to ceftolozane-tazobactam could be even more predictive once AST for this drug is more widely available.

Sanchez R, Ranjit N, Kelder SH, Gill M, Hoelscher DM. Intention to lose weight and use of electronic cigarettes among adolescents. Prev Med Rep. 2021;23:101406. doi:10.1016/j.pmedr.2021.101406 
Electronic cigarette use among American adolescents is a major public health concern given the negative health consequences of nicotine in youth. Recent literature has shown that weight control may be one motivation for use in this population. This study examined associations between intention to lose weight and e-cigarette use among adolescents having overweight or obesity from an ethnically diverse sample of Texas youth by gender. We performed a cross-sectional analysis of a state representative sample of 9056 eighth and eleventh grade students from the 2015-2016 Texas School Physical Activity and Nutrition (Texas SPAN) study. Validated survey items assessed weight intentions and e-cigarette use. Staff collected anthropometric measures. Logistic regression analysis was conducted to assess the relationship between e-cigarette use and weight intentions with gender interaction, adjusting for grade, race/ethnicity, economic status, weight-behaviors and stratified by BMI class. More than half (50.9%) of the weighted sample were Hispanic and 12.5% were Non-Hispanic Black; 8.5% used e-cigarettes; and 50.0% intended to lose weight. Of the 40.2% of the sample having overweight or obesity, 82.9% intended to lose weight. Among respondents with obesity, use of e-cigarettes was significantly higher among males intending to lose weight than among females intending to lose weight (12% versus 6%, p = 0.007). These findings contrast with previous research suggesting that e-cigarette use in females is more likely to be motivated by an intent to lose weight. The ethnic diversity of the Texas SPAN population may explain this discrepancy.

Canfield MA, et al. Causes of neonatal and postneonatal death among infants with birth defects in Texas. Birth Defects Res. 2021 May 15;113(9):665-675. Epub 2021 Feb 15. doi: 10.1002/bdr2.1879
Background: The proportion of deaths attributed to various causes has not been quantified among infants with birth defects. We sought to describe the causes of neonatal and postneonatal death among infants in the Texas Birth Defects Registry.
Methods: We calculated frequencies and percentages for both underlying causes and all causes (underlying or contributing) of neonatal (0-27 days) and postneonatal (28-364 days) death listed on death certificates among infants born alive with birth defects and delivered in Texas during 1999-2013 (n = 8,389 deaths). Analyses were repeated separately for infants with isolated, multiple, and syndromic defects.
Results: After birth defects, the most frequently listed causes of neonatal death were preterm/low birth weight (10%), circulatory system diseases (8%), and sepsis (5%). The leading postneonatal causes of death beyond birth defects were circulatory system diseases (32%), sepsis (11%), and renal failure (7%).
Conclusions: Improved understanding of the causes of mortality among infants with birth defects may help identify priorities for postnatal care. Our results suggest that potentially modifiable causes of death (e.g., circulatory system diseases, sepsis) contribute substantially to mortality in this population. Prioritizing continued improvements in prevention, diagnosis, and management of preventable conditions may reduce mortality among infants born with birth defects.

Buendia JR, Sears S, Griffin E, Mgbere OO. Prevalence and risk factors of type II diabetes mellitus among people living with HIV in Texas. AIDS Care. 2021 May 11:1-8. [published online ahead of print]. doi: 10.1080/09540121.2021.1925212
This study aimed to determine the prevalence and risk factors associated with type II diabetes mellitus (T2DM) among people living with HIV (PLWH). Cross-sectional data of 989 PLWH in Texas obtained from the 2015-2017 Texas and Houston Medical Monitoring Project were examined. T2DM was identified by formal medical chart diagnosis, insulin/oral hypoglycemic prescriptions, or most recent fasting blood glucose ≥126 mg/dL. T2DM adjusted prevalence ratios and 95% confidence intervals (CIs) were estimated using multiple logistic regression. Participants were mostly male (72%), ≥40 years (68%), overweight (31%) or obese (28%) and virally suppressed (62%). T2DM prevalence was 15% with variations by age, body mass index, education and health insurance (p < 0.05 for all). Compared to PLWH ≥60 years, 18-39-year-olds had significantly lower likelihood of T2DM (p < 0.001). Overweight and obese PLWH were 2.11 (95% CI: 1.23-3.63) and 3.89 times (95% CI: 2.30-6.56) more likely to have T2DM compared to normal weight PLWH. Over 1 in 6 PLWH in Texas had T2DM, with age and BMI as significant predictors. Since DM is a risk factor for cardiovascular disease and PLWH are living longer, increased education and lifestyle modification interventions are warranted to prevent T2DM development among PLWH.

Ivanova M, Oh B, Khan IUH, et al. Draft genome assemblies of two Campylobacter novaezeelandiae and four unclassified thermophilic campylobacter isolates from Canadian agricultural surface water. Microbiol Resour Announc. 2021 Apr 29;10(17):e00249-21. doi: 10.1128/MRA.00249-21
This report presents the draft genome sequences of two Campylobacter novaezeelandiae and four unclassified Campylobacter isolates from Canadian agricultural surface water. Phylogenomic analysis revealed that the six isolates formed unique clades, closely related to the disease-causing species C. jejuni, C. coli, and C. hepaticus.

Langlois PH, Canfield MA, et al. Birth defect co-occurrence patterns among infants with cleft lip and/or palate. Cleft Palate Craniofac J. 2021 Apr 28:10556656211010060. [published online ahead of print]. doi: 10.1177/10556656211010060
Objective: To investigate 2- to 5-way patterns of defects co-occurring with orofacial clefts using data from a population-based registry.
Design: We used data from the Texas Birth Defects Registry for deliveries between 1999 and 2014 to Texas residents, including 1884 cases with cleft palate (CP) and 5289 cases with cleft lip with or without cleft palate (CL±P) without a known syndrome. We identified patterns of defects co-occurring with CP and with CL±P observed more frequently than would be expected if these defects occurred independently. We calculated adjusted observed-to-expected (O/E) ratios to account for the known tendency of birth defects to cluster nonspecifically.
Results: Among infants without a syndrome, 23% with CP and 21% with CL±P had at least 1 additional congenital anomaly. Several combinations of defects were observed much more often than expected. For example, the combination of CL±P, congenital hydrocephaly, anophthalmia, and other nose anomalies had an O/E ratio of 605. For both CP and CL±P, co-occurrence patterns with the highest O/E ratios involved craniofacial and brain abnormalities, and many included the skeletal, cardiovascular, and renal systems.
Conclusions: The patterns of defects we observed co-occurring with clefts more often than expected may help improve our understanding of the relationships between multiple defects. Further work to better understand some of the top defect combinations could reveal new phenotypic subgroups and increase our knowledge of the developmental mechanisms that underlie the respective defects.

Canfield MA, et al. Risks of nonchromosomal birth defects, small-for-gestational age birthweight, and prematurity with in vitro fertilization: effect of number of embryos transferred and plurality at conception versus at birth. J Assist Reprod Genet. 2021 Apr;38(4):835-846. Epub 2021 Feb 5. doi: 10.1007/s10815-021-02095-3
Purpose: Excess embryos transferred (ET) (> plurality at birth) and fetal heartbeats (FHB) at 6 weeks' gestation are associated with reductions in birthweight and gestation, but prior studies have been limited by small sample sizes and limited IVF data. This analysis evaluated associations between excess ET, excess FHB, and adverse perinatal outcomes, including the risk of nonchromosomal birth defects.
Methods: Live births conceived via IVF from Massachusetts, New York, North Carolina, and Texas included 138,435 children born 2004-2013 (Texas), 2004-2016 (Massachusetts and North Carolina), and 2004-2017 (New York) were classified by ET and FHB. Major birth defects were reported by statewide registries within the first year of life. Logistic regression was used to estimate adjusted odds ratios (AORs) and 95% CIs of the risks of a major nonchromosomal birth defect, small-for-gestational age birthweight (SGA), low birthweight (LBW), and preterm birth (≤36 weeks), by excess ET, and excess ET + excess FHB, by plurality at birth (singletons and twins).
Results: In singletons with [2 ET, FHB =1] and [≥3 ET, FHB=1], risks [AOR (95% CI)] were increased, respectively, for major nonchromosomal birth defects [1.13 (1.00-1.27) and 1.18 (1.00-1.38)], SGA [1.10 (1.03-1.17) and 1.15 (1.05-1.26)], LBW [1.09 (1.02-1.13) and 1.17 (1.07-1.27)], and preterm birth [1.06 (1.00-1.12) and 1.14 (1.06-1.23)]. With excess ET + excess FHB, risks of all adverse outcomes except major nonchromosomal birth defects increased further for both singletons and twins.
Conclusion: Excess embryos transferred are associated with increased risks for nonchromosomal birth defects, reduced birthweight, and prematurity in IVF-conceived births.

Garcia F, et al. Efficacy, pharmacokinetics, and safety over 48 weeks with ibalizumab-based therapy in treatment-experienced adults infected with HIV-1: A Phase 2a study. J Acquir Immune Defic Syndr. 2021 Apr 1;86(4):482-489. doi: 10.1097/QAI.0000000000002591
Ibalizumab, a humanized monoclonal antibody targeting CD4, blocks HIV-1 entry into cells and is the first Food and Drug Administration-approved long-acting agent for HIV-1 treatment. In this phase 2a study, 82 HIV-infected adults failing antiretroviral therapy were assigned an individually optimized background regimen (OBR) and randomized 1:1:1 to arm A (15 mg/kg ibalizumab q2wk), arm B (10 mg/kg weekly for 9 weeks, then q2wk), or placebo. Subjects with an inadequate response at week 16 were permitted to cross over to a new OBR plus 15 mg/kg ibalizumab q2wk. At week 16, viral load (VL) reduction was significantly greater than placebo (0.26 log10) in arms A (1.07 log10; P = 0.002) and B (1.33 log10; P < 0.001); CD4+ T cell counts increased significantly in arm A. After week 16, 11/27 (arm B) and 19/27 (placebo) subjects crossed over to OBR plus 15 mg/kg ibalizumab; 8/28 in arm A initiated a new OBR. Ibalizumab treatment resulted in VL reduction at week 24 (-0.77 and -1.19 log10 for arms A and B, respectively, versus -0.32 log10 for placebo) and 48 weeks (-0.54 and -0.77 versus -0.22 log10). Compared with placebo, VL differences were statistically significant for arm B at week 24 (P = 0.001) and week 48 (P = 0.027). CD4+ T cell counts increased significantly by week 48 in both arm A and arm B, relative to placebo. No ibalizumab-related serious adverse events were reported. The durable antiviral activity and tolerability of ibalizumab support its use in treating individuals harboring multidrug-resistant HIV-1.

Canfield MA, et al. Prevalence and mortality in children with congenital diaphragmatic hernia: a multicountry study. Ann Epidemiol. 2021 Apr;56:61-69.e3. Epub 2020 Nov 27. doi:10.1016/j.annepidem.2020.11.007
Purpose: This study determined the prevalence, mortality, and time trends of children with congenital diaphragmatic hernia (CDH).
Methods: Twenty-five hospital- and population-based surveillance programs in 19 International Clearinghouse for Birth Defects Surveillance and Research member countries provided birth defects mortality data between 1974 and 2015. CDH cases included live births, stillbirths, or elective termination of pregnancy for fetal anomalies. Prevalence, cumulative mortality rates, and 95% confidence intervals (CIs) were calculated using Poisson regression and a Kaplan-Meier product-limit method. Joinpoint regression analyses were conducted to assess time trends.
Results: The prevalence of CDH was 2.6 per 10,000 total births (95% CI: 2.5-2.7), slightly increasing between 2001 and 2012 (average annual percent change = 0.5%; 95% CI:-0.6 to 1.6). The total percent mortality of CDH was 37.7%, with hospital-based registries having more deaths among live births than population-based registries (45.1% vs. 33.8%). Mortality rates decreased over time (average annual percent change = -2.4%; 95% CI: -3.8 to 1.1). Most deaths due to CDH occurred among 2- to 6-day-old infants for both registry types (36.3%, hospital-based; 12.1%, population-based).
Conclusions: The mortality of CDH has decreased over time. Mortality remains high during the first week and varied by registry type.

Garza E, et al. Epidemiology surveillance and capacity improvement: A characterization of Texas, 2017. Disaster Med Public Health Prep. 2021 Mar 17:1-8.  [published online ahead of print]. doi: 10.1017/dmp.2020.471
Objectives: In response to increasing caseloads of foodborne illnesses and high consequence infectious disease investigations, the Texas Department of State Health Services (DSHS) requested funding from the Texas Legislature in 2013 and 2015 for a new state-funded epidemiologist (SFE) program.
Methods: Primary cross-sectional survey data were collected from 32 of 40 local health departments (LHDs) via an online instrument and analyzed to quantify roles, responsibilities, and training of epidemiologists in Texas in 2017 and compared to similar state health department assessments.
Results: Sixty-six percent of SFEs had epidemiology-specific training (eg, master's in public health) compared to 45% in state health department estimates. For LHDs included in this study, the mean number of epidemiologists per 100,000 was 0.73 in medium LHDs and 0.46 in large LHDs. SFE positions make up approximately 40% of the LHD epidemiology workforce of all sizes and 56% of medium-sized LHD epidemiology staff in Texas specifically.
Conclusions: Through this program, DSHS increased epidemiology capacity almost twofold from 0.28 to 0.47 epidemiologists per 100,000 people. These findings suggest that capacity funding programs like this improve epidemiology capacity in local jurisdictions and should be considered in other regions to improve general public health preparedness and epidemiology capacity.

Hall N, et al. Myopericarditis associated with smallpox vaccination among US Army personnel - Fort Hood, Texas, 2018. Disaster Med Public Health Prep. 2021 Mar 15:1-7.  [published online ahead of print]. doi: 10.1017/dmp.2020.478
Objective: In March 2018, the US Department of Defense (DOD) added the smallpox vaccination, using ACAM2000, to its routine immunizations, increasing the number of persons receiving the vaccine. The following month, Fort Hood reported a cluster of 5 myopericarditis cases. The Centers for Disease Control and Prevention and the DOD launched an investigation.
Methods: The investigation consisted of a review of medical records, establishment of case definitions, causality assessment, patient interviews, and active surveillance. A 2-sided exact rate ratio test was used to compare myopericarditis incidence rates.
Results: This investigation identified 4 cases of probable myopericarditis and 1 case of suspected myopericarditis. No alternative etiology was identified as a cause. No additional cases were identified. There was no statistically significant difference in incidence rates between the observed cluster (5.23 per 1000 vaccinated individuals, 95% CI: 1.7-12.2) and the ACAM2000 clinical trial outcomes for symptomatic persons, which was 2.29 per 1000 vaccinated individuals (95% CI: 0.3-8.3).
Conclusions: Vaccination with ACAM2000 is the presumptive cause of this cluster. Caution should be exercised before considering vaccination campaigns for smallpox given the clinical morbidity and costs incurred by a case of myopericarditis. Risk of myopericarditis should be carefully weighed with risk of exposure to smallpox.

Shuford JA, Prot E, Cuevas E, et al. Travel from the United Kingdom to the United States by a symptomatic patient infected with the SARS-CoV-2 B.1.1.7 variant - Texas, January 2021. MMWR Morb Mortal Wkly Rep. 2021 Mar 12;70(10):348-349. doi: 10.15585/mmwr.mm7010e2
In December 2020, the B.1.1.7 genetic variant of SARS-CoV-2, the virus that causes COVID-19, was first reported after emergence and rapid circulation in the United Kingdom (1). Evidence suggests that the B.1.1.7 variant is more efficiently transmitted than are other SARS-CoV-2 variants, and widespread circulation could thereby increase SARS-CoV-2 infection and hospitalization rates (1,2). The first reported SARS-CoV-2 B.1.1.7 variant case in the United States was confirmed by sequencing in Colorado on December 29, 2020.* This report describes a person who traveled from the United Kingdom to the United States after experiencing COVID-19-compatible symptoms† and was eventually confirmed to be infected with the B.1.1.7 variant.

Stoner D, et al. Cost-Effectiveness of the Wellness Incentives and Navigation (WIN) Program. Value Health. 2021 Mar;24(3):361-368. doi: 10.1016/j.jval.2020.06.019
Objectives: Promoting patient involvement in managing co-occurring physical and mental health conditions is increasingly recognized as critical to improving outcomes and controlling costs in this growing chronically ill population. The main objective of this study was to conduct an economic evaluation of the Wellness Incentives and Navigation (WIN) intervention as part of a longitudinal randomized pragmatic clinical trial for chronically ill Texas Medicaid enrollees with co-occurring physical and mental health conditions.
Methods: The WIN intervention used a personal navigator, motivational interviewing, and a flexible wellness expense account to increase patient activation, that is, the patient's knowledge, skills, and confidence in managing their self-care and co-occurring physical and mental health conditions. Regression models were fit to both participant-level quality-adjusted life years (QALYs) and total costs of care (including the intervention) controlling for demographics, health status, poverty, Medicaid managed care plan, intervention group, and baseline health utility and costs. Incremental costs and QALYs were calculated based on the difference in predicted costs and QALYs under intervention versus usual care and were used to calculate the incremental cost-effectiveness ratios (ICERs). Confidence intervals were calculated using Fieller's method, and sensitivity analyses were performed.
Results: The mean ICER for the intervention compared with usual care was $12,511 (95% CI $8,971-$16,842), with a sizable majority of participants (70%) having ICERs below $40,000. The WIN intervention also produced higher QALY increases for participants who were sicker at baseline compared to those who were healthier at baseline.
Conclusion: The WIN intervention shows considerable promise as a cost-effective intervention in this challenging chronically ill population.

Sardell R, Miller P, et al. Texas has the highest hepatocellular carcinoma incidence rates in the USA. Dig Dis Sci. 2021 Mar;66(3):912-916. doi: 10.1007/s10620-020-06231-4
Background: Texas is the second largest state by area and population in the USA and is reported to have high incidence and mortality rates for hepatocellular carcinoma (HCC). The reasons for the increasingly high burden of HCC in Texas are not clear.
Aims: We explored trends and demographic and regional variations in HCC incidence to better understand reasons for the high burden in Texas.
Methods: We analyzed Texas Cancer Registry incidence data from 2001 to 2015 and compared results to the U.S. National Program of Cancer Registries and SEER for the same period. Rates were stratified by sex, race/ethnicity, and age at diagnosis. Rates were also compared between the US/Mexico border region of Texas and the rest of Texas.
Results: Texas had the highest HCC age-adjusted incidence rate of all states, 13.2/100,000, which was 45% higher than the national average. In Texas and nationally, rates increased by 4% per year between 2001 and 2015. Rates in Texas were 26-37% greater than national rates for Hispanics, African-Americans, and non-Hispanic whites. Among Hispanics in states with the largest percentage of Hispanics, Texas-based Hispanics had the highest HCC incidence rate in 2015 (21.2/100,000) compared with Hispanics in New Mexico, California, Arizona, Nevada, and Florida. Incidence rates were highest in South Texas and US/Mexico border regions.
Conclusions: Increasing rates in the large Hispanic population may explain why Texas now has the highest HCC incidence rate in the USA.

Waldrup K, et al. Surveillance of Trypanosoma cruzi infection in triatomine vectors, feral dogs and cats, and wild animals in and around El Paso county, Texas, and New Mexico. PLoS Negl Trop Dis. 2021 Feb 18;15(2):e0009147. doi: 10.1371/journal.pntd.0009147
The causative agent of Chagas disease, Trypanosoma cruzi, is transmitted by triatomine vectors. The insect is endemic in the Americas, including the United States, where epidemiological studies are limited, particularly in the Southwestern region. Here, we have determined the prevalence of T. cruzi in triatomines, feral cats and dogs, and wild animals, the infecting parasite genotypes and the mammalian host bloodmeal sources of the triatomines at four different geographical sites in the U.S.-Mexico border, including El Paso County, Texas, and nearby cities in New Mexico. Using qualitative polymerase chain reaction to detect T. cruzi infections, we found 66.4% (n = 225) of triatomines, 45.3% (n = 95) of feral dogs, 39.2% (n = 24) of feral cats, and 71.4% (n = 7) of wild animals positive for T. cruzi. Over 95% of T. cruzi genotypes or discrete typing units (DTUs) identified were TcI and some TcIV. Furthermore, Triatoma rubida was the triatomine species most frequently (98.2%) collected in all samples analyzed. These findings suggest a high prevalence of T. cruzi infections among triatomines, and feral and wild animals in the studied sites. Therefore, our results underscore the urgent need for implementation of a systematic epidemiological surveillance program for T. cruzi infections in insect vectors, and feral and wild animals, and Chagas disease in the human population in the southwestern region of the United States.

Canfield MA, et al. Maternal hypertension-related genotypes and congenital heart defects. Am J Hypertens. 2021 Feb 18;34(1):82-91. doi: 10.1093/ajh/hpaa116
Background: Maternal hypertension has been associated with congenital heart defect occurrence in several studies. We assessed whether maternal genotypes associated with this condition were also associated with congenital heart defect occurrence.
Methods: We used data from the National Birth Defects Prevention Study to identify non-Hispanic white (NHW) and Hispanic women with (cases) and without (controls) a pregnancy in which a select simple, isolated heart defect was present between 1999 and 2011. We genotyped 29 hypertension-related single nucleotide polymorphisms (SNPs). We conducted logistic regression analyses separately by race/ethnicity to assess the relationship between the presence of any congenital heart defect and each SNP and an overall blood pressure genetic risk score (GRS). All analyses were then repeated to assess 4 separate congenital heart defect subtypes.
Results: Four hypertension-related variants were associated with congenital heart defects among NHW women (N = 1,568 with affected pregnancies). For example, 1 intronic variant in ARHGAP2, rs633185, was associated with conotruncal defects (odds ratio [OR]: 1.3, 95% confidence interval [CI]: 1.1-1.6). Additionally, 2 variants were associated with congenital heart defects among Hispanic women (N = 489 with affected pregnancies). The GRS had a significant association with septal defects (OR: 2.1, 95% CI: 1.2-3.5) among NHW women.
Conclusions: We replicated a previously reported association between rs633185 and conotruncal defects. Although additional hypertension-related SNPs were also associated with congenital heart defects, more work is needed to better understand the relationship between genetic risk for maternal hypertension and congenital heart defects occurrence.

Langlois P, Canfield M, et al. Patterns of co-occurring birth defects among infants with hypospadias [published correction appears in J Pediatr Urol. 2021 Aug;17(4):e1]. J Pediatr Urol. 2021;17(1):64.e1-64.e8. doi: 10.1016/j.jpurol.2020.11.015
Introduction: Hypospadias, one of the most common male genital birth defects, occurs in 1 out of every 200 male births in the United States and is increasing in prevalence globally.
Objective: This study aimed to characterize the combinations of birth defects that co-occur with hypospadias more often than expected by chance, while accounting for the complex clustering patterns of congenital defects.
Study design: We analyzed cases with hypospadias and at least one additional co-occurring defect from the Texas Birth Defect Registry born between 1999 and 2014. For each combination, we calculated adjusted observed-to-expected (O/E) ratios, using Co-Occurring Defect Analysis (CODA).
Results: Among 16,442 cases with hypospadias and without known syndromes, 2,084 (12.7%) had at least one additional defect. Many of the birth defect combinations within the highest adjusted O/E ratios included cardiac, musculoskeletal, and additional urogenital defects. For example, a top combination with an adjusted O/E of 139.0 included renal agenesis and dysgenesis, reduction defects of the upper limb, and other anomalies of upper limb (including shoulder girdle). High adjusted O/E ratios were also observed in combinations that included defects outside of the urogenital developmental field. For instance, the combination with the highest O/E ratio included buphthalmos, and congenital cataract and lens anomalies (adjusted O/E ratio: 192.9). Similar results were obtained when we restricted our analyses to cases with second- or third-degree hypospadias.
Discussion: Many combinations in the top results were expected (e.g., multiple urogenital defects); however, some combinations with seemingly unrelated patterns of defects may suggest the presence of some etiologic mechanisms yet to be identified.
Conclusion: In summary, this study described patterns of co-occurring defect combinations with hypospadias that can inform further study and may provide insights for screening and diagnostic practices.

Johnson EP, et al. ChicagO Multiethnic Prevention and Surveillance Study (COMPASS): Increased response rates among African American residents in low socioeconomic status neighborhoods. Racial Ethn Health Disparities. 2021 Feb;8(1):186-198. doi: 10.1007/s40615-020-00770-2
African American (AA) populations experience persistent health disparities in the USA. Low representation in bio-specimen research precludes stratified analyses and creates challenges in studying health outcomes among AA populations. Previous studies examining determinants of bio-specimen research participation among minority participants have focused on individual-level barriers and facilitators. Neighborhood-level contextual factors may also inform bio-specimen research participation, possibly through social norms and the influence of social views and behaviors on neighbor's perspectives. We conducted an epidemiological study of residents in 5108 Chicago addresses to examine determinants of bio-specimen research participation among predominantly AA participants solicited for participation in the first 6 years of ChicagO Multiethnic Prevention and Surveillance Study (COMPASS). We used a door-to-door recruitment strategy by interviewers of predominantly minority race and ethnicity. Participants were compensated with a $50 gift card. We achieved response rates of 30.4% for non-AA addresses and 58.0% for AA addresses, with as high as 80.3% response among AA addresses in low socioeconomic status (SES) neighborhoods. After multivariable adjustment, we found approximately 3 times the odds of study participation among predominantly AA addresses in low vs. average SES neighborhoods (odds ratio (OR) = 3.06; 95% confidence interval (CI) = 2.20-4.24). Conversely, for non-AA addresses, we observed no difference in the odds of study participation in low vs. average SES neighborhoods (OR = 0.89; 95% CI = 0.69-1.14) after multivariable adjustment. Our findings suggest that AA participants in low SES neighborhoods may be recruited for bio-specimen research through door-to-door approaches with compensation. Future studies may elucidate best practices to improve bio-specimen research participation among minority populations.

Pont, SJ, et al. School-based gardening, cooking and nutrition intervention increased vegetable intake but did not reduce BMI: Texas sprouts - a cluster randomized controlled trial. Int J Behav Nutr Phys Act. 2021 Jan 23;18(1):18. doi: 10.1186/s12966-021-01087-x
Background: Although school garden programs have been shown to improve dietary behaviors, there has not been a cluster-randomized controlled trial (RCT) conducted to examine the effects of school garden programs on obesity or other health outcomes. The goal of this study was to evaluate the effects of a one-year school-based gardening, nutrition, and cooking intervention (called Texas Sprouts) on dietary intake, obesity outcomes, and blood pressure in elementary school children.
Methods: This study was a school-based cluster RCT with 16 elementary schools that were randomly assigned to either the Texas Sprouts intervention (n = 8 schools) or to control (delayed intervention, n = 8 schools). The intervention was one school year long (9 months) and consisted of: a) Garden Leadership Committee formation; b) a 0.25-acre outdoor teaching garden; c) 18 student gardening, nutrition, and cooking lessons taught by trained educators throughout the school-year; and d) nine monthly parent lessons. The delayed intervention was implemented the following academic year and received the same protocol as the intervention arm. Child outcomes measured were anthropometrics (i.e., BMI parameters, waist circumference, and body fat percentage via bioelectrical impedance), blood pressure, and dietary intake (i.e., vegetable, fruit, and sugar sweetened beverages) via survey. Data were analyzed with complete cases and with imputations at random. Generalized weighted linear mixed models were used to test the intervention effects and to account for clustering effect of sampling by school.
Results: A total of 3135 children were enrolled in the study (intervention n = 1412, 45%). Average age was 9.2 years, 64% Hispanic, 47% male, and 69% eligible for free and reduced lunch. The intervention compared to control resulted in increased vegetable intake (+ 0.48 vs. + 0.04 frequency/day, p = 0.02). There were no effects of the intervention compared to control on fruit intake, sugar sweetened beverages, any of the obesity measures or blood pressure.
Conclusion: While this school-based gardening, nutrition, and cooking program did not reduce obesity markers or blood pressure, it did result in increased vegetable intake. It is possible that a longer and more sustained effect of increased vegetable intake is needed to lead to reductions in obesity markers and blood pressure.
Clinical trials number: NCT02668744

Le M, et al. Prevalence of structural birth defects among infants with Down syndrome, 2013-2017: A US population-based study. Birth Defects Res. 2021 Jan 15;113(2):189-202. doi: 10.1002/bdr2.1854
Background: Down syndrome is the most common chromosomal disorder at birth and is often accompanied by structural birth defects. Current data on major structural defects in this population are limited.
Methods: States and territorial population-based surveillance programs submitted data on identified cases of Down syndrome and identified structural birth defects during 2013-2017. We estimated prevalence by program type and maternal and infant characteristics. Among programs with active case ascertainment, we estimated the prevalence of birth defects by organ system and for specific defects by maternal age (<35, ≥35) and infant sex.
Results: We identified 13,376 cases of Down syndrome. Prevalence among all programs was 12.7 per 10,000 live births. Among these children, 75% had at least one reported co-occurring birth defect diagnosis code. Among 6,210 cases identified by active programs, 66% had a cardiovascular defect with septal defects being the most common: atrial (32.5%), ventricular (20.6%), and atrioventricular (17.4%). Defect prevalence differed by infant sex more frequently than by maternal age. For example, atrioventricular septal defects were more common in female children (20.1% vs. 15.1%) while limb deficiencies were more prevalent in male children (0.4% vs. 0.1%).
Conclusions: Our study provides updated prevalence estimates for structural defects, including rare defects, among children with Down syndrome using one of the largest and most recent cohorts to date. These data may aid clinical care and surveillance.

Langlois PH, et al. Associations between cumulative environmental quality and ten selected birth defects in Texas. Birth Defects Res. 2021 Jan 15;113(2):161-172. doi: 10.1002/bdr2.1788
Background: Causes of most birth defects are largely unknown. Genetics, maternal factors (e.g., age, smoking) and environmental exposures have all been linked to some birth defects, including neural tube, oral cleft, limb reduction, and gastroschisis; however, the contribution of cumulative exposures across several environmental domains in association with these defects is not well understood.
Methods: The Environmental Quality Index (EQI) and its domains (air, water, land, sociodemographic, built) were used to estimate county-level cumulative environmental exposures from 2006-2010 and matched to birth defects identified from Texas Birth Defects Registry and live birth records from births in years 2007-2010 (N = 1,610,709). Poisson regression models estimated prevalence ratios (PR) and 95% confidence intervals (CI) for associations between 10 birth defects and the EQI.
Results: We observed some positive associations between worst environmental quality and neural tube, anencephaly, spina bifida, oral cleft, cleft palate, cleft lip with and without cleft palate, and gastroschisis [PR range: 1.12-1.55], but near null associations with limb reduction defects. Among domain specific results, we observed the strongest positive associations with the sociodemographic domain across birth defects but varied positive associations among the air and water domains, and negative or null associations with the land and built domains. Overall, few exposure-response patterns were evident.
Conclusions: Our results highlight the complexities of cumulative, simultaneous environmental exposures in the prevalence rates of 10 selected birth defects. We were able to explore the impact of overall and domain specific environmental quality on birth defects and identify potential domain specific drivers of these associations.

Ethen MK, Canfield MA, et al. The risk of birth defects with conception by ART. Hum Reprod. 2021 Jan 1;36(1):116-129. doi: 10.1093/humrep/deaa272
Study question: What is the association between ART conception and treatment parameters and the risk of birth defects?
Summary answer: Compared to naturally conceived singleton infants, the risk of a major nonchromosomal defect among ART singletons conceived with autologous oocytes and fresh embryos without use of ICSI was increased by 18%, with increases of 42% and 30% for use of ICSI with and without male factor diagnosis, respectively.
What is known already: Prior studies have indicated that infertility and ART are associated with an increased risk of birth defects but have been limited by small sample size and inadequate statistical power, failure to differentiate results by plurality, differences in birth defect definitions and methods of ascertainment, lack of information on ART treatment parameters or study periods spanning decades resulting in a substantial historical bias as ART techniques have improved.
Study size, design, duration: This was a population-based cohort study linking ART cycles reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) from 1 January 2004 to 31 December 2015 that resulted in live births from 1 September 2004 to 31 December 2016 in Massachusetts and North Carolina and from 1 September 2004 to 31 December 2015 for Texas and New York: these were large and ethnically diverse States, with birth defect registries utilizing the same case definitions and data collected, and with high numbers of ART births annually. A 10:1 sample of non-ART births were chosen within the same time period as the ART birth. Naturally conceived ART siblings were identified through the mother's information. Non-ART children were classified as being born to women who conceived with ovulation induction (OI)/IUI when there was an indication of infertility treatment on the birth certificate, but the woman did not link to the SART CORS; all others were classified as being naturally conceived.
Participants/materials, setting, methods: The study population included 135 051 ART children (78 362 singletons and 56 689 twins), 23 647 naturally conceived ART siblings (22 301 singletons and 1346 twins) and 9396 children born to women treated with OI/IUI (6597 singletons and 2799 twins) and 1 067 922 naturally conceived children (1 037 757 singletons and 30 165 twins). All study children were linked to their respective State birth defect registries to identify major defects diagnosed within the first year of life. We classified children with major defects as either chromosomal (i.e. presence of a chromosomal defect with or without any other major defect) or nonchromosomal (i.e. presence of a major defect but having no chromosomal defect), or all major defects (chromosomal and nonchromosomal). Logistic regression models were used to generate adjusted odds ratios (AORs) and 95% CI to evaluate the risk of birth defects due to conception with ART (using autologous oocytes and fresh embryos), and with and without the use of ICSI in the absence or presence of male factor infertility, with naturally conceived children as the reference. Analyses within the ART group were stratified by combinations of oocyte source (autologous, donor) and embryo state (fresh, thawed), with births from autologous oocytes and fresh embryos as the reference. Analyses limited to fresh embryos were stratified by oocyte source (autologous, donor) and the use of ICSI. Triplets and higher-order multiples were excluded.
Main results and the role of chance: A total of 21 998 singleton children (1.9%) and 3037 twin children (3.3%) had a major birth defect. Compared to naturally conceived children, ART singletons (conceived from autologous oocytes, fresh embryos without the use of ICSI) had increased risks of a major nonchromosomal birth defect (AOR 1.18, 95% 1.05, 1.32), cardiovascular defects (AOR 1.20, 95% CI 1.03, 1.40), and any birth defect (AOR 1.18, 95% CI 1.09, 1.27). Compared to naturally conceived children, ART singletons conceived (from autologous oocytes, fresh embryos) with the use of ICSI, the risks were increased for a major nonchromosomal birth defect (AOR 1.30, 95% CI 1.16, 1.45 without male factor diagnosis; AOR 1.42, 95% CI 1.28, 1.57 with male factor diagnosis); blastogenesis defects (AOR 1.49, 95% CI 1.08, 2.05 without male factor; AOR 1.56, 95% CI 1.17, 2.08 with male factor); cardiovascular defects (AOR 1.28, 95% CI 1.10,1.48 without male factor; AOR 1.45, 95% CI 1.27, 1.66 with male factor); in addition, the risk for musculoskeletal defects was increased (AOR 1.34, 95% CI 1.01, 1.78 without male factor) and the risk for genitourinary defects in male infants was increased (AOR 1.33, 95% CI 1.08, 1.65 with male factor). Comparisons within ART singleton births conceived from autologous oocytes and fresh embryos indicated that the use of ICSI was associated with increased risks of a major nonchromosomal birth defect (AOR 1.18, 95% CI 1.03, 1.35), blastogenesis defects (AOR 1.65, 95% CI 1.08, 2.51), gastrointestinal defects (AOR 2.21, 95% CI 1.28, 3.82) and any defect (AOR 1.11, 95% CI 1.01, 1.22). Compared to naturally conceived children, ART singleton siblings had increased risks of musculoskeletal defects (AOR 1.32, 95% CI 1.04, 1.67) and any defect (AOR 1.15, 95% CI 1.08, 1.23). ART twins (conceived with autologous oocytes, fresh embryos, without ICSI) were at increased risk of chromosomal defects (AOR 1.89, 95% CI 1.10, 3.24) and ART twin siblings were at increased risk of any defect (AOR 1.26, 95% CI 1.01, 1.57). The 18% increased risk of a major nonchromosomal birth defect in singleton infants conceived with ART without ICSI (∼36% of ART births), the 30% increased risk with ICSI without male factor (∼33% of ART births), and the 42% increased risk with ICSI and male factor (∼31% of ART births) translates into an estimated excess of 386 major birth defects among the 68 908 singleton children born by ART in 2017.
Limitations, reasons for caution: In the SART CORS database, it was not possible to differentiate method of embryo freezing (slow freezing vs vitrification), and data on ICSI was only available in the fresh embryo ART group. In the OI/IUI group, it was not possible to differentiate type of non-ART treatment utilized, and in both the ART and OI/IUI groups, data were unavailable on duration of infertility.
Wider implications of the findings: The use of ART is associated with increased risks of a major nonchromosomal birth defect, cardiovascular defect and any defect in singleton children, and chromosomal defects in twins; the use of ICSI further increases this risk, the most with male factor infertility. These findings support the judicious use of ICSI only when medically indicated. The relative contribution of ART treatment parameters versus the biology of the subfertile couple to this increased risk remains unclear and warrants further study.
Study finding/competing interest(s): This project was supported by grant R01 HD084377 from the National Institute of Child Health and Human Development. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Child Health and Human Development, or the National Institutes of Health, nor any of the State Departments of Health which contributed data. E.W. is a contract vendor for SART; all other authors report no conflicts.

Langlois PH, Canfield MA, et al. Risk factors and time trends for isolated craniosynostosis. Birth Defects Res. 2021 Jan 1;113(1):43-54. doi: 10.1002/bdr2.1824
Background: We sought to investigate associations between maternal/infant characteristics and isolated craniosynostosis as well as its subtypes sagittal, metopic, and coronal synostosis, and assess trends in the prevalence of these conditions.
Methods: We identified cases in the Texas Birth Defects Registry from 1999 to 2014. We used Poisson regression to identify associations between maternal/infant characteristics and craniosynostosis. We used joinpoint regression and unadjusted Poisson regression to evaluate temporal trends. Finally, we computed adjusted Poisson models to evaluate whether temporal trends were evident after accounting for changes in the population distributions of maternal/infant characteristics over time.
Results: Relative to all live births in the general population, cases were more frequently male or preterm. Mothers of cases were more frequently non-Hispanic white and more frequently obese. Non-Hispanic black or Hispanic maternal race/ethnicity was associated with a lower prevalence of all craniosynostosis subtypes. Previous live births were associated with sagittal synostosis; residence on the U.S.-Mexico border was associated with sagittal and coronal synostosis. The prevalence of any isolated craniosynostosis increased (average annual percent change estimated from joinpoint regression [AAPC]: 2.9%), as did the prevalences of sagittal (AAPC: 3.3%) and metopic synostosis (AAPC: 5.4%). In crude Poisson models, the same temporal trends were observed, however these were attenuated after adjusting for maternal/infant characteristics.
Conclusions: Prevalence of isolated craniosynostosis increased from 1999 to 2014. The largest AAPC was observed for metopic synostosis. Changes in the population distribution of associated maternal/infant characteristics may explain these trends.

Langlois PH, et al. Comprehensive assessment of the associations between maternal diabetes and structural birth defects in offspring: A phenome-wide association study. Ann Epidemiol. 2021 Jan;53:14-20.e8. doi: 10.1016/j.annepidem.2020.08.006
Purpose: Our objective was to comprehensively evaluate the risk of a broad range of birth defects among offspring of women with diabetes, overall and stratified by pregestational versus gestational diagnosis, using the phenome-wide association (PheWAS) methodology.
Methods: We performed a registry linkage study of all live births (>6,500,000) and birth defects cases (>290,000) in Texas, 1999-2015. We ascertained diabetes from birth and fetal death certificates. We calculated prevalence rate ratios (PRR) for phenotypes with ≥10 cases among exposed offspring (n = 130).
Results: Diabetes was associated with the prevalence of any defect (PRR 1.40, 95% confidence interval [CI] 1.38-1.42), multiple defects (PRR 1.86, 95% CI 1.81-1.91), and 60 specific phenotypes, including novel (hypospadias, mitral stenosis) and previously reported phenotypes (renal a-/dysgenesis, spinal anomalies). Pregestational diabetes was a stronger risk factor for any defect (PRR 2.00, 95% CI 1.93-2.07), multiple defects (PRR 3.27, 95% CI 3.11-3.44), and the 60 specific phenotypes evaluated. Gestational diabetes was associated with any defect (PRR 1.21, 95% CI 1.19-1.23) and 47 specific birth defects phenotypes, although associations were weaker than for pregestational diabetes.
Conclusions: The PheWAS is an efficient way to identify risk factors for disease using population-based registry data. Pregestational diabetes is associated with a broader range of phenotypes than previously reported. Because diabetes is diagnosed in 1% of women prior to pregnancy and 6%-9% during pregnancy, our results highlight a significant public health concern.

(In date order with the most recent first):

Langlois PH, Canfield MA, et al. A comprehensive assessment of co-occurring birth defects among infants with non-syndromic anophthalmia or microphthalmia. Ophthalmic Epidemiol. 2020 Dec 20:1-8. doi: 10.1080/09286586.2020.1862244
Purpose: Infants with anophthalmia or microphthalmia frequently have co-occurring birth defects. Nonetheless, there have been few investigations of birth defect patterns among these children. Such studies may identify novel multiple malformation syndromes, which could inform future research into the developmental processes that lead to anophthalmia/microphthalmia and assist physicians in determining whether further testing is appropriate.
Methods: This study includes cases with anophthalmia/microphthalmia identified by the Texas Birth Defects Registry from 1999 to 2014 without clinical or chromosomal diagnoses of recognized syndromes. We calculated adjusted observed-to-expected ratios for two - through five-way birth defect combinations involving anophthalmia/microphthalmia to estimate whether these combinations co-occur more often than would be expected if they were independent. We report combinations observed in ≥5 cases.
Results: We identified 653 eligible cases with anophthalmia/microphthalmia (514 [79%] with co-occurring birth defects), and 111 birth defect combinations, of which 44 were two-way combinations, 61 were three-way combinations, six were four-way combinations and none were five-way combinations. Combinations with the largest observed-to-expected ratios were those involving central nervous system (CNS) defects, head/neck defects, and orofacial clefts. We also observed multiple combinations involving cardiovascular and musculoskeletal defects.
Conclusion: Consistent with previous reports, we observed that a large proportion of children diagnosed with anophthalmia/microphthalmia have co-occurring birth defects. While some of these defects may be part of a sequence involving anophthalmia/microphthalmia (e.g., CNS defects), other combinations could point to as yet undescribed susceptibility patterns (e.g., musculoskeletal defects). Data from population-based birth defect registries may be useful for accelerating the discovery of previously uncharacterized malformation syndromes.

Canfield MA, et al. A multi-country study of prevalence and early childhood mortality among children with omphalocele. Birth Defects Res. 2020 Dec;112(20):1787-1801. doi: 10.1002/bdr2.1822
Background: Omphalocele is the second most common abdominal birth defect and often occurs with other structural and genetic defects. The objective of this study was to determine omphalocele prevalence, time trends, and mortality during early childhood, by geographical region, and the presence of associated anomalies.
Methods: We conducted a retrospective study with 23 birth defect surveillance systems in 18 countries that are members of the International Clearinghouse for Birth Defects Surveillance and Research that submitted data on cases ascertained from 2000 through 2012, approximately 16 million pregnancies were surveyed that resulted in live births, stillbirths, or elective terminations of pregnancy for fetal anomalies (ETOPFA) and cases with omphalocele were included. The overall prevalence and mortality rates for specific ages were calculated (day of birth, neonatal, infant, and early childhood). We used Kaplan-Meier estimates with 95% confidence intervals (CI) to calculate cumulative mortality and joinpoint regression for time trend analyses.
Results: The prevalence of omphalocele was 2.6 per 10,000 births (95% CI: 2.5, 2.7) and showed no temporal change from 2000-2012 (average annual percent change = -0.19%, p = .52). The overall mortality rate was 32.1% (95% CI: 30.2, 34.0). Most deaths occurred during the neonatal period and among children with multiple anomalies or syndromic omphalocele. Prevalence and mortality varied by registry type (e.g., hospital- vs. population-based) and inclusion or exclusion of ETOPFA.
Conclusions: The prevalence of omphalocele showed no temporal change from 2000-2012. Approximately one-third of children with omphalocele did not survive early childhood with most deaths occurring in the neonatal period.

Canfield MA, et al. Prevalence and mortality in children with congenital diaphragmatic hernia: A multicountry study. Ann Epidemiol. 2020 Nov 27:S1047-2797(20)30415-4. doi: 10.1016/j.annepidem.2020.11.007
Purpose: This study determined the prevalence, mortality, and time trends of children with congenital diaphragmatic hernia (CDH).
Methods: Twenty-five hospital- and population-based surveillance programs in 19 International Clearinghouse for Birth Defects Surveillance and Research member countries provided birth defects mortality data between 1974 and 2015. CDH cases included live births, stillbirths, or elective termination of pregnancy for fetal anomalies. Prevalence, cumulative mortality rates, and 95% confidence intervals (CIs) were calculated using Poisson regression and a Kaplan-Meier product-limit method. Joinpoint regression analyses were conducted to assess time trends.
Results: The prevalence of CDH was 2.6 per 10,000 total births (95% CI: 2.5-2.7), slightly increasing between 2001 and 2012 (average annual percent change = 0.5%; 95% CI:-0.6 to 1.6). The total percent mortality of CDH was 37.7%, with hospital-based registries having more deaths among live births than population-based registries (45.1% vs. 33.8%). Mortality rates decreased over time (average annual percent change = -2.4%; 95% CI: -3.8 to 1.1). Most deaths due to CDH occurred among 2- to 6-day-old infants for both registry types (36.3%, hospital-based; 12.1%, population-based).
Conclusions: The mortality of CDH has decreased over time. Mortality remains high during the first week and varied by registry type.

Langlois PH, Canfield MA, et al. Birth defects that co-occur with non-syndromic gastroschisis and omphalocele. Am J Med Genet A. 2020 Nov;182(11):2581-2593. doi.org/10.1002/ajmg.a.61830
Gastroschisis and omphalocele are the two most common abdominal wall birth defects, and epidemiologic characteristics and frequency of occurrence as part of a syndromic condition suggest distinct etiologies between the two defects. We assessed complex patterns of defect co-occurrence with these defects separately using the Texas Birth Defects Registry. We used co-occurring defect analysis (CODA) to compute adjusted observed-to-expected (O/E) ratios for all observed birth defect patterns. There were 2,998 non-syndromic (i.e., no documented syndrome diagnosis identified) cases with gastroschisis and 789 (26%) of these had additional co-occurring defects. There were 720 non-syndromic cases with omphalocele, and 404 (56%) had additional co-occurring defects. Among the top 30 adjusted O/E ratios for gastroschisis, most of the co-occurring defects were related to the gastrointestinal system, though cardiovascular and kidney anomalies were also present. Several of the top 30 combinations co-occurring with omphalocele appeared suggestive of OEIS (omphalocele, exstrophy of cloaca, imperforate anus, spinal defects) complex. After the exclusion of additional cases with features suggestive of OEIS in a post-hoc sensitivity analysis, the top combinations involving defects associated with OEIS (e.g., spina bifida) were no longer present. The remaining top combinations involving omphalocele included cardiovascular, gastrointestinal, and urogenital defects. In summary, we identified complex patterns of defects that co-occurred more frequently than expected with gastroschisis and omphalocele using a novel software platform. Better understanding differences in the patterns between gastroschisis and omphalocele could lead to additional etiologic insights.

Canfield MA, et al. Quantification of selection bias in studies of risk factors for birth defects among livebirths. Paediatr Perinat Epidemiol. 2020 Nov;34(6):655-664. doi: 10.1111/ppe.12650
Background: Risk factors for birth defects are frequently investigated using data limited to liveborn infants. By conditioning on survival, results of such studies may be distorted by selection bias, also described as "livebirth bias." However, the implications of livebirth bias on risk estimation remain poorly understood.
Objectives: We sought to quantify livebirth bias and to investigate the conditions under which it arose.
Methods: We used data on 3,994 birth defects cases and 11,829 controls enrolled in the National Birth Defects Prevention Study to compare odds ratio (OR) estimates of the relationship between three established risk factors (antiepileptic drug use, smoking, and multifetal pregnancy) and four birth defects (anencephaly, spina bifida, omphalocele, and cleft palate) when restricted to livebirths as compared to among livebirths, stillbirths, and elective terminations. Exposures and birth defects represented varying strengths of association with livebirth; all controls were liveborn. We performed a quantitative bias analysis to evaluate the sensitivity of our results to excluding terminated and stillborn controls.
Results: Cases ranged from 33% liveborn (anencephaly) to 99% (cleft palate). Smoking and multifetal pregnancy were associated with livebirth among anencephaly (crude OR [cOR] 0.61 and cOR 3.15, respectively) and omphalocele cases (cOR 2.22 and cOR 5.22, respectively). For analyses of the association between exposures and birth defects, restricting to livebirths produced negligible differences in estimates except for anencephaly and multifetal pregnancy, which was twofold higher among livebirths (adjusted OR [aOR] 4.93) as among all pregnancy outcomes (aOR 2.44). Within tested scenarios, bias analyses suggested that results were not sensitive to the restriction to liveborn controls.
Conclusions: Selection bias was generally limited except for high mortality defects in the context of exposures strongly associated with livebirth. Findings indicate that substantial livebirth bias is unlikely to affect studies of risk factors for most birth defects.

Ethen MK, Canfield MA, Williams M, et al. Assessment of birth defects and cancer risk in children conceived via in vitro fertilization in the US. JAMA Netw Open. 2020 Oct 1;3(10):e2022927. doi: 10.1001/jamanetworkopen.2020.22927
Importance: Children with birth defects have a greater risk of developing cancer, but this association has not yet been evaluated in children conceived with in vitro fertilization (IVF).
Objective: To assess whether the association between birth defects and cancer is greater in children conceived via IVF compared with children conceived naturally.
Design, setting, and participants: This cohort study of live births, birth defects, and cancer from Massachusetts, New York, North Carolina, and Texas included 1,000,639 children born to fertile women and 52,776 children conceived via IVF (using autologous oocytes and fresh embryos) during 2004-2016 in Massachusetts and North Carolina, 2004-2015 in New York, and 2004-2013 in Texas. Children were followed up for an average of 5.7 years (6 008 985 total person-years of exposure). Data analysis was conducted from April 1 to August 31, 2020.
Exposures: Conception by IVF for state residents who gave birth to liveborn singletons during the study period. Birth defect diagnoses recorded by statewide registries.
Main outcomes and measures: Cancer diagnosis as recorded by state cancer registries. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% CIs for birth defect-cancer associations separately in fertile and IVF groups.
Results: A total of 1,000,639 children (51.3% boys; 69.7% White; and 38.3% born between 2009-2012) were in the fertile group and 52 776 were in the IVF group (51.3% boys; 81.3% White; and 39.6% born between 2009-2012). Compared with children without birth defects, cancer risks were higher among children with a major birth defect in the fertile group (hazard ratio [HR], 3.15; 95% CI, 2.40-4.14) and IVF group (HR, 6.90; 95% CI, 3.73-12.74). The HR of cancer among children with a major nonchromosomal defect was 2.07 (95% CI, 1.47-2.91) among children in the fertile group and 4.04 (95% CI, 1.86-8.77) among children in the IVF group. The HR of cancer among children with a chromosomal defect was 15.45 (95% CI, 10.00-23.86) in the fertile group and 38.91 (95% CI, 15.56-97.33) in the IVF group.
Conclusions and relevance: This study found that among children with birth defects, those conceived via IVF were at greater risk of developing cancer compared with children conceived naturally.

Harker EJ, et al. Human prion disease surveillance in Washington State, 2006-2017. JAMA Netw Open. 2020 Oct 1;3(10):e2020690. doi: 10.1001/jamanetworkopen.2020.20690
Importance: Human prion disease surveillance is critical to detect possible cases of variant Creutzfeldt-Jakob disease and other acquired forms of prion disease in the United States. Results are presented here that describe 12 years of surveillance in Washington, the only US state that has reported the presence of classic bovine spongiform encephalopathy, an animal prion disease that has been shown to transmit to humans.
Objective: To describe the current prion disease surveillance system in Washington and the epidemiological and clinical results of surveillance from 2006 through 2017.
Design, setting, and participants: This cross-sectional study reports findings from the human prion disease surveillance system in place in Washington state from January 1, 2006, through December 31, 2017. Participants included Washington residents with a clinical suspicion of human prion disease or suggestive test results from the National Prion Disease Pathology Surveillance Center or with prion disease listed as a cause of death on the death certificate. Data for this report were analyzed from June 1, 2016, to July 1, 2020.
Exposure: Human prion disease diagnosis.
Main outcomes and measures: The main outcome was incidence of human prion disease cases, including identification of variant Creutzfeldt-Jakob disease.
Results: A total of 143 human prion disease cases were detected during the study period, none of which met criteria for a variant Creutzfeldt-Jakob disease diagnosis. Among 137 definite or probable cases, 123 (89.8%) occurred in persons aged 55 years or older, with a median age at death of 66 years (range, 38-84 years). Most patients were White (124 [92.5%] among 134 with reported race), and slightly over half were male (70 [51.1%]). The average annual age-adjusted prion disease incidence was 1.5 per million population per year, slightly higher than the national rate of 1.2 per million. A total of 99 cases (69.2%) were confirmed by neuropathology. Sporadic prion disease was the most common diagnosis, in 134 cases (93.7%), followed by familial prion disease in 8 cases (5.6%). One iatrogenic prion disease case (0.7%) was also reported.
Conclusions and relevance: The findings of this cross-sectional study suggest that demographic characteristics of patients with prion disease in Washington are consistent with national findings. The slightly higher incidence rate may be due to the state's enhanced surveillance activities, including close collaboration with key partners and educational efforts targeted toward health care providers. Results indicate that surveillance will continue to be beneficial for monitoring epidemiological trends, facilitating accurate diagnoses, and detecting variant Creutzfeldt-Jakob disease or other emerging human prion disease cases.

Kipp EJ, Hergert M, et al. An atypical case of autochthonous cutaneous leishmaniasis associated with naturally infected phlebotomine sand flies in Texas, United States. Am J Trop Med Hyg. 2020 Oct;103(4):1496-1501. doi: 10.4269/ajtmh.20-0107
In the United States, phlebotomine sand flies carrying Leishmania (Leishmania) mexicana are endemic along the southern border. However, relatively little is known about the enzootic and zoonotic transmission of L. (L.) mexicana within the United States, and autochthonous cases of the consequent disease are rarely reported. We investigated an atypical case of cutaneous leishmaniasis (CL) caused by L. (L.) mexicana in a patient from central Texas which did not respond to a typical antileishmanial chemotherapy. We also investigated sand fly vectors around the patient's residence. PCR followed by DNA sequencing was used for determination of Leishmania spp., sand fly species, and host blood meal source. The L. (L.) mexicana genotype from the patient was identical to one found in a positive sand fly. Moreover, this genotype presented the same single-nucleotide polymorphisms as other historical CL cases acquired in Texas over the last 10 years, but distinct from those originating in Mexico and Central America. Three sand fly species were identified among the samples analyzed (n = 194), the majority of which were Lutzomyia (Dampfomyia) anthophora (n = 190), of which four specimens tested positive for Leishmania and two blood-fed specimens showed the presence of a human blood meal. This study highlights the complexity of clinical management of CL in a setting where the disease is infrequently encountered. The detection of human blood in Lu. (D.) anthophora is the first documentation of anthropophagy in this species. This is the first report of wild-caught, naturally infected sand flies found in association with an autochthonous case of human leishmaniasis and the specific strain of Leishmania (Leishmania) mexicana in the United States.

Lamprecht L, et al. Using Public Health Workforce Surveillance Data to prioritize retention efforts for younger staff. Am J Prev Med. 2020 Oct;59(4):562-569. doi: 10.1016/j.amepre.2020.03.017
Introduction: The public health enterprise has a people problem. An aging workforce coupled with a sustained, strong economy and healthcare sector has made the recruitment and retention of young, educated staff challenging. Approximately one third of public health staff aged 33 years and younger are considering leaving their organization in the next year. Their reasons for leaving, and considerations for staying, are not well characterized within public health.
Methods: Data were drawn from the Public Health Workforce Interests and Needs Survey, a nationally representative survey of state and local governmental public health employees across the U.S. In 2017, a total of 43,701 staff responded. Descriptive statistics across age groups were examined, and reasons for leaving were characterized. A latent class model and an intent-to-leave logit model were fit in 2019.
Results: Pay and lack of opportunities for advancement were most frequently selected as reasons for considering leaving. Results of a logit model showed that being somewhat or very dissatisfied (versus somewhat or very satisfied) was associated with higher odds of intending to leave (AOR=4.4, p<0.0001), as was pay dissatisfaction (AOR=2.0, p<0.0001). Scoring higher than the agency median on a construct measuring perceived lack of organizational support (AOR=1.8, p<0.0001) and on a scale measuring burnout (AOR=2.6, p<0.0001) was also associated with higher odds of intending to leave.
Conclusions: Many factors associated with an increased intent to leave are present among all age groups. However, support is needed for managers as they attempt to develop and implement solutions that seek to retain the younger workforce in particular. Creating paths for promotion, competitive pay practices, organizational support, and engagement are all critical for retention in this group.

Waldrup KA, et al. Rickettsia parkeri (Rickettsiales: Rickettsiaceae) in the sky islands of West Texas. J Med Entomol. 2020 Sep 7;57(5):1582-1587. doi: 10.1093/jme/tjaa059
Rickettsia parkeri, a tick-borne pathogen distributed throughout several countries of the Americas, causes a mild to moderately severe, eschar-associated spotted fever rickettsiosis. Although most U.S. cases of R. parkeri rickettsiosis are reported from southeastern states, some have been reported recently from remote regions of southern Arizona. These cases are linked to R. parkeri-infected ticks of the Amblyomma maculatum (Acari: Ixodidae) group found in several isolated mountain ranges of southern Arizona and New Mexico, referred to as 'sky islands'. Archival records also document ticks of the A. maculatum group collected from domestic and wild animals in West Texas. We surveyed sites in two sky island chains of Jeff Davis and Brewster counties to document the off-host occurrence of these ticks and identify the presence of R. parkeri in the Trans-Pecos region of Texas. During August 2019, 43 adult A. maculatum group ticks were flagged from vegetation or removed from a road-killed, female mule deer. Of 39 samples evaluated by PCR, eight contained a partial sca0 sequence with complete identity to R. parkeri and two with complete identity to 'Candidatus Rickettsia andeanae', a species of undetermined pathogenicity. Four isolates of R. parkeri were obtained using cell culture. Persons at risk for R. parkeri rickettsiosis include those who work or recreate in these mountains, such as hikers, backpackers, research scientists, foresters, and border enforcement personnel. Additional investigations are needed to define the distribution of these medically important arthropods in other parts of the southwestern United States and northern Mexico.

Prot E, et al. Bovine tuberculosis case intervention using the T.SPOT.TB assay to screen dairy workers in Bailey County, Texas. Front Public Health. 2020 Sep 2;8:479. doi: 10.3389/fpubh.2020.00479
Background: One potential exposure on a dairy farm is Mycobacterium bovis or bovine tuberculosis (bTB)-an infectious zoonotic pathogen. The prevalence of tuberculosis among dairy workers in the U.S. is unknown largely due to insufficient surveillance and testing practices. Our objective was to determine the prevalence and risk factors of LTBI among dairy workers potentially exposed to cattle infected with bTB in two Bailey County, Texas dairy farms in 2016. 
Methods: This study involved a secondary analysis of data that were collected by Texas Department of State Health Services (DSHS) Public Health Region 1 (PHR 1). A total of 140 dairy workers were tested using the T.SPOT.TB test assay. As a proxy for occupational exposures, we used three categories of cattle exposure groups based on work task, duration, and conditions of exposure to cattle-high, medium, low. 
Results: Positive LTBI was found among 14/140 (10.0%) of the dairy workers tested with 12/87 (13.8%) in Dairy A and 2/53 (3.8%) in Dairy B. All LTBI cases were determined to be from Hispanic workers with 71.4% indicating having been vaccinated with the BCG vaccine in their country of birth and none indicated previously known exposure to TB. The high category of cattle exposure group experienced the highest prevalence of LTBI (64.3%), followed by the medium cattle exposure group (28.6%), and the low cattle exposure group (7.1%). 
Conclusion: Our findings suggest that the prevalence of LTBI among dairy workers in Bailey County, Texas is higher than demographically comparable workforces. Future efforts should focus on the development, delivery, and evaluation of a tuberculosis-and other zoonotic diseases-health and safety training which can become a part of a more comprehensive safety management and training program on dairy farms.

Langlois PH, Canfield MA, Hua F, Reilly B, Hunt P, Freedenberg D, Lee R, Villanacci JF, et al. The association between newborn screening analytes as measured on a second screen and childhood autism in a Texas Medicaid population. Am J Med Genet B Neuropsychiatr Genet. 2020 Sep;183(6):331-340. doi: 10.1002/ajmg.b.32804
Autism (or autism spectrum disorder [ASD]) is an often disabling childhood neurologic condition of mostly unknown cause. We previously explored whether there was an association of ASD with any analyte measured in the first newborn screening blood test. Here we explore the second screen. Our matched case-control study examined data on 3-5 year-old patients with any ASD diagnosis in the Texas Medicaid system in 2010-2012. Subjects were linked to their 2007-2009 newborn screening blood test data, which included values for 36 analytes or analyte ratios. Data were available for 3,005 cases and 6,212 controls. The most compelling associations were evident for fatty acid oxidation analytes octanoylcarnitine (C8) and octanoylcarnitine/acetylcarnitine (C8/C2). Their adjusted odds ratios comparing 10th versus first analyte deciles were between 1.42 and 1.54 in total births, term births, and males. C8 was consistent with first screen results. Adipylcarnitine (C6DC), an organic acid analyte, showed opposite results in the two screens. Several other analytes exhibiting significant associations in the first screen did not in the second. Our results provide evidence that abnormal newborn blood levels of some carnitines may be associated with risk of later ASD, possibly related to their involvement with mitochondrial function in the developing brain.

Arbona SI, et al. Exploring the spatial determinants of late HIV diagnosis in Texas. Prev Chronic Dis. 2020 Aug 27;17:E96. doi: 10.5888/pcd17.190346
Introduction: Despite statewide progress and continuous HIV prevention efforts in Texas, HIV diagnosis at a late stage of infection persists. Diagnosis delay differs in magnitude and spatial distribution. We examined the local spatial relationships of late HIV diagnosis with a selection of variables in an area of Texas that includes large metropolises and high HIV morbidity.
Methods: We compared regression modeling approaches to study the associations between the regional percentage of late HIV diagnosis from 2011 through 2015, regional measures of poverty, lack of health insurance (uninsurance), educational attainment, unemployment, and the average regional distance from residence to an HIV testing site: global ordinary least squares linear regression, spatial error model, geographically weighted regression, and multiscale geographically weighted regression (MGWR). Cartographic representation of the local R2, coefficient estimates, and their t values assisted in the interpretation of results.
Results: The MGWR model resulted in a better fit and identified education and uninsurance as globally fixed predictors, whereas the relationships between late HIV diagnosis and poverty, unemployment, and distance varied spatially. The model performed better in rural areas and in suburban areas of the largest cities than in urban areas.
Conclusion: The MGWR results provided local estimates of associations. The results highlight the importance of focusing on a local context. Modeling at the local scale is particularly useful for characterizing relationships between explanatory and dependent variables when the relationships vary spatially. In the context of HIV prevention, relationships that are of local relevance can inform local policy and complement routine screening in clinical settings.

Pont S, et al. Disparities in incidence of COVID-19 among underrepresented racial/ethnic groups in counties identified as hotspots during June 5-18, 2020 - 22 States, February-June 2020. MMWR Morb Mortal Wkly Rep. 2020 Aug 21;69(33):1122-1126. doi: 10.15585/mmwr.mm6933e1
During January 1, 2020-August 10, 2020, an estimated 5 million cases of coronavirus disease 2019 (COVID-19) were reported in the United States.* Published state and national data indicate that persons of color might be more likely to become infected with SARS-CoV-2, the virus that causes COVID-19, experience more severe COVID-19-associated illness, including that requiring hospitalization, and have higher risk for death from COVID-19 (1-5). CDC examined county-level disparities in COVID-19 cases among underrepresented racial/ethnic groups in counties identified as hotspots, which are defined using algorithmic thresholds related to the number of new cases and the changes in incidence.† Disparities were defined as difference of ≥5% between the proportion of cases and the proportion of the population or a ratio ≥1.5 for the proportion of cases to the proportion of the population for underrepresented racial/ethnic groups in each county. During June 5-18, 205 counties in 33 states were identified as hotspots; among these counties, race was reported for ≥50% of cumulative cases in 79 (38.5%) counties in 22 states; 96.2% of these counties had disparities in COVID-19 cases in one or more underrepresented racial/ethnic groups. Hispanic/Latino (Hispanic) persons were the largest group by population size (3.5 million persons) living in hotspot counties where a disproportionate number of cases among that group was identified, followed by black/African American (black) persons (2 million), American Indian/Alaska Native (AI/AN) persons (61,000), Asian persons (36,000), and Native Hawaiian/other Pacific Islander (NHPI) persons (31,000). Examining county-level data disaggregated by race/ethnicity can help identify health disparities in COVID-19 cases and inform strategies for preventing and slowing SARS-CoV-2 transmission. More complete race/ethnicity data are needed to fully inform public health decision-making. Addressing the pandemic's disproportionate incidence of COVID-19 in communities of color can reduce the community-wide impact of COVID-19 and improve health outcomes.

Montour J, et al. Health screening results of Cubans settling in Texas, USA, 2010-2015: A cross-sectional analysis. PLoS Med. 2020 Aug 14;17(8):e1003233. doi: 10.1371/journal.pmed.1003233
Background: Protecting the health of refugees and other migrant populations in the United States is key to ensuring successful resettlement. Therefore, to identify and address health concerns early, the US Centers for Disease Control and Prevention (CDC) recommends a domestic medical examination (screening for infectious and noninfectious diseases/conditions) shortly after arrival in the US. However, because refugee/migrant populations often have differing health patterns from one another and the US population, the collection and analysis of health information is key to developing population-specific clinical guidelines to guide the care of resettled individuals. Yet little is known regarding the health status of Cubans resettling in the US. Among the tens of thousands of Cuban migrants who have resettled in the US, some applied as refugees in Cuba, some applied for parole (a term used to indicate temporary US admission status for urgent humanitarian reasons or reasons of public benefit under US immigration law) in Cuba, and others applied for parole status after crossing the border. These groups were eligible for US government benefits to help them resettle, including a domestic medical examination. We reviewed health differences found in these examinations of those who were determined to be refugees or parolees in Cuba and those who were given parole status after arrival.
Methods and findings: We conducted a retrospective cross-sectional analysis of the Texas Department of State Health Services database. Cubans who arrived from 2010 to 2015 and received a domestic medical examination in Texas were included. Those granted refugee/parolee status in Cuba were listed in federal databases for US-bound refugees/parolees; those who were paroled after arrival were not listed. Overall, 2,189 (20%) obtained either refugee or parolee status in Cuba, and 8,709 (80%) received parolee status after arrival. Approximately 62% of those who received parolee status after arrival at the border were male, compared with 49% of those who obtained prior refugee/parolee status in Cuba. Approximately one-half (45%) of those paroled after arrival were 19-34 years old (versus 26% among those who obtained refugee/parolee status in Cuba). Separate models were created for each screening indicator as the outcome, with entry route as the main exposure variable. Crude and adjusted prevalence ratios were estimated using PROC GENMOD procedures in SAS 9.4. Individuals paroled after arrival were less likely to screen positive for parasitic infections (9.6% versus 12.2%; adjusted prevalence ratio: 0.79, 0.71-0.88) and elevated blood lead levels (children ≤16 years old, 5.2% versus 12.3%; adjusted prevalence ratio: 0.42, 0.28-0.63). Limitations include potential disease misclassification, missing clinical information, and cross-sectional nature.
Conclusions: Within-country variations in health status are often not examined in refugee populations, yet they are critical to understand granular health trends. Results suggests that the health profiles of Cuban Americans in Texas differed by entry route. This information could assist in developing targeted screenings and health interventions.

Snider C, Tuladhar R, Zhang J, et al. Evaluation of an ensemble-based distance statistic for clustering MLST datasets using epidemiologically defined clusters of cyclosporiasis. Epidemiol Infect. 2020 Aug 3;148:e172. doi: 10.1017/S0950268820001697
Outbreaks of cyclosporiasis, a food-borne illness caused by the coccidian parasite Cyclospora cayetanensis have increased in the USA in recent years, with approximately 2300 laboratory-confirmed cases reported in 2018. Genotyping tools are needed to inform epidemiological investigations, yet genotyping Cyclospora has proven challenging due to its sexual reproductive cycle which produces complex infections characterized by high genetic heterogeneity. We used targeted amplicon deep sequencing and a recently described ensemble-based distance statistic that accommodates heterogeneous (mixed) genotypes and specimens with partial genotyping data, to genotype and cluster 648 C. cayetanensis samples submitted to CDC in 2018. The performance of the ensemble was assessed by comparing ensemble-identified genetic clusters to analogous clusters identified independently based on common food exposures. Using these epidemiologic clusters as a gold standard, the ensemble facilitated genetic clustering with 93.8% sensitivity and 99.7% specificity. Hence, we anticipate that this procedure will greatly complement epidemiologic investigations of cyclosporiasis.

Langlois PH, Canfield MA, et al. Cancer diagnostic profile in children with structural birth defects: An assessment in 15,000 childhood cancer cases. Cancer. 2020 Aug 1;126(15):3483-3492. doi: 10.1002/cncr.32982
Background: Birth defects are established risk factors for childhood cancer. Nonetheless, cancer epidemiology in children with birth defects is not well characterized.
Methods: Using data from population-based registries in 4 US states, this study compared children with cancer but no birth defects (n = 13,111) with children with cancer and 1 or more nonsyndromic birth defects (n = 1616). The objective was to evaluate cancer diagnostic characteristics, including tumor type, age at diagnosis, and stage at diagnosis.
Results: Compared with the general population of children with cancer, children with birth defects were diagnosed with more embryonal tumors (26.6% vs 18.7%; q < 0.001), including neuroblastoma (12.5% vs 8.2%; q < 0.001) and hepatoblastoma (5.0% vs 1.3%; q < 0.001), but fewer hematologic malignancies, including acute lymphoblastic leukemia (12.4% vs 24.4%; q < 0.001). In age-stratified analyses, differences in tumor type were evident among children younger than 1 year and children 1 to 4 years old, but they were attenuated among children 5 years of age or older. The age at diagnosis was younger in children with birth defects for most cancers, including leukemia, lymphoma, astrocytoma, medulloblastoma, ependymoma, embryonal tumors, and germ cell tumors (all q < 0.05).
Conclusions: The results indicate possible etiologic heterogeneity in children with birth defects, have implications for future surveillance efforts, and raise the possibility of differential cancer ascertainment in children with birth defects.
Lay summary: Scientific studies suggest that children with birth defects are at increased risk for cancer. However, these studies have not been able to determine whether important tumor characteristics, such as the type of tumor diagnosed, the age at which the tumor is diagnosed, and the degree to which the tumor has spread at the time of diagnosis, are different for children with birth defects and children without birth defects. This study attempts to answer these important questions. By doing so, it may help scientists and physicians to understand the causes of cancer in children with birth defects and diagnose cancer at earlier stages when it is more treatable.

Langlois PH, et al. A genome-wide association study implicates the BMP7 locus as a risk factor for nonsyndromic metopic craniosynostosis. Hum Genet. 2020 Aug;139(8):1077-1090. doi: 10.1007/s00439-020-02157-z
Our previous genome-wide association study (GWAS) for sagittal nonsyndromic craniosynostosis (sNCS) provided important insights into the genetics of midline CS. In this study, we performed a GWAS for a second midline NCS, metopic NCS (mNCS), using 215 non-Hispanic white case-parent triads. We identified six variants with genome-wide significance (P ≤ 5 × 10-8): rs781716 (P = 4.71 × 10-9; odds ratio [OR] = 2.44) intronic to SPRY3; rs6127972 (P = 4.41 × 10-8; OR = 2.17) intronic to BMP7; rs62590971 (P = 6.22 × 10-9; OR = 0.34), located ~ 155 kb upstream from TGIF2LX; and rs2522623, rs2573826, and rs2754857, all intronic to PCDH11X (P = 1.76 × 10-8, OR = 0.45; P = 3.31 × 10-8, OR = 0.45; P = 1.09 × 10-8, OR = 0.44, respectively). We performed a replication study of these variants using an independent non-Hispanic white sample of 194 unrelated mNCS cases and 333 unaffected controls; only the association for rs6127972 (P = 0.004, OR = 1.45; meta-analysis P = 1.27 × 10-8, OR = 1.74) was replicated. Our meta-analysis examining single nucleotide polymorphisms common to both our mNCS and sNCS studies showed the strongest association for rs6127972 (P = 1.16 × 10-6). Our imputation analysis identified a linkage disequilibrium block encompassing rs6127972, which contained an enhancer overlapping a CTCF transcription factor binding site (chr20:55,798,821-55,798,917) that was significantly hypomethylated in mesenchymal stem cells derived from fused metopic compared to open sutures from the same probands. This study provides additional insights into genetic factors in midline CS.

Shuford JA, McFarlane JR, et al. Use of drug-level testing and single-genome sequencing to unravel a case of HIV seroconversion on PrEP. Clin Infect Dis. 2020 Jul 20:ciaa1011. doi: 10.1093/cid/ciaa1011
Cases of seroconversion on PrEP should be carefully investigated given their public health implications and rarity. We report a case of transmitted drug resistance causing seroconversion on PrEP in spite of high adherence, confirmed with dried blood spot and segmental hair drug-level testing and single-genome sequencing.

Langlois PH, et al. Maternal occupational exposure to polycyclic aromatic hydrocarbons and the risk of isolated congenital heart defects among offspring. Environ Res. 2020 Jul;186:109550. doi: 10.1016/j.envres.2020.109550
Background: Although there is evidence in experimental model systems that exposure to polycyclic aromatic hydrocarbons (PAHs) is linked with congenital heart defects (CHDs), few studies have examined the association in humans. We conducted a case-control study to examine the association between maternal exposure to PAHs and CHDs in offspring using data from the National Birth Defects Prevention Study (NBDPS) (1997-2011).
Methods: We obtained detailed information on maternal occupation during the month before to three months after conception. Expert raters, masked to case-control status, assessed job descriptions to assign categorical levels of exposure. Categories were quantitatively mapped to estimate cumulative exposure to PAHs, incorporating exposure intensity, frequency, work duration, and work hours. Quartiles were generated for cumulative maternal exposure to PAHs. Crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using unconditional logistic regression for quartiles of PAH exposure and six CHD groupings (e.g. conotruncal) and specific subtypes (e.g. tetralogy of Fallot [ToF]). Final models were adjusted for maternal age, race/ethnicity, education, smoking, anticonvulsant use, folic acid supplementation, and study center.
Results: There were 4,775 case and 7,734 control infants eligible for the study. The prevalence of occupational exposure to PAHs was 10.2% among both case and control mothers. In adjusted analysis, compared to mothers with no occupational PAH exposure, those in the highest quartile of exposure were more likely to have offspring in the conotruncal heart defects group (OR 1.41; 95% CI 1.00-2.00), and with ToF (OR 1.83; 95% CI 1.21-2.78).
Conclusions: Women in the highest quartile of estimated cumulative occupational PAH exposure during early pregnancy were more likely to have offspring with conotruncal heart defects, specifically ToF, compared to women with no occupational PAH exposure. Other comparisons between PAHs and other CHDs subgroups did not show any statistically precise associations.

Miller PE, et al. The Weight Optimization Revamping Lifestyle using the Dietary guidelines (WORLD) study: Sustained weight loss over 12 months. Obesity (Silver Spring). 2020 Jul;28(7):1235-1244. doi: 10.1002/oby.22824
Objective: This study aimed to compare two energy-restricted, nutrient-dense diets at the upper or lower ends of the dietary fat recommendation range (lower fat [20% energy from fat] versus moderate fat [35%]) on weight loss using behavioral theory-based nutrition education.
Methods: A total of 101 premenopausal women with overweight or obesity were randomized to an energy-restricted lower-fat or moderate-fat diet for 1 year. Interventions included 28 behavioral theory-based nutrition education sessions plus weekly exercise sessions.
Results: Both treatment groups experienced weight loss (-5.0 kg for lower fat and -4.3 kg for moderate fat; P < 0.0001), but there was no difference in weight loss or fat intake between groups. Total and low-density lipoprotein cholesterol decreased (-3. 4 mg/dL and -3.8 mg/dL; P < 0.05), and high-density lipoprotein cholesterol increased (1.9 mg/dL; P < 0.05) in both groups at 12 months. Diet quality, assessed by the Healthy Eating Index, increased significantly at 4 months versus baseline (70.8 [0.9] vs. 77.8 [1.0]) and was maintained through 12 months. Higher Healthy Eating Index scores were associated with greater weight loss at 4 months (r = -0.2; P < 0.05).
Conclusions: In the context of a well-resourced, free-living weight-loss intervention, total fat intake did not change; however, theory-based nutrition education underpinned by food-based recommendations resulted in caloric deficits, improvements in diet quality, and weight loss that was sustained for 1 year.

Sanders K, et al. (contributor, Antimicrobial-Resistant Neisseria meningitidis Team). Detection of ciprofloxacin-resistant, β-Lactamase-producing Neisseria meningitidis serogroup Y isolates - United States, 2019-2020. MMWR Morb Mortal Wkly Rep. 2020 Jun 19;69(24):735-739. doi: 10.15585/mmwr.mm6924a2
Meningococcal disease is a sudden-onset, life-threatening illness caused by the bacterium Neisseria meningitidis. Prompt empiric antibiotic treatment can reduce morbidity and mortality among patients, and antibiotic prophylaxis can prevent secondary disease in close contacts. Historically, N. meningitidis isolates in the United States have largely been susceptible to the antibiotics recommended for treatment and prophylaxis, including penicillin and ciprofloxacin. This report describes detection of penicillin-resistant and ciprofloxacin-resistant N. meningitidis serogroup Y (NmY) isolates in the United States. NmY isolates containing a blaROB-1 β-lactamase enzyme gene conferring resistance to penicillins (1) were recovered from 33 cases reported during 2013-2020. Isolates from 11 of these cases, reported during 2019-2020, harbored a ciprofloxacin resistance-associated mutation in a chromosomal gene (gyrA). Cases were reported from 12 geographically disparate states; a majority of cases (22 of 33, 67%) occurred in Hispanic persons. These cases represent a substantial increase in penicillin-resistant and ciprofloxacin-resistant meningococci in the United States since 2013. Ceftriaxone and cefotaxime, the recommended first-line agents for empiric bacterial meningitis treatment, can continue to be used for treatment, but health care providers should ascertain susceptibility of meningococcal isolates to penicillin before switching to penicillin or ampicillin. Ongoing monitoring for antimicrobial resistance among meningococcal isolates and prophylaxis failures will be important to inform treatment and prophylaxis recommendations.

Langlois PH, Canfield MA, et al. Male sex and the risk of childhood cancer: The mediating effect of birth defects. JNCI Cancer Spectr. 2020 Jun 11;4(5):pkaa052. doi: 10.1093/jncics/pkaa052
Background: There is a persistent, unexplained disparity in sex ratio among childhood cancer cases, whereby males are more likely to develop most cancers. This male predominance is also seen for most birth defects, which are strongly associated with risk of childhood cancer. We conducted mediation analysis to estimate whether the increased risk of cancer among males is partially explained by birth defect status.
Methods: We used a population-based birth cohort with linked data from birth certificates, birth defects registries, and cancer registries from Arkansas, Michigan, North Carolina, and Texas. We conducted counterfactual mediation analysis to estimate the natural direct and indirect effects of sex on cancer risk, modeling birth defect status as mediator. State; birth year; plurality; and maternal race and ethnicity, age, and education were considered confounders. We conducted separate analyses limited to cancers diagnosed younger than 1 year of age.
Results: Our dataset included 10,181,074 children: 15,110 diagnosed with cancer, 539,567 diagnosed with birth defects, and 2,124 co-occurring cases. Birth defect status mediated 38% of the association between sex and cancer overall. The proportion mediated varied by cancer type, including acute myeloid leukemia (93%), neuroblastoma (35%), and non-Hodgkin lymphoma (6%). Among children younger than 1 year of age at cancer diagnosis, the proportion mediated was substantially higher (82%).
Conclusions: Our results suggest that birth defects mediate a statistically significant proportion of the relationship between sex and childhood cancer. The proportion mediated varied by cancer type and diagnosis age. These findings improve our understanding of the causal pathway underlying male sex as a risk factor for childhood cancer.

Bolling BG, et al. Movement of St. Louis encephalitis virus in the western United States, 2014- 2018. PLoS Negl Trop Dis. 2020 Jun 10;14(6):e0008343. doi: 10.1371/journal.pntd.0008343
St. Louis encephalitis virus (SLEV) is a flavivirus that circulates in an enzootic cycle between birds and mosquitoes and can also infect humans to cause febrile disease and sometimes encephalitis. Although SLEV is endemic to the United States, no activity was detected in California during the years 2004 through 2014, despite continuous surveillance in mosquitoes and sentinel chickens. In 2015, SLEV-positive mosquito pools were detected in Maricopa County, Arizona, concurrent with an outbreak of human SLEV disease. SLEV-positive mosquito pools were also detected in southeastern California and Nevada in summer 2015. From 2016 to 2018, SLEV was detected in mosquito pools throughout southern and central California, Oregon, Idaho, and Texas. To understand genetic relatedness and geographic dispersal of SLEV in the western United States since 2015, we sequenced four historical genomes (3 from California and 1 from Louisiana) and 26 contemporary SLEV genomes from mosquito pools from locations across the western US. Bayesian phylogeographic approaches were then applied to map the recent spread of SLEV. Three routes of SLEV dispersal in the western United States were identified: Arizona to southern California, Arizona to Central California, and Arizona to all locations east of the Sierra Nevada mountains. Given the topography of the Western United States, these routes may have been limited by mountain ranges that influence the movement of avian reservoirs and mosquito vectors, which probably represents the primary mechanism of SLEV dispersal. Our analysis detected repeated SLEV introductions from Arizona into southern California and limited evidence of year-to-year persistence of genomes of the same ancestry. By contrast, genetic tracing suggests that all SLEV activity since 2015 in central California is the result of a single persistent SLEV introduction. The identification of natural barriers that influence SLEV dispersal enhances our understanding of arbovirus ecology in the western United States and may also support regional public health agencies in implementing more targeted vector mitigation efforts to protect their communities more effectively.

Qualls WA, et al. Texas mosquito control response following Hurricane Harvey. J Am Mosq Control Assoc. 2020 Jun 1;36(2s):61-67. doi: 10.2987/19-6883.1
Hurricane Harvey has been recorded as the wettest cyclone in United States history, resulting in devastating and catastrophic flooding for the Texas Gulf Coast. The nature of the path of the hurricane, with multiple landfalls along the Texas Gulf Coast, resulted in the largest aerial mosquito control effort for one single storm. Two mosquito control contractors and the Air Force Aerial Spray Unit of the US Air Force Reserve were used to aerial treat 6,765,971 acres (3,075,441 ha) in 29 of the 60 disaster-declared counties in Texas. During the response, 101,253 liters of Dibrom® (active ingredient [AI]: naled) and 48,735 liters of Duet™ (AI: 1% prallethrin and 5% sumithrin) were used. In 23/29 counties requesting aerial spraying, mosquito control contractors were used to conduct pre- and postaerial application mosquito surveillance. The remaining 6 counties conducted their own surveillance during the response. A total of 105,153 mosquitoes in 7 genera and 35 species were collected during this response with the major floodwater nuisance mosquito being Psorophora columbiae. The most abundant vector mosquito collected was Culex nigripalpus. Duet at the 0.8% and 1% application rates resulted in 49% and 69% control of Ps. columbiae, respectively. Dibrom application resulted in 95% and 93% control of Ps. Columbia and Cx. nigripalpus populations, respectively.

Qualls WA. Texas Department of State Health Services' technical guidance: Mosquito abatement post-weather incident. J Am Mosq Control Assoc. 2020 Jun 1;36(2s):68-73. doi: 10.2987/8756-971X-36.2s.68
The Texas Department of State Health Services provides assistance to local health departments following severe weather events and other public health emergencies. Following the reports of large mosquito populations hindering recovery efforts after Hurricane Harvey, the Texas State Medical Operations Center created the Vector Control Task Force (VCTF) to organize the mosquito response requested through the State of Texas Assistance Requests. Since Hurricane Harvey, there have been other severe weather events that have activated the VCTF. The purpose of this developed document is to provide guidance to local jurisdictions requesting mosquito abatement assistance from the state level in response to a proliferation of nuisance mosquitoes that hinders governmental response and recovery efforts after a severe weather incident. The document also establishes criteria that the VCTF will evaluate to determine if and how resources should be allocated to programs requesting assistance for mosquito abatement. The guidance document provides background information on mosquito surveillance and control and identifies tasks, roles, and responsibilities for local jurisdictions, state, and federal partners.

Ward HM, Qualls WA. Integrating vector and nuisance mosquito control for severe weather response. J Am Mosq Control Assoc. 2020 Jun 1;36(2s):41-48. doi: 10.2987/19-6879.1
Ideally, all mosquito control programs would have public health-driven and nuisance population-focused components in their mosquito control plan. However, due to resource limitations many mosquito control programs focus attention on one specific component of integrated mosquito control, i.e., adulticiding only. Programs run by public health departments with limited resources are frequently heavily focused on vector control, targeting a few mosquito species that are locally medically relevant in human and animal disease cycles. Focusing their mosquito management on these specific vector species can result in inefficiencies after hurricanes and severe flooding events that create a need for nuisance mosquito control. Floodwater nuisance species that emerge are not routinely a public health threat, but hinder operations related to response efforts and can negatively affect the lives of people in areas recovering from these disaster events. Staff, training, equipment, and facilities, when aimed at public health vector control, may not have the experience, knowledge, or tools to effectively respond to postdisaster, floodwater mosquito populations. As such, all mosquito management programs should have plans in place to handle not only known vectors of public health concern in response to mosquito-borne disease, but also to manage floodwater mosquito populations after natural disasters to safeguard public health and facilitate recovery operations. The current paper discusses the severe weather events in South Texas in 2018 and the resulting integrated nuisance floodwater mosquito control guidance developed by the Texas Department of State Health Services.

Ethen MK, Canfield MA, et al. Third grade academic achievement among children conceived with the use of in vitro fertilization: A population-based study in Texas. Fertil Steril. 2020 Jun;113(6):1242-1250.e4. doi: 10.1016/j.fertnstert.2020.01.015
Objective: To evaluate if there are differences in standardized testing results at the end of third grade between children conceived with the use of in vitro fertilization (IVF) and those conceived spontaneously.
Design: Retrospective population-based cohort.
Setting: Texas public school system.
Patient(s): Singleton and twin children 8-9 years of age who took the third-grade public school standardized testing in Texas from 2012 to 2018.
Intervention(s): None.
Main outcome measure(s): Standardized testing in reading and mathematics.
Result(s): After exclusions, there were 6,970 IVF and 12,690 non-IVF children with reading scores and 6,973 IVF and 12,729 non-IVF children with mathematics scores. IVF children scored significantly higher in reading (singletons: 1,543 ± 2 vs. 1,525 ± 1; twins: 1,534 ± 2 vs. 1,504 ± 5 [mean ± SE]), and mathematics (singletons: 1,566 ± 2 vs. 1,550 ± 1; twins: 1,557 ± 2 vs. 1,529 ± 5). Children of mothers ≥30 years of age scored consistently higher than children of mothers 18-29 years of age. The differences were of similar magnitude between IVF and control children for older ages, but not significant for IVF. Within the IVF group, there were no significant differences between children born from fresh versus froze-thawed embryos.
Conclusion(s): Children of ages 8-9 years who were conceived with the use of IVF performed as well on third-grade reading and math assessments as their counterparts who were conceived spontaneously. We also found consistent racial and ethnic differences, gender differences, and beneficial effects of older maternal age. Because we were not able to adjust adequately for socioeconomic status and other confounding factors, which may explain some of the observed differences, we conclude that there is no negative effect of IVF conception on academic achievement in third grade.

Stagg J, et al. Support for breastfeeding employees: Assessing statewide worksite lactation support recognition initiatives in the United States. J Hum Lact. 2020 May;36(2):328-336. doi:10.1177/0890334419865902
Background: Although the reasons for discontinued breastfeeding are multifactorial, an unsupportive work environment is consistently reported as a barrier to continued breastfeeding. In the United States, several state breastfeeding advocates have taken a distinctive approach to promote worksite lactation support by developing statewide recognition initiatives aimed at incentivizing employers to support breastfeeding employees by offering public recognition for the worksites' efforts.
Research aim: To identify and describe statewide worksite lactation support recognition initiatives in the United States.
Methods: Between May 2016 and June 2017, semi-structured phone interviews were conducted with breastfeeding experts in each U.S. state (N = 60 participants) for this cross-sectional study. Experts in states with a recognition initiative were asked about the background, structure, and requirements of the initiative.
Results: Twenty-six states had a current initiative, and some had requirements for providing a private space (n = 19; 73%) and time (n = 18; 69%) for employees to express human milk, as well as a written worksite lactation support policy (n = 10; 38%).
Conclusions: This was the first study in which researchers systematically identified ongoing worksite lactation support recognition initiatives in the United States. The results of this work also served to highlight both the similarities and the variety between initiatives. Future researchers should aim to determine the components of an initiative that increase employer support and, in turn, breastfeeding rates.

Hoyt AT, Le MT, Shumate CJ, Canfield MA, et al. Acculturation and selected birth defects among non-Hispanic Blacks in a population-based case-control study. Birth Defects Res. 2020 Apr 15;112(7):535-554. doi: 10.1002/bdr2.1665
Background: There are noted birth defects prevalence differences between race/ethnicity groups. For instance, non-Hispanic (NH) Black mothers are more likely to have an infant with encephalocele, although less likely to have an infant with anotia/microtia compared to NH Whites. When stratifying by nativity and years lived within the United States, additional variations become apparent.
Methods: Data from the National Birth Defects Prevention Study were used to calculate descriptive statistics and estimate crude/adjusted odds ratios (aORs) and 95% confidence intervals (95%CIs) among NH Blacks with one of 30 major defects and non-malformed controls. Total case/controls were as follows: U.S.- (2,773/1101); Foreign- (343/151); African-born (161/64). Study participants were also examined by number of years lived in the U.S. (≤5 vs. 6+ years).
Results: Compared to U.S.-born, foreign-born NH Black controls tended to be older, had more years of education, and were more likely to have a higher household income. They also had fewer previous livebirths and were less likely to be obese. In the adjusted analyses, two defect groups were significantly attenuated: limb deficiencies, aORs/95%CIs = (0.44 [0.20-0.97]) and septal defects (0.69 [0.48-0.99]). After stratifying by years lived in the United States, the risk for hydrocephaly (2.43 [1.03-5.74]) became apparent among those having lived 6+ years in the United States. When restricting to African-born mothers, none of the findings were statistically significant.
Conclusions: Foreign-born NH Blacks were at a reduced risk for a few selected defects. Results were consistent after restricting to African-born mothers and did not change considerably when stratifying by years lived in the United States.

Montour J, et al. Health screenings administered during the domestic medical examination of refugees and other eligible immigrants in nine US states, 2014-2016: A cross-sectional analysis. PLoS Med. 2020 Mar 31;17(3):e1003065. doi: 10.1371/journal.pmed.1003065
Background: Refugees and other select visa holders are recommended to receive a domestic medical examination within 90 days after arrival to the United States. Limited data have been published on the coverage of screenings offered during this examination across multiple resettlement states, preventing evaluation of this voluntary program's potential impact on postarrival refugee health. This analysis sought to calculate and compare screening proportions among refugees and other eligible populations to assess the domestic medical examination's impact on screening coverage resulting from this examination.
Methods and findings: We conducted a cross-sectional analysis to summarize and compare domestic medical examination data from January 2014 to December 2016 from persons receiving a domestic medical examination in seven states (California, Colorado, Minnesota, New York, Kentucky, Illinois, and Texas); one county (Marion County, Indiana); and one academic medical center in Philadelphia, Pennsylvania. We analyzed screening coverage by sex, age, nationality, and country of last residence of persons and compared the proportions of persons receiving recommended screenings by those characteristics. We received data on disease screenings for 105,541 individuals who received a domestic medical examination; 47% were female and 51.5% were between the ages of 18 and 44. The proportions of people undergoing screening tests for infectious diseases were high, including for tuberculosis (91.6% screened), hepatitis B (95.8% screened), and human immunodeficiency virus (HIV; 80.3% screened). Screening rates for other health conditions were lower, including mental health (36.8% screened). The main limitation of our analysis was reliance on data that were collected primarily for programmatic rather than surveillance purposes.
Conclusions: In this analysis, we observed high rates of screening coverage for tuberculosis, hepatitis B, and HIV during the domestic medical examination and lower screening coverage for mental health. This analysis provided evidence that the domestic medical examination is an opportunity to ensure newly arrived refugees and other eligible populations receive recommended health screenings and are connected to the US healthcare system. We also identified knowledge gaps on how screenings are conducted for some conditions, notably mental health, identifying directions for future research.

Montour J, et al. Health of Special Immigrant Visa holders from Iraq and Afghanistan after arrival into the United States using Domestic Medical Examination data, 2014-2016: A cross-sectional analysis. PLoS Med. 2020 Mar 31;17(3):e1003083. doi: 10.1371/journal.pmed.1003083
Background: Since 2008, the United States has issued between 2,000 and 19,000 Special Immigrant Visas (SIV) annually, with the majority issued to applicants from Iraq and Afghanistan. SIV holders (SIVH) are applicants who were employed by, or on behalf of, the US government or the US military. There is limited information about health conditions in SIV populations to help guide US clinicians caring for SIVH. Thus, we sought to describe health characteristics of recently arrived SIVH from Iraq and Afghanistan who were seen for domestic medical examinations.
Methods and findings: This cross-sectional analysis included data from Iraqi and Afghan SIVH who received a domestic medical examination from January 2014 to December 2016. Data were gathered from state refugee health programs in seven states (California, Colorado, Illinois, Kentucky, Minnesota, New York, and Texas), one county, and one academic medical center and included 6,124 adults and 4,814 children. Data were collected for communicable diseases commonly screened for during the exam, including tuberculosis (TB), hepatitis B, hepatitis C, malaria, strongyloidiasis, schistosomiasis, other intestinal parasites, syphilis, gonorrhea, chlamydia, and human immunodeficiency virus, as well as elevated blood lead levels (EBLL). We investigated the frequency and proportion of diseases and whether there were any differences in selected disease prevalence in SIVH from Iraq compared to SIVH from Afghanistan. A majority of SIV adults were male (Iraqi 54.0%, Afghan 58.6%) and aged 18-44 (Iraqi 86.0%, Afghan 97.7%). More SIV children were male (Iraqi 56.2%, Afghan 52.2%) and aged 6-17 (Iraqi 50.2%, Afghan 40.7%). The average age of adults was 29.7 years, and the average age for children was 5.6 years. Among SIV adults, 14.4% were diagnosed with latent tuberculosis infection (LTBI), 63.5% were susceptible to hepatitis B virus (HBV) infection, and 31.0% had at least one intestinal parasite. Afghan adults were more likely to have LTBI (prevalence ratio [PR]: 2.0; 95% confidence interval [CI] 1.5-2.7) and to be infected with HBV (PR: 4.6; 95% CI 3.6-6.0) than Iraqi adults. Among SIV children, 26.7% were susceptible to HBV infection, 22.1% had at least one intestinal parasite, and 50.1% had EBLL (≥5 mcg/dL). Afghan children were more likely to have a pathogenic intestinal parasite (PR: 2.7; 95% CI 2.4-3.2) and EBLL (PR: 2.0; 95% CI 1.5-2.5) than Iraqi children. Limitations of the analysis included lack of uniform health screening data collection across all nine sites and possible misclassification by clinicians of Iraqi and Afghan SIVH as Iraqi and Afghan refugees, respectively.
Conclusion: In this analysis, we observed that 14% of SIV adults had LTBI, 27% of SIVH had at least one intestinal parasite, and about half of SIV children had EBLL. Most adults were susceptible to HBV. In general, prevalence of infection was higher for most conditions among Afghan SIVH compared to Iraqi SIVH. The Centers for Disease Control and Prevention (CDC) Guidelines for the US Domestic Medical Examination for Newly Arriving Refugees can assist state public health departments and clinicians in the care of SIVH during the domestic medical examination. Future analyses can explore other aspects of health among resettled SIV populations, including noncommunicable diseases and vaccination coverage.

Poole M, et al. A synergistic approach to data-driven response planning. Disaster Med Public Health Prep. 2020 Mar 9:1-7. doi: 10.1017/dmp.2019.162
Public health practitioners face challenging, potentially high-consequence, problems that require computational support. Available computational tools may not adequately fit these problems, thus forcing practitioners to rely on qualitative estimates when making critical decisions. Scientists at the Center for Computational Epidemiology and Response Analysis and practitioners from the Texas Department of State Health Services (TXDSHS) have established a participatory development cycle where public health practitioners work closely with academia to foster the development of data-driven solutions for specific public health problems and to translate these solutions to practice. Tools developed through this cycle have been deployed at TXDSHS offices where they have been used to refine and enhance the region's medical countermeasure distribution and dispensing capabilities. Consequently, TXDSHS practitioners planning for a 49-county region in North Texas have achieved a 29% reduction in the number of points of dispensing required to complete dispensing to the region within time limitations. Further, an entire receiving, staging, and storing site has been removed from regional plans, thus freeing limited resources (eg, personnel, security, and infrastructure) for other uses. In 2018, planners from Southeast Texas began using these tools to plan for a multi-county, full-scale exercise which was scheduled to be conducted in October 2019.

Langlois PH, et al. Association between maternal occupational exposure to polycyclic aromatic hydrocarbons and rare birth defects of the face and central nervous system. Birth Defects Res. 2020 Mar;112(5):404-417. doi: 10.1002/bdr2.1643
Background: Previous studies suggested associations between maternal smoking, a source of exposure to polycyclic aromatic hydrocarbons (PAHs) and other chemicals, and central nervous system and face birth defects; however, no previous studies have evaluated maternal occupational PAH exposure itself.
Methods: Jobs held in the periconceptional period were retrospectively assigned for occupational PAH exposures. Associations between maternal occupational PAH exposure and selected rare defects of the face (cataracts, microphthalmia, glaucoma, microtia, and choanal atresia) and central nervous system (holoprosencephaly, hydrocephaly, cerebellar hypoplasia, and Dandy-Walker malformation) were evaluated using data from the National Birth Defects Prevention Study, a population-based case-control study in the United States. Crude and adjusted odds ratios (ORs) with 95% confidence intervals were calculated to estimate associations between each evaluated defect and PAH exposure using multivariable logistic regression.
Results: Food and beverage serving, as well as cooks and food preparation occupations, were among the most frequent jobs held by exposed mothers. Cataracts, microtia, microphthalmia, and holoprosencephaly were significantly associated with PAH exposure with evidence of dose-response (P-values for trend ≤.05). Hydrocephaly was associated with any PAH exposure, but not significant for trend. Sensitivity analyses that reduced possible sources of exposure misclassification tended to strengthen associations.
Conclusions: This is the first population-based case-control study to evaluate associations between maternal occupational PAH exposures and these rare birth defects of the central nervous system and face.

Tupy S, et al. PCR ribotypes of Clostridioides difficile across Texas from 2011 to 2018 including emergence of ribotype 255. Emerg Microbes Infect. 2020 Feb 10;9(1):341-347. doi.org/10.1080/22221751.2020.1721335
Clostridioides difficile infection (CDI) is the most prevalent healthcare-associated infection in the United States and carries a significant healthcare system burden. As part of an ongoing, active surveillance system of C. difficile throughout Texas, the objective of this study was to assess changes in C. difficile ribotypes of clinical isolates obtained from hospitalized patients in Texas over the past seven years. Fifty hospitals located in Texas, USA sent C. difficile positive stool specimens to a centralized laboratory for PCR ribotyping and toxin characterization between 2011 and 2018. Data collected included specimen collection date, patient age, and sex. Strain genotypes were compiled, and changes in ribotype distribution over time were assessed. Overall, 7796 samples were ribotyped from predominately female patients (58.4%) aged 62 ± 19 years. Samples were obtained from all geographic regions of Texas including Houston/Southwest region (n = 5129; 85%), Dallas/North Texas (n = 579, 9.6%), Central Texas (n = 164; 2.7%), and South Texas (n = 162; 2.6%). The 10 most common ribotypes comprised 73% of all isolates tested during the study period. The most common ribotypes were 027 (17.5%), followed by 014-020 (16.1%), 106 (11.6%), and 002 (9.1%). The prevalence of ribotypes 027, 001, and 078-126 declined significantly over time, while ribotypes 106 and 054 increased in prevalence (P < 0.001). Furthermore, the emergence of a novel ribotype 255 strain was observed. Differences in ribotype distribution were also noted based on age and geographic distribution (P < 0.001, each). This seven-year study demonstrated changing molecular epidemiology of C. difficile in Texas, including the emergence of a novel ribotype 255.

Langlois PH, et al. Pre-pregnancy dietary arsenic consumption among women in the United States. Birth Defects Res. 2020 Feb 1;112(3):270-277. doi: 10.1002/bdr2.1634
Background: Arsenic is associated with several adverse health outcomes, including some birth defects. Although diet is the predominant route of arsenic exposure in the United States (U.S.), limited data exist regarding pre-pregnancy dietary arsenic consumption among U.S. women.
Methods: Using data collected in the National Birth Defects Prevention Study (NBDPS), we estimated daily dietary arsenic consumption during the year before pregnancy for 10,886 mothers of nonmalformed control children delivered from 1997-2011. Responses to the NBDPS dietary assessment and food item estimates of total and inorganic arsenic were used to estimate consumption. Associations between total and inorganic arsenic consumption and selected maternal characteristics were estimated using multinomial logistic regression.
Results: Estimates of mean maternal total and inorganic dietary arsenic consumption were 14.9 and 5.2 μg/day, respectively. Several positive and inverse associations with confidence intervals that excluded the null were observed. Comparing mothers in the middle or high total arsenic consumption tertiles to those in the low tertile, we observed positive associations (odds ratios = 1.3-3.8) for maternal age (≥30 years), lower (0-8 years) or higher (>12 years) education, race/ethnicity (non-Hispanic Black, Hispanic, other), and early pregnancy drinking with no binge episodes, and inverse associations (odds ratios = 0.4-0.8) for age (<25 years), body mass index (≥30.0 kg/m2 ), and early pregnancy smoking. Findings tended to be similar for inorganic arsenic consumption.
Conclusions: These contemporary estimates of pre-pregnancy dietary arsenic consumption among U.S. women show associations between both total and inorganic dietary arsenic consumption and several maternal characteristics, improving characterization of the public health impact of this exposure.

Alva H, et al. Disaster-related shelter surveillance during the Hurricane Harvey response - Texas 2017. Disaster Med Public Health Prep. 2020 Feb;14(1):49-55. doi: 10.1017/dmp.2019.25
Objectives: Hurricane Harvey left a path of destruction in its wake, resulting in over 100 deaths and damaging critical infrastructure. During a disaster, public health surveillance is necessary to track emerging illnesses and injuries, identify at-risk populations, and assess the effectiveness of response efforts. The Centers for Disease Control and Prevention (CDC) and American Red Cross collaborate on shelter surveillance to monitor the health of the sheltered population and help guide response efforts.
Methods: We analyzed data collected from 24 Red Cross shelters between August 25, 2017, and September 14, 2017. We described the aggregate morbidity data collected during Harvey compared with previous hurricanes (Gustav, Ike, and Sandy).
Results: Over one-third (38%) of reasons for visit were for health care maintenance; 33% for acute illnesses, which includes respiratory conditions, gastrointestinal symptoms, and pain; 19% for exacerbation of chronic disease; 7% for mental health; and 4% for injury. The Red Cross treated 41% of clients within the shelters; however, reporting of disposition was often missed. These results are comparable to previous hurricanes.
Conclusion: The capacity of Red Cross shelter staff to address the acute health needs of shelter residents is a critical resource for local public health agencies overwhelmed by the disaster. However, there remains room for improvement because reporting remained inconsistent.

Hall NB, Heines V, Cantu V, et al. Cyclosporiasis epidemiologically linked to consumption of green onions: Houston metropolitan area, August 2017. J Food Prot. 2020 Jan 21:326-330. doi: 10.4315/0362-028X.JFP-19-254
During July 2017, Texas public health officials noted an increase in the number of reported cyclosporiasis cases. They detected a cluster in the Houston metropolitan area that involved four locations of a Mediterranean restaurant chain, restaurant A. A case-control study was conducted among patrons of restaurant A to identify a common food vehicle among items containing fresh produce. In matched case-control ingredient-level analyses that included both probable and confirmed cases, consumption of green onions, red onions, tomatoes, and cabbage was significantly associated with illness. A substantial percentage of case patients reported consumption of green onions, and only green onions remained statistically significantly associated with illness, whether probable and confirmed cases were included in analyses (matched odds ratio: 11.3; 95% confidence interval: 2.5 to 104.7), or only confirmed cases were included in analyses (matched odds ratio: 17.6; 95% confidence interval: 2.5 to 775.7). These results provide evidence that green onions were the likely vehicle of infection. It was not possible to trace the green onions to their source due to the need to redirect public health resources to Hurricane Harvey response efforts in Texas.

Ethen MK, Canfield MA, et al. Change in prepregnancy body mass index and gastroschisis. Ann Epidemiol. 2020 Jan;41:21-27. doi: 10.1016/j.annepidem.2019.12.005
Purpose: Maternal body mass index (BMI) is inversely associated with gastroschisis, but a causal relationship has not been established. As data demonstrating that a change in exposure status is related to a change in the frequency of the outcome can add to the evidence for causality, we conducted a case-control study of change in maternal BMI, assessed using interpregnancy change in BMI (IPC-BMI), and gastroschisis.
Methods: Data for 258 gastroschisis cases and 2561 controls were obtained from the Texas Birth Defects Registry and vital records (2006-2012). Logistic regression was used to estimate the adjusted association between IPC-BMI and gastroschisis.
Results: The continuous IPC-BMI variable was inversely associated with gastroschisis (adjusted odds ratio [aOR] = 0.90, 95% confidence interval [CI]: 0.86, 0.95). When assessed as a six-level categorical variable, with weight stable women as the referent, the odds of gastroschisis were higher following a BMI decrease of greater than 1 unit (aOR = 1.37, 95% CI: 0.91, 2.06) and lower after a BMI increase of ≥3 units (aOR = 0.62, 95% CI: 0.42, 0.94).
Conclusions: Our findings suggest that maternal change in BMI is associated with gastroschisis and, thus, add to the epidemiological evidence that can be used to inform our understanding of the relationship between BMI and gastroschisis.

Wozniak EJ, et al. Pathology and discrete typing unit associations of Trypanosoma cruzi infection in coyotes (Canis latrans) and raccoons (Procyon lotor) of Texas, USA. J Wildl Dis. 2020 Jan;56(1):134-144. doi: 10.7589/2019-03-071
Trypanosoma cruzi is a vector-borne, protozoal parasite of mammals. Infected humans, dogs (Canis lupus familiaris), and nonhuman primates may remain asymptomatic or may develop Chagas disease, most commonly characterized by lymphoplasmacytic myocarditis with myocardial degeneration and fibrosis, ultimately resulting in heart failure. Although wildlife species have important roles as sylvatic reservoirs, investigations into the pathology of T. cruzi in wildlife are limited to a few studies documenting histologic lesions in opossums (Didelphis spp.) and raccoons (Procyon lotor). Pathology in coyotes (Canis latrans) has not, to our knowledge, been described, despite their recognition as a reservoir and close genetic relationship to domestic dogs. Our objectives were to perform a detailed, comparative cardiac pathology study of sympatric, naturally infected coyotes and raccoons, to characterize the overall T. cruzi infection prevalence in the heart and blood of each species via PCR, and to identify infecting discrete typing units (DTUs). We sampled hunter-harvested coyotes (n=120) and raccoons (n=24) in a 28-county region of central and south Texas, US. Raccoons were significantly more likely to have positive PCR results (P<0.001) with a prevalence of 62% (15/24), comprising DTU TcIV exclusively, with mild to no evidence of cardiac pathology. In contrast, coyotes had a lower infection prevalence (8%, 10/120), comprising DTU TcI exclusively, with lymphoplasmacytic myocarditis observed in four of the six PCR-positive animals. Many raccoons had PCR-positive blood and heart tissue simultaneously, supporting previous reports that raccoons maintain parasitemia into chronic stages of infection; in contrast, none of the PCR-positive coyotes were positive in both heart and blood. Our findings demonstrate marked differences in T. cruzi infection dynamics between coyotes and raccoons, with important implications for reservoir potential and their role in transmission cycles.

Owens K, et al. Postnatally acquired Zika virus disease among children, United States, 2016-2017. Clin Infect Dis. 2020 Jan 2;70(2):227-231. doi: 10.1093/cid/ciz195
Background: The clinical findings among children with postnatally acquired Zika virus disease are not well characterized. We describe and compare clinical signs and symptoms for children aged <18 years.
Methods: Zika virus disease cases were included if they met the national surveillance case definition, had illness onset in 2016 or 2017, resided in a participating state, and were reported to the Centers for Disease Control and Prevention. Pediatric cases were aged <18 years; congenital and perinatal infections were excluded. Pediatric cases were matched to adult cases (18‒49 years). Clinical information was compared between younger and older pediatric cases and between children and adults.
Results: A total of 141 pediatric Zika virus disease cases were identified; none experienced neurologic disease. Overall, 28 (20%) were treated in an emergency department, 1 (<1%) was hospitalized; none died. Of the 4 primary clinical signs and symptoms associated with Zika virus disease, 133 (94%) children had a rash, 104 (74%) fever, 67 (48%) arthralgia, and 51 (36%) conjunctivitis. Fever, arthralgia, and myalgia were more common in older children (12‒17 years) than younger children (1‒11 years). Arthralgia, arthritis, edema, and myalgia were more common in adults compared to children.
Conclusions: This report supports previous findings that Zika virus disease is generally mild in children. The most common symptoms are similar to other childhood infections, and clinical findings and outcomes are similar to those in adults. Healthcare providers should consider a diagnosis of Zika virus infection in children with fever, rash, arthralgia, or conjunctivitis, who reside in or have traveled to an area where Zika virus transmission is occurring.

(In date order with the most recent first):

Mai CT, Isenburg JL, Canfield MA, et al. National population-based estimates for major birth defects, 2010-2014. Birth Defects Res. 2019 Nov 1;111(18):1420-1435. Epub 2019 Oct 3.  doi: 10.1002/bdr2.1589
Background: Using the National Birth Defects Prevention Network (NBDPN) annual data report, U.S. national prevalence estimates for major birth defects are developed based on birth cohort 2010-2014.
Methods: Data from 39 U.S. population-based birth defects surveillance programs (16 active case-finding, 10 passive case-finding with case confirmation, and 13 passive without case confirmation) were used to calculate pooled prevalence estimates for major defects by case-finding approach. Fourteen active case-finding programs including at least live birth and stillbirth pregnancy outcomes monitoring approximately one million births annually were used to develop national prevalence estimates, adjusted for maternal race/ethnicity (for all conditions examined) and maternal age (trisomies and gastroschisis). These calculations used a similar methodology to the previous estimates to examine changes over time.
Results: The adjusted national birth prevalence estimates per 10,000 live births ranged from 0.62 for an interrupted aortic arch to 16.87 for clubfoot, and 19.93 for the 12 critical congenital heart defects combined. While the birth prevalence of most birth defects studied remained relatively stable over 15 years, an increasing prevalence was observed for gastroschisis and Down syndrome. Additionally, the prevalence of atrioventricular septal defect, tetralogy of Fallot, omphalocele, and trisomy 18 increased in this period compared to the previous periods. Active case-finding programs generally had higher prevalence rates for most defects examined, most notably for anencephaly, anophthalmia/microphthalmia, trisomy 13, and trisomy 18.
Conclusion: National estimates of birth defect prevalence provide data for monitoring trends and understanding the impact of these conditions. Increasing prevalence rates observed for selected conditions warrant further examination.

Hodo CL, Bañuelos RM, Edwards EE, Wozniak EJ, Hamer SA. Pathology and discrete typing unit associations of Trypanosoma cruzi infection in coyotes (Canis latrans) and raccoons (Procyon lotor) of Texas, USA. J Wildl Dis. 2020 Jan;56(1):134-144. Epub 2019 Sep 30. doi:10.7589/2019-03-071 
Trypanosoma cruzi is a vector-borne, protozoal parasite of mammals. Infected humans, dogs (Canis lupus familiaris), and nonhuman primates may remain asymptomatic or may develop Chagas disease, most commonly characterized by lymphoplasmacytic myocarditis with myocardial degeneration and fibrosis, ultimately resulting in heart failure. Although wildlife species have important roles as sylvatic reservoirs, investigations into the pathology of T. cruzi in wildlife are limited to a few studies documenting histologic lesions in opossums (Didelphis spp.) and raccoons (Procyon lotor). Pathology in coyotes (Canis latrans) has not, to our knowledge, been described, despite their recognition as a reservoir and close genetic relationship to domestic dogs. Our objectives were to perform a detailed, comparative cardiac pathology study of sympatric, naturally infected coyotes and raccoons, to characterize the overall T. cruzi infection prevalence in the heart and blood of each species via PCR, and to identify infecting discrete typing units (DTUs). We sampled hunter-harvested coyotes (n=120) and raccoons (n=24) in a 28-county region of central and south Texas. Raccoons were significantly more likely to have positive PCR results (P<0.001) with a prevalence of 63% (15/24), comprising DTU TcIV exclusively, with mild to no evidence of cardiac pathology. In contrast, coyotes had a lower infection prevalence (8%, 10/120), comprising DTU TcI exclusively, with lymphoplasmacytic myocarditis observed in four of the six PCR-positive animals. Many raccoons had PCR-positive blood and heart tissue simultaneously, supporting previous reports that raccoons maintain parasitemia into chronic stages of infection; in contrast, none of the PCR-positive coyotes were positive in both heart and blood. Our findings demonstrate marked differences in T. cruzi infection dynamics between coyotes and raccoons, with important implications for reservoir potential and their role in transmission cycles.

Goel N, Morris JK, Tucker D, et al. Trisomy 13 and 18-Prevalence and mortality-A multi-registry population-based analysis. Am J Med Genet A. 2019;179(12):2382-2392. Epub 2019 Sep 30. doi.org/10.1002/ajmg.a.61365
The aim of the study is to determine the prevalence, outcomes, and survival (among live births [LB]), in pregnancies diagnosed with trisomy 13 (T13) and 18 (T18), by congenital anomaly register and region. Twenty-four population- and hospital-based birth defects surveillance registers from 18 countries, contributed data on T13 and T18 between 1974 and 2014 using a common data-reporting protocol. The mean total birth prevalence (i.e., LB, stillbirths, and elective termination of pregnancy for fetal anomalies [ETOPFA]) in the registers with ETOPFA (n = 15) for T13 was 1.68 (95% CI 1.3-2.06), and for T18 was 4.08 (95% CI 3.01-5.15), per 10,000 births. The prevalence varied among the various registers. The mean prevalence among LB in all registers for T13 was 0.55 (95%CI 0.38-0.72), and for T18 was 1.07 (95% CI 0.77-1.38), per 10,000 births. The median mortality in the first week of life was 48% for T13 and 42% for T18, across all registers, half of which occurred on the first day of life. Across 16 registers with complete 1-year follow-up, mortality in the first year of life was 87% for T13 and 88% for T18. This study provides an international perspective on the prevalence and mortality of T13 and T18. Overall outcomes and survival among LB were poor with about half of live-born infants not surviving the first week of life; nevertheless, about 10% survived the first year of life. Prevalence and outcomes varied by country and termination policies. The study highlights the variation in screening, data collection, and reporting practices for these conditions.

Choi G, Stingone JA, Desrosiers TA, et al. Maternal exposure to outdoor air pollution and congenital limb deficiencies in the National Birth Defects Prevention Study. Environ Res. 2019 Sep 10;179(Pt A):108716. Epub 2019 Sep 10. doi: 10.1016/j.envres.2019.108716
Background: Congenital limb deficiencies (CLDs) are a relatively common group of birth defects whose etiology is mostly unknown. Recent studies suggest maternal air pollution exposure as a potential risk factor.
Aim: To investigate the relationship between ambient air pollution exposure during early pregnancy and offspring CLDs.
Methods: The study population was identified from the National Birth Defects Prevention Study, a population-based multi-center case-control study, and consisted of 615 CLD cases and 5,701 controls with due dates from 1997 through 2006. Daily averages and/or maxima of six criteria air pollutants (particulate matter <2.5 μm [PM2.5], particulate matter <10 μm [PM10], nitrogen dioxide [NO2], sulfur dioxide [SO2], carbon monoxide [CO], and ozone [O3]) were averaged over gestational weeks 2-8, as well as for individual weeks during this period, using data from EPA air monitors nearest to the maternal address. Logistic regression was used to estimate odds ratios (aORs) and 95% confidence intervals (CIs) adjusted for maternal age, race/ethnicity, education, and study center. We estimated aORs for any CLD and CLD subtypes (i.e., transverse, longitudinal, and preaxial). Potential confounding by co-pollutant was assessed by adjusting for one additional air pollutant. Using the single pollutant model, we further investigated effect measure modification by body mass index, cigarette smoking, and folic acid use. Sensitivity analyses were conducted restricting to those with a residence closer to an air monitor.
Results: We observed near-null aORs for CLDs per interquartile range (IQR) increase in PM10, PM2.5, and O3. However, weekly averages of the daily average NO2 and SO2, and daily max NO2, SO2, and CO concentrations were associated with increased odds of CLDs. The crude ORs ranged from 1.03 to 1.12 per IQR increase in these air pollution concentrations, and consistently elevated aORs were observed for CO. Stronger associations were observed for SO2 and O3 in subtype analysis (preaxial). In co-pollutant adjusted models, associations with CO remained elevated (aORs: 1.02-1.30); but aORs for SO2 and NO2 became near-null. The aORs for CO remained elevated among mothers who lived within 20 km of an air monitor. The aORs varied by maternal BMI, smoking status, and folic acid use.
Conclusion: We observed modest associations between CLDs and air pollution exposures during pregnancy, including CO, SO2, and NO2, though replication through further epidemiologic research is warranted.

Maughan BC, Becker EA. Drug-related mortality after discharge from treatment: A record-linkage study of substance abuse clients in Texas, 2006-2012. Drug Alcohol Depend. 2019 Aug 30;204:107473. Epub 2019 Aug 30. doi: 10.1016/j.drugalcdep.2019.05.011
Background: Patients have higher mortality immediately after substance abuse treatment discharge, but there are few data on post-discharge mortality differences across treatment modalities.
Methods: A retrospective cohort study examined individuals discharged from substance abuse treatment during 2006-2012 and probabilistically matched treatment records to death records. Logistic regression examined associations between drug-related death (DRD) and demographics; route, frequency, and classes of drugs abused; and treatment. Primary outcome was DRD during post-discharge days 0-28; secondary outcomes examined DRD during days 29-90 and 91-365.
Results: We examined 178,749 patients discharged from 254,814 treatment episodes. There were 97 DRD during days 0-28 (4.1/1000 person-years), 115 DRD during days 29-90 (2.6/1000 person-years; IRR 0.6 [95% CI 0.5-0.8]), and 293 DRD during days 91-365 (1.9/1000 person-years; IRR 0.5 [0.4-0.6]). Higher 28-day DRD was associated with abuse of opioids (aOR 2.5 [1.4-4.4]), depressants (aOR 2.0 [1.2-3.4]), or alcohol (aOR 1.7 [1.1-2.6]); and opioid injection (aOR 2.2 [1.3-3.7]). Lower DRD was associated with treatment completion (aOR 0.6 [0.4-0.9]), female sex (aOR 0.6 [0.4-0.8]), and employment (aOR 0.5 [0.3-0.9]). Among all patients, DRD rates were higher following residential (IRR 2.6, [1.6-4.2]) and detoxification (IRR 2.9, [1.7-4.9]) treatment compared to outpatient. Patients with prior opioid abuse had higher 28-day DRD after outpatient (6.7/1000 person-years; IRR 4.1 [1.8-9.1]), residential (13.6/1000 person-years; IRR 4.2 [2.2-8.2]), and detoxification (8.8/1000 person-years; IRR 3.2 [1.2, 8.5]) compared to those without.
Conclusions: Drug-related mortality is highest during days 0-28 after discharge, especially following residential and detoxification treatment. Opioid abuse is strongly associated with early post-discharge mortality.

Johnson KE, Sales A, Rew L, Haussler Garing J, Crosnoe R. Using polytomous latent class analysis to compare patterns of substance use and co-occurring health-risk behaviors between students in alternative and mainstream high schools. J Adolesc. 2019 Aug;75:151-162. Epub 2019 Aug 6. doi: 10.1016/j.adolescence.2019.07.010
Introduction: Alternative high school (AHS) students, an understudied and underserved population, experience educational, social, and health disparities relative to students in mainstream high schools. Disparities in single types of substance use are particularly high, yet no known studies have compared patterns of substance use or relationships between these patterns and other health-risk behaviors between AHS and mainstream high schools.
Methods: Using data from the Texas Alternative School Health Survey (n = 515; mean age 17.1 years, 49% male, 59% Hispanic, 23% White, 15% Black) and the Texas Youth Risk Behavior Survey (n = 2,113; mean age 16 years, 47% male, 64% Hispanic, 22% White, 7% Black), we used latent class analyses to compare patterns of substance use in AHSs and mainstream high schools. We used latent class regression to examine relationships between patterns of substance use and involvement in other health-risk behaviors in each school setting.
Results: Students in AHSs and mainstream high schools had similar patterns of substance use, and youth in higher-risk categories engaged in higher levels of other health-risk behaviors. A substantially greater proportion of AHS students, however, fell into the moderate and high-use categories, in support of continuing disparities for AHS students.
Conclusions: Additional support is needed in AHSs to address the prevalence of high-risk patterns of substance use and associated health-risk behaviors. For example, ongoing public health surveillance is needed in AHSs, just as is done in mainstream high schools, to monitor trends in substance use and the impact of policies and interventions.

Pace ND, Siega-Riz AM, Olshan AF, et al. Survival of infants with spina bifida and the role of maternal prepregnancy body mass index. Birth Defects Res. 2019 Oct 1;111(16):1205-1216. Epub 2019 Jul 19. doi: 10.1002/bdr2.1552
Objective: To investigate first-year survival of infants born with spina bifida and examine the association of maternal prepregnancy body mass index (BMI) with infant mortality.
Methods: This is a retrospective cohort study of 1,533 liveborn infants with nonsyndromic spina bifida with estimated dates of delivery from 1998 to 2011 whose mothers were eligible for the National Birth Defects Prevention Study (NBDPS). NBDPS data were linked to death records to conduct survival analyses. Kaplan-Meier survival functions estimated mortality risk over the first year of life. Cox proportional hazards models estimated hazard ratios (HRs) for maternal prepregnancy BMI categorized as underweight (<18.5), normal (18.5-24.9), overweight (25-29.9), and obese (≥30).
Results: Infant mortality risk among infants with spina bifida was (4.4% [3.52, 5.60%]). Infants with multiple co-occurring defects, very preterm delivery, multiple gestation, high-level spina bifida lesions, or non-Hispanic Black mothers had an elevated risk of infant mortality. Maternal prepregnancy underweight and obesity were associated with higher infant mortality (15.7% [7.20, 32.30%] and 5.82% [3.60, 9.35%], respectively). Adjusted HR estimates showed underweight and obese mothers had a greater hazard of infant mortality compared to normal-weight mothers (HR: 4.5 [1.08, 16.72] and 2.6 [1.36, 8.02], respectively).
Conclusion: The overall risk of infant mortality for infants born with spina bifida was lower than most previously reported estimates. Infants born with spina bifida to mothers who were underweight or obese prepregnancy were at higher risk of infant mortality. This study provides additional evidence of the importance of healthy maternal weight before pregnancy.

Benjamin RH, Yu X, Navarro Sanchez ML, et al. Co-occurring defect analysis: A platform for analyzing birth defect co-occurrence in registries. Birth Defects Res. 2019 Nov 1;111(18):1356-1364. Epub 2019 Jul 16. doi: 10.1002/bdr2.1549
Background: Few studies have systematically evaluated birth defect co-occurrence patterns, perhaps, in part, due to the lack of software designed to implement large-scale, complex analytic methods.
Methods: We created an R-based platform, "co-occurring defect analysis" (CODA), designed to implement analyses of birth defect co-occurrence patterns in birth defect registries. CODA uses an established algorithm for calculating the observed-to-expected ratio of a given birth defect combination, accounting for the known tendency of birth defects to co-occur nonspecifically. To demonstrate CODA's feasibility, we evaluated the computational time needed to assess 2- to 5-way combinations of major birth defects in the Texas Birth Defects Registry (TBDR) (1999-2014). We report on two examples of pairwise patterns, defects co-occurring with trisomy 21 or with non-syndromic spina bifida, to demonstrate proof-of-concept.
Results: We evaluated combinations of 175 major birth defects among 206,784 infants in the TBDR. CODA performed efficiently in the data set, analyzing 1.5 million 5-way combinations in 18 hr. As anticipated, we identified large observed-to-expected ratios for the birth defects that co-occur with trisomy 21 or spina bifida.
Conclusions: CODA is available for application to birth defect data sets and can be used to better understand co-occurrence patterns. Co-occurrence patterns elucidated by using CODA may help identify new birth defect associations and may provide etiological insights regarding potentially shared pathogenic mechanisms. CODA may also have wider applications, such as assessing patterns of additional types of co-occurrence patterns in other large data sets (e.g., medical records).

Sapp SGH, Alhabshan RN, Bishop HS, et al. Ocular trematodiasis caused by the avian eye fluke Philophthalmus in southern Texas. Open Forum Infect Dis. 2019 Jun 13;6(7):ofz265. doi: 10.1093/ofid/ofz265
A trematode identified as a Philophthalmus sp was extracted from the bulbar conjunctiva of a patient in southern Texas with short-distance travel to Mexico. This parasite is very rarely reported from humans, and species identification is challenging. Aspects of diagnosis, zoonotic transmission, and unresolved questions about Philophthalmus spp are discussed.

Yu X, Nassar N, Mastroiacovo P, et al. Hypospadias prevalence and trends in international birth defect surveillance systems, 1980-2010. Eur Urol. 2019 Oct;76(4):482-490. Epub 2019 Jul 9. doi: 10.1016/j.eururo.2019.06.027
Background: Hypospadias is a common male birth defect that has shown widespread variation in reported prevalence estimates. Many countries have reported increasing trends over recent decades.
Objective: To analyze the prevalence and trends of hypospadias for 27 international programs over a 31-yr period.
Design, setting, and participants: The study population included live births, stillbirths, and elective terminations of pregnancy diagnosed with hypospadias during 1980-2010 from 27 surveillance programs around the world.
Outcome measurements and statistical analysis: We used joinpoint regression to analyze changes over time in the international total prevalence of hypospadias across programs, the prevalence for each specific program, and the prevalence across different degrees of severity of hypospadias.
Results and limitations: The international total prevalence of hypospadias for all years was 20.9 (95% confidence interval: 19.2-22.6) per 10000 births. The prevalence for each program ranged from 2.1 to 39.1 per 10000 births. The international total prevalence increased 1.6 times during the study period, by 0.25 cases per 10000 births per year (p<0.05). When analyzed separately, there were increasing trends for first-, second-, and third-degree hypospadias during the early 1990s to mid-2000s. The majority of programs (61.9%) had a significantly increasing trend during many of the years evaluated. Limitations include known differences in data collection methods across programs.
Conclusions: Although there have been changes in clinical practice and registry ascertainment over time in some countries, the consistency in the observed increasing trends across many programs and by degrees of severity suggests that the total prevalence of hypospadias may be increasing in many countries. This observation is contrary to some previous reports that suggested that the total prevalence of hypospadias was no longer increasing in recent decades.
Patient summary: We report on the prevalence and trends of hypospadias among 27 birth defect surveillance systems, which indicate that the prevalence of hypospadias continues to increase internationally.

Benjamin RH, Ethen MK, Canfield MA, et al. Association of interpregnancy change in body mass index and spina bifida. 2019 Nov 1;111(18):1389-1398. Birth Defects Res. Epub 2019 Jul 10. doi: 10.1002/bdr2.1547
Background: Epidemiologic studies have consistently identified an association between spina bifida and maternal body mass index (BMI). Whether this reflects a causal relationship is unknown. If this association does reflect a causal relationship, the risk of spina bifida should change with changes in maternal BMI. We evaluated the association between spina bifida and maternal change in BMI and assessed using interpregnancy change in BMI (IPC-BMI).
Methods: We used data from the Texas Birth Defects Registry and statewide vital records for 248 spina bifida cases and 2,562 controls (2006-2012) to conduct a case-control study. We used logistic regression to estimate the association between IPC-BMI and spina bifida, with adjustment for potential confounders.
Results: When assessed as a continuous variable, IPC-BMI was associated with spina bifida, with a 5% increase in the odds of spina bifida per unit (approximately 6 pounds) increase in BMI (adjusted odds ratios [aOR] = 1.05, 95% CI: 1.02, 1.09). When assessed as a categorical variable, with weight-stable women as the referent, the odds of spina bifida were lower in women with any BMI decrease (aOR = 0.73, 95% CI: 0.50, 1.08) and higher in women with an increase of ≥1 BMI units (aOR = 1.17, 95% CI: 0.85, 1.62).
Conclusions: Our findings provide suggestive, although not conclusive, evidence that maternal prepregnancy change in BMI, assessed using IPC-BMI, is associated with spina bifida in later pregnancy. Additional studies aimed at confirming this association and further strengthening the evidence for a causal relationship between spina bifida and maternal BMI are needed.

Le MT, Shumate CJ, Hoyt AT, Wilkinson AV, Canfield MA. The prevalence of birth defects among non-Hispanic Asian/Pacific Islanders and American Indians/Alaska Natives in Texas, 1999-2015. Birth Defects Res. 2019 Nov 1;111(18):1380-1388. Epub 2019 Jul 1. doi: 10.1002/bdr2.1543
Background: There is considerable variability in the prevalence of birth defects among racial/ethnic groups. This study estimated birth defect prevalence among the less studied non-Hispanic (NH) Asian/Pacific Islander (PI) and American Indian/Alaska Native (AI/AN) populations in Texas relative to NH Whites.
Methods: Data were obtained from the Texas Birth Defect Registry from 1999 to 2015 for deliveries to Texas-resident women who were NH White, NH Asian/PI, or AI/AN. This covers a live birth population of 2.6 million. Prevalence ratios and 95% confidence intervals (95% CIs) were calculated for NH Asian/PIs and AI/ANs (relative to NH Whites) for 44 birth defects using Poisson regression adjusting for maternal age.
Results: After adjustment, there were 33 statistically significant prevalence ratios (aPRs). Among NH Asian/PIs, 23 defects had a lower aPR (0.38-0.86) and three defects had a higher aPR (1.19-2.50). AI/ANs had one defect with a significantly lower aPR (0.64) and six with a higher aPR (1.36-4.63).
Conclusions: Non-Hispanic Asian/PIs generally have a lower prevalence ratio for many birth defects while AI/ANs have a higher prevalence ratio compared to NH Whites. These findings update the limited literature on this topic and warrant additional research to identify the true associations across a range of birth defects among these understudied racial/ethnic groups.

Stoops CA, Qualls WA, Nguyen TT, Richards SL. A review of studies evaluating insecticide barrier treatments for mosquito control from 1944 to 2018. Environ Health Insights. 2019 Jun 26;13:1178630219859004. doi: 10.1177/1178630219859004
Background and purpose: Barrier insecticide treatments have a long history in mosquito control programs but have been used more frequently in the United States in recent years for control of invasive "backyard" species (eg, Aedes albopictus) and increases in the incidence of vector-borne diseases (eg, Zika).
Methods: We reviewed the published literature for studies investigating barrier treatments for mosquito control during the last 74 years (1944-2018). We searched databases such as PubMed, Web of Science, and Google Scholar to retrieve worldwide literature on barrier treatments.
Results: Forty-four studies that evaluated 20 active ingredients (AIs) and 21 formulated products against multiple mosquito species are included. Insecticides investigated for efficacy included organochlorines (dichlorodiphenyltrichloroethane [DDT], β-hexachlorocyclohexane [BHC]), organophosphates (malathion), and pyrethroids (bifenthrin, deltamethrin, permethrin, lambda-cyhalothrin) as AIs. Study design varied with multiple methods used to evaluate the effectiveness of barrier treatments. Barrier treatments were effective at lowering mosquito populations although there was variation between studies and for different mosquito species. Factors other than AI, such as exposure to rainfall and application equipment used, also influenced control efficacy.
Conclusions: Many of the basic questions on the effectiveness of barrier insecticide applications have been answered, but several important details still must be investigated to improve precision and impact on vector-borne pathogen transmission. Recommendations are made to assist future evaluations of barrier treatments for mosquito control and to limit the potential development of insecticide resistance.

Matas JL, Agana DFG, Germanos GJ, et al. Exploring classification of birth defects severity in national hospital discharge databases compared to an active surveillance program. Birth Defects Res. 2019 Nov 1;111(18):1343-1355. Epub 2019 Jun 20. doi: 10.1002/bdr2.1539 
Objective: To explore the extent to which the severity of birth defects could be differentiated using severity of illness (SOI) and risk of mortality (ROM) measures available in national discharge databases.
Methods: Data from the 2012-14 National Inpatient Sample (NIS) was used to identify hospitalizations with one or more major birth defects reported annually to the National Birth Defects Prevention Network using the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) diagnosis codes. Each hospitalization also contained a 4-level SOI and 4-level ROM classification measure. For each birth defect and each individual birth defect-related ICD-9-CM code, we calculated mean and median SOI and ROM, the proportion of hospitalizations in each level of SOI and ROM, the inpatient mortality rate, and level of agreement between various existing or derived severity proxies in the NIS and the Texas Birth Defects Registry (TBDR).
Results: Mean SOI ranged from 1.5 (cleft lip alone) to 3.7 (single ventricle), and mean ROM ranged from 1.1 (cleft lip alone) to 3.9 (anencephaly). As a group, critical congenital heart defects had the highest average number of co-occurring defects, mean SOI, and ROM, whereas orofacial and genitourinary defects had the lowest SOI and ROM. We found strong levels of agreement between TBDR severity classifications and NIS severity classifications defined using Level 3 or 4 SOI or ROM Level 3 or 4.
Conclusions: This preliminary investigation demonstrated how severity indices of birth defects could be differentiated and compared to a severity algorithm of an existing surveillance program.

Schnall AH, Hanchey A, Nakata N, et al. Disaster-related shelter surveillance during the Hurricane Harvey response - Texas 2017. Disaster Med Public Health Prep. 2020;14(1):49-55. Epub 2019 Jun 21. doi: 10.1017/dmp.2019.25
Objectives: Hurricane Harvey left a path of destruction in its wake, resulting in over 100 deaths and damaging critical infrastructure. During a disaster, public health surveillance is necessary to track emerging illnesses and injuries, identify at-risk populations, and assess the effectiveness of response efforts. The Centers for Disease Control and Prevention (CDC) and American Red Cross collaborate on shelter surveillance to monitor the health of the sheltered population and help guide response efforts.
Methods: We analyzed data collected from 24 Red Cross shelters between August 25, 2017, and September 14, 2017. We described the aggregate morbidity data collected during Harvey compared with previous hurricanes (Gustav, Ike, and Sandy).
Results: Over one-third (38%) of reasons for visit were for health care maintenance; 33% for acute illnesses, which includes respiratory conditions, gastrointestinal symptoms, and pain; 19% for exacerbation of chronic disease; 7% for mental health; and 4% for injury. The Red Cross treated 41% of clients within the shelters; however, reporting of disposition was often missed. These results are comparable to previous hurricanes.
Conclusion: The capacity of Red Cross shelter staff to address the acute health needs of shelter residents is a critical resource for local public health agencies overwhelmed by the disaster. However, there remains room for improvement because reporting remained inconsistent.

Haidar A, Ranjit N, Archer N, Hoelscher DM. Parental and peer social support is associated with healthier physical activity behaviors in adolescents: a cross-sectional analysis of Texas School Physical Activity and Nutrition (TX SPAN) data. BMC Public Health. 2019 May 27;19(1):640. doi: 10.1186/s12889-019-7001-0
Background: Parental and peer support can influence children's physical activity; however, these associations have not been fully examined in a multi-ethnic population across early and late adolescence. The objective of this study was to examine associations between perceived parental/peer social support, perceived parental disapproval for not exercising, and physical activity/screen time behaviors among a multi-ethnic sample of adolescents.
Methods: The Texas School Physical Activity and Nutrition (TX SPAN) survey is a cross-sectional statewide probability-based survey, used to assess obesity-related behaviors such as diet and physical activity. The SPAN 2009-2011 study measured 8th and 11th-grade students using a self-report questionnaire with established psychometric properties, along with objectively measured height and weight. Associations were examined using multiple logistic and linear regression.
Results: For every 1-point increase in parental physical activity support, adolescents had 1.14 higher odds of engaging in five or more days of moderate physical activity per week (p < 0.001), and 1.12 higher odds of engaging in three or more days of vigorous physical activity per week (p < 0.001). For every 1-point increase in peer physical activity support, adolescents had 1.17 higher odds of engaging in five or more days of moderate physical activity per week (p < 0.001), and 1.15 higher odds of engaging in three or more days of vigorous physical activity per week (p < 0.001).
Conclusions: Parental and peer social support is associated with positive physical activity behaviors in adolescents. Strategies to focus on parent and peer support should be integral to intervention programs designed to increase physical activity in adolescents in middle and high schools.

Lopez A, Benjamin RH, Raut JR, et al. Mode of delivery and mortality among neonates with gastroschisis: A population-based cohort in Texas. Paediatr Perinat Epidemiol. 2019 May;33(3):204-212. Epub 2019 May 14. doi: 10.1111/ppe.12554
Background: Mode of delivery is hypothesized to influence clinical outcomes among neonates with gastroschisis. Results from previous studies of neonatal mortality have been mixed; however, most studies have been small, clinical cohorts and have not adjusted for potential confounders.
Objectives: To evaluate whether cesarean delivery is associated with mortality among neonates with gastroschisis.
Methods: We studied liveborn, nonsyndromic neonates with gastroschisis delivered during 1999-2014 using data from the Texas Birth Defect Registry. Using multivariable Cox proportional hazards regression, we separately assessed the relationship between cesarean and death during two different periods, before 29 days (<29 days) and before 365 days (<365 days) after delivery, adjusting for potential confounders. We also updated a recent meta-analysis on this relationship, combining our estimates with those from the literature.
Results: Among 2925 neonates with gastroschisis, 63% were delivered by cesarean. No associations were observed between cesarean delivery and death <29 days (adjusted hazard ratio [aHR] 1.00, 95% confidence interval [CI] 0.63, 1.61) or <365 days after delivery (aHR 0.99, 95% CI 0.70, 1.41). The results were similar among those with additional malformations and among those without additional malformations. When we combined our estimate with prior estimates from the literature, the results were similar (combined risk ratio [RR] 1.00, 95% CI 0.84, 1.19).
Conclusions: Although cesarean rates among neonates with gastroschisis were high, our results suggest that the mode of delivery is not associated with mortality among these individuals. However, data on morbidity outcomes (eg intestinal damage, infection) were not available in this study.

Hyde JR, Sears SC, Buendia JR, Odem SL, Vaaler ML, Mgbere OO. HIV comorbidities: Pay attention to hypertension amid changing guidelines - an analysis of Texas Medical Monitoring Project Data. Am J Hypertens. 2019 May 9. pii: hpz078. doi: 10.1093/ajh/hpz078
Background: Hypertension is a significant risk factor for cardiovascular disease, a leading cause of death among people living with HIV (PLWH). Studies suggest that hypertension prevalence among PLWH is high, yet none assess how the 2017 redefinition of hypertension as ≥130/80 rather than the previous standard of ≥140/90 mmHg will impact prevalence among PLWH. The present study addresses this gap.
Methods: We examined medical record abstractions of 957 PLWH in Texas from the 2013-2014 Medical Monitoring Project survey. Hypertensive participants were identified by charted diagnosis, antihypertensive medication use, or blood pressure readings ≥140/90 and ≥130/80 mmHg. Associations with sociodemographic and clinical variables were assessed using Rao-Scott chi-square tests, and the odds of having hypertension were calculated using multivariable logistic regression models while adjusting for several demographic and HIV-related variables.
Results: The 2017 redefinition of hypertension increased prevalence in the sample by 44.3%, from 47.6% to 68.7%. Age group, body mass index, sex, and race remained significantly associated with hypertension (all p<0.01). While prevalence was near equal between males and females at ≥140/90 mmHg (47.4 and 48.5%, respectively), males were 2.36 times more likely to have hypertension than females (95% CI: 1.55-3.60) at ≥130/80 mmHg. Prevalence remained comparable between white (73.3%) and black participants (72.9%).
Conclusions: This study shows that hypertension prevalence is remarkably high among PLWH and is further increased by updated guidelines. Barriers to hypertension control in the HIV care setting should be identified and addressed to facilitate continued improvement in the quality and length of life for PLWH.

Pezzi C, Lee D, Kennedy L, et al. Blood lead levels among resettled refugee children in select US states, 2010-2014. Pediatrics. 2019;143(5):e20182591. doi: 10.1542/peds.2018-2591
Background: Elevated blood lead levels (EBLLs; ≥5 µg/dL) are more prevalent among refugee children resettled in the United States than the general US population and contribute to permanent health and neurodevelopmental problems. The Centers for Disease Control and Prevention recommends screening of refugee children aged 6 months to 16 years on arrival in the United States and retesting those aged 6 months to 6 years between 3- and 6 months post-arrival.
Methods: We analyzed EBLL prevalence among refugee children aged 6 months to 16 years who received a domestic refugee medical examination between January 1, 2010, and September 30, 2014. We assessed EBLL prevalence by pre-departure examination country and, among children rescreened 3 to 6 months after initial testing, we assessed EBLL changes during follow-up screening.
Results: Twelve sites provided data on 27 284 children representing nearly 25% of refugee children resettling during the period of this analysis. The EBLL prevalence during initial testing was 19.3%. EBLL was associated with younger age, male sex, and overseas examination country. Among 1121 children from 5 sites with available follow-up test results, EBLL prevalence was 22.7%; higher follow-up BLLs were associated with younger age and pre-departure examination country.
Conclusions: EBLL decreased over the period of our analysis in this population of refugee children. Refugee children may be exposed to lead before and after resettlement to the United States. Efforts to identify incoming refugee populations at high risk for EBLL can inform prevention efforts both domestically and overseas.

Yeh CY, Wheeler A, Bethea L, et al. Identifying barriers to implementation of emergency epinephrine bills: The Texas experience. J Allergy Clin Immunol Pract. 2019;7(8):2875-2877.e2. doi:10.1016/j.jaip.2019.04.032. Epub 2019 May 3. doi.org/10.1016/j.jaip.2019.04.032
Despite the passage of a law allowing the use of undesignated stock epinephrine in public schools, a surprisingly small number of school districts in Texas have implemented the policy. We identified the common barriers to widespread adoption.

Gray MS, Judd SE, Sloane R, Snyder DC, Miller PE, Demark-Wahnefried W. Rural-urban differences in health behaviors and outcomes among older, overweight, long-term cancer survivors in the RENEW randomized control trial. Cancer Causes Control. 2019 Apr;30(4):301-309. Epub 2019 Feb 19. doi: 10.1007/s10552-019-01141-x
Purpose: Rural cancer survivors (RCS) have poorer health outcomes and face multiple challenges-older age, and limited transportation, education, income, and healthcare access. Yet, RCS are understudied. The Reach-out to ENhancE Wellness(RENEW) trial, a home-based, diet and exercise intervention among 641 breast, prostate, and colorectal cancer survivors addressed many of these challenges.
Methods: We examined whether rural and urban participants differed in their response to the RENEW intervention (e.g., physical functioning, quality-of-life, intakes of fruits and vegetables (F&V) and saturated fat, body mass index(BMI), physical activity, and adverse events).
Results: Rural versus urban survivors report significantly more favorable mean (SE) changes in physical functioning [- 0.66 (1.47) v - 1.71 (1.00)], physical health [+ 0.14 (0.71) v - 0.74 (0.50)], and fewer adverse events [1.58 (0.08) v 1.64 (0.06)]. Rural versus urban survivors reported smaller increases in F&Vs [+ 1.47 (0.23) v + 1.56(0.16); p = 0.018], and lower percentages achieved goal behavior for endurance exercise and intakes of F&Vs and saturated fat.
Conclusions: The RENEW intervention reduced declines in physical health and functioning among RCS to a significantly greater extent than for urban cancer survivors. All survivors significantly improved intakes of F&V and saturated fat, and endurance exercise; however, lower percentages of rural versus urban survivors met the goal suggesting that more intensive interventions may be needed for RCS.

Hoyt AT, Shumate CJ, Canfield MA, Le M, Ramadhani T, Scheuerle AE. Selected acculturation factors and birth defects in the National Birth Defects Prevention Study, 1997-2011. Birth Defects Res. 2019 Jun 1;111(10):598-612. Epub 2019 Apr 25. doi: 10.1002/bdr2.1494
Background: Acculturation has been examined concerning various pregnancy adverse outcomes, including birth defects. Given the mixed and limited findings on the association between nativity and birth defects, we sought to further explore parental nativity and years lived in the U.S. across a range of defects.
Methods: Data from the National Birth Defects Prevention Study were used for this analysis. Infants with one of 46 major isolated birth defects (30 noncardiac/16 cardiac conditions) and infants without birth defects (controls) born during 1997-2011 were included. We examined parental nativity (foreign-born mothers, fathers, and both parents combined compared to a referent of both U.S.-born parents) and the number of years lived in the U.S. (≤5/6+ years). Descriptive statistics and logistic regression analyses were performed to estimate crude/adjusted odds ratios and 95% confidence intervals.
Results: Compared to U.S.-born mothers, foreign-born mothers tended to be older (25+ years), of Hispanic or Other race/ethnicity, and were less likely to have reported drinking, smoking, illicit drug use, or having taken folic acid. In the adjusted analysis, seven findings among both parents reporting a foreign birth were significant, including an increased association with spina bifida, anotia/microtia, and diaphragmatic hernia (aORs range: 1.3-1.7), and a reduced association with craniosynostosis and gastroschisis (aORs = 0.7). A generally protective effect was observed among foreign-born subjects living in the U.S. ≤5 years.
Conclusions: We found that nativity was associated with some selected isolated defects, although the direction of the effect varied by phenotype and by the number of years residing in the U.S.

Canfield MA, Langlois PH, Rutenberg GW, et al. The association between newborn screening analytes and childhood autism in a Texas Medicaid population, 2010-2012. Am J Med Genet B Neuropsychiatr Genet. 2019 Jul;180(5):291-304. Epub 2019 Apr 24. doi: 10.1002/ajmg.b.32728
Autism (or autism spectrum disorder [ASD]) is an often disabling childhood neurologic condition of mostly unknown cause. It is commonly diagnosed at 3 or 4 years of age. We explored whether there was an association of any analytes measured by newborn screening tests with a later diagnosis of ASD. A database was compiled of 3-5-year-old patients with any ASD diagnosis in the Texas Medicaid system in 2010-2012. Two controls (without any ASD diagnosis) were matched to each case by infant sex and birth year/month. All study subjects were linked to their 2007-2009 birth and newborn screening laboratory records, including values for 36 analytes or analyte ratios. We examined the association of analytes/ratios with a later diagnosis of ASD. Among 3,258 cases and 6,838 controls, seven analytes (e.g., 17-hydroxyprogesterone, acylcarnitines) were associated with a later ASD diagnosis. In this exploratory study, an ASD diagnosis was associated with 7 of 36 newborn screening analytes/ratios. These findings should be replicated in other population-based datasets.

Hoang TT, Lei Y, Mitchell LE, et al. Maternal genetic markers for risk of celiac disease and their potential association with neural tube defects in offspring. Mol Genet Genomic Med. 2019 Jun;7(6):e688. Epub 2019 Apr 9. doi: 10.1002/mgg3.688
Background: We examined the association between the maternal genotype for celiac disease-associated variants and the risk of neural tube defects (NTDs).
Methods: We conducted a case-control study, using data from the National Birth Defects Prevention Study. We evaluated 667 cases (women with offspring with NTD) and 743 controls (women with offspring without a birth defect). We classified women as having low, intermediate, or high risk of celiac disease based on human leukocyte antigen (HLA) variants. We used logistic regression to assess the relationship between the HLA celiac risk group (low, intermediate, high) and the risk of NTDs. Fifteen non-HLA variants (identified from genome-wide association studies of celiac disease) were individually evaluated and modeled additively.
Results: There was no association between HLA celiac risk group and NTDs (intermediate vs. low risk: aOR, 1.0; 95% CI, 0.8-1.3; high vs. low risk: aOR, 0.8; 95% CI, 0.5-1.3). Of the fifteen non-HLA variants, we observed five significant associations after accounting for multiple comparisons. Three negative associations were observed with rs10903122, rs13314993, rs13151961 (aOR range: 0.69-0.81), and two positive associations were observed with rs13003464 and rs11221332 (aOR range: 1.27-1.73).
Conclusion: If confirmed, our results suggest that the maternal variants related to celiac disease may be involved in the risk of NTDs.

Benjamin RH, Littlejohn S, Canfield MA, Ethen MK, Hua F, Mitchell LE. Interpregnancy change in body mass index and infant outcomes in Texas: a population-based study. BMC Pregnancy Childbirth. 2019 Apr 5;19(1):119. doi: 10.1186/s12884-019-2265-z
Background: Maternal prepregnancy body mass index (BMI) is associated with several infant outcomes, but it is unclear whether these associations reflect causal relationships. We conducted a study of interpregnancy change in BMI (IPC-BMI) to improve understanding of the associations between BMI and large for gestational age (LGA), small for gestational age (SGA), and preterm birth (PTB).
Methods: Birth certificate data from 2481 linked sibling pairs (Texas, 2005-2012) were used to estimate IPC-BMI and evaluate its association with LGA, SGA, and PTB in the younger sibling of the pair. Multivariable logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) using data from the full sample and within strata defined by prepregnancy BMI for the older sibling.
Results: On average, women gained 1.1 BMI units between pregnancies. In the full sample, interpregnancy BMI decreases were associated with reduced odds of LGA and increased odds of SGA and PTB (IPC-BMI < -1 versus 0 to < 1: LGA aOR 0.7, 95% CI 0.4, 1.1; SGA aOR 1.6, 95% CI 1.0, 2.7; PTB aOR 1.9, 95% CI 1.3, 2.8). In stratified analyses, similar associations were observed in some, but not all, strata. Findings for interpregnancy BMI increases were less consistent, with little evidence for associations between these outcomes and the most extreme IPC-BMI increases.
Conclusions: There is growing evidence that interpregnancy BMI decreases are associated with LGA, SGA, and PTB. However, taken as a whole, the literature provides insufficient evidence to establish causal links between maternal BMI and these outcomes.

Sheth KR, Kovar E, White JT, et al. Hypospadias risk is increased with maternal residential exposure to hormonally active hazardous air pollutants. Birth Defects Res. 2019 Apr 15;111(7):345-352. Epub 2019 Jan 29. doi: 10.1002/bdr2.1461
Background: With the increasing birth prevalence of hypospadias, there is growing concern for pollutant exposure interfering with normal penile development. We assess the association between hypospadias and hormonally active hazardous air pollutants (HAHAPs) through a nationwide database of hazardous air pollutants and the Texas Birth Defects Registry (TBDR).
Methods: Using the TBDR, we identified 8,981 nonsyndromic isolated hypospadias cases from 1999 to 2008. Birth certificate controls were matched for birth year at a 10:1 ratio to cases. Estimated HAHAP concentrations from the 2005 U.S. EPA National-Scale Air Toxics Assessment were used to assign exposure based on maternal residence at birth. Exposure levels were categorized as quintiles based on the distribution in controls. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (CI) for each increasing exposure category of selected HAHAPs.
Results: Of the 10 HAHAPs studied, seven were significantly associated with hypospadias risk. The HAHAP that was most strongly associated with hypospadias was phenol, which was associated with risk in all groups except the high-exposure group. Cumulative HAHAP exposure demonstrated a modest increase in hypospadias risk (OR 1.15, 95% CI: 1.07-1.24, p < 0.001) in the medium and medium-high quintiles.
Conclusions: While maternal exposure to some HAHAPs was significantly associated with the risk of hypospadias in male offspring, the effects were modest, and no dose-response effects were observed. Future work should employ biomarkers of exposure to better delineate the relationship.

Spector LG, Brown MB, Wantman E, et al. Association of In Vitro Fertilization With Childhood Cancer in the United States. JAMA Pediatr. 2019 Jun 1;173(6):e190392. Epub 2019 Apr 1. doi: 10.1001/jamapediatrics.2019.0392
Importance: In vitro fertilization (IVF) is associated with birth defects and imprinting disorders. Because these conditions are associated with an increased risk of childhood cancer, many of which originate in utero, descriptions of cancers among children conceived via IVF are imperative.
Objective: To compare the incidence of childhood cancers among children conceived in vitro with those conceived naturally.
Design, setting, and participants: A retrospective, population-based cohort study linking cycles reported to the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System from January 1, 2004, to December 31, 2012, that resulted in live births from September 1, 2004, to December 31, 2013, to the birth and cancer registries of 14 states, comprising 66% of United States births and 75% of IVF-conceived births, with follow-up from September 1, 2004, to December 31, 2014. The study included 275,686 children conceived via IVF and a cohort of 2,266,847 children, in which 10 births were randomly selected for each IVF birth. Statistical analysis was performed from April 1, 2017, to October 1, 2018.
Exposure: In vitro fertilization.
Main outcomes and measures: Cancer diagnosed in the first decade of life.
Results: A total of 321 cancers were detected among the children conceived via IVF (49.1% girls and 50.9% boys; mean [SD] age, 4.6 [2.5] years for singleton births and 5.9 [2.4] years for multiple births), and a total of 2042 cancers were detected among the children not conceived via IVF (49.2% girls and 50.8% boys; mean [SD] age, 6.1 [2.6] years for singleton births and 4.7 [2.6] years for multiple births). The overall cancer rate (per 1 000 000 person-years) was 251.9 for the IVF group and 192.7 for the non-IVF group (hazard ratio, 1.17; 95% CI, 1.00-1.36). The rate of hepatic tumors was higher among the IVF group than the non-IVF group (hepatic tumor rate: 18.1 vs 5.7; hazard ratio, 2.46; 95% CI, 1.29-4.70); the rates of other cancers did not differ between the 2 groups. There were no associations with specific IVF treatment modalities or indications for IVF.
Conclusions and Relevance: This study found a small association of IVF with overall cancers of early childhood, but it did observe an increased rate of embryonal cancers, particularly hepatic tumors, that could not be attributed to IVF rather than to underlying infertility. Continued follow-up for cancer occurrence among children conceived via IVF is warranted.

Sears S, Buendia JR, Odem S, et al. Metabolic syndrome among people living with HIV receiving medical care in the southern United States: prevalence and risk factors. AIDS Behav. 2019 Nov;23(11):2916-2925. Epub 2019 Mar 30. doi: 10.1007/s10461-019-02487-8
Using representative data among 1861 care people living with HIV (PLWH) in four southern states (Texas, Mississippi, Florida, and Georgia) from the 2013-2014 Medical Monitoring Project (MMP) survey, we estimated the prevalence and odds of metabolic syndrome (MetS) among various demographic and HIV related risk factors. Overall MetS prevalence was 34%, with our participants being mostly black (55%), male (72%), ≥ 50 years old (46%), and overweight or obese (60%) with undetectable viral loads (≤ 200 copies/ml, 69%), and were currently taking antiretroviral medication (98%). Compared to those who were ≥ 60 years, 18-39 year-olds had a 79% (95% CI 0.13-0.33) lower odds of having MetS. Women were 2.24 times more likely to have MetS than men (95% CI 1.69-2.97). Age and sex were significant predictors of MetS. Since MetS is a combination of chronic disease risk factors, regular screening for MetS risk factors among aging PLWH is crucial.

Ryan MA, Olshan AF, Canfield MA, et al. Sociodemographic, health behavioral, and clinical risk factors for anotia/microtia in a population-based case-control study. Int J Pediatr Otorhinolaryngol. 2019 Jul;122:18-26. Epub 2019 Mar 23. doi: 10.1016/j.ijporl.2019.03.026
Objective: Anotia and microtia are congenital malformations of the external ear with few known risk factors. We conducted a comprehensive assessment of a wide range of potential risk factors using data from the National Birth Defects Prevention Study (NBDPS), a population-based case-control study of non-chromosomal structural birth defects in the United States.
Methods: Mothers of 699 infants with anotia or microtia (cases) and 11,797 non-malformed infants (controls) delivered between 1997 and 2011 were interviewed to obtain information about sociodemographic, health behavioral, and clinical characteristics. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated with logistic regression.
Results: Infants with anotia/microtia were more likely to be male (aOR, 1.29; 95% CI, 1.10-1.50) and from a multifetal pregnancy (aOR, 1.68; 95% CI, 1.16-2.42). Cases were also more likely to have parents of Hispanic ethnicity (maternal aOR, 3.19; 95% CI, 2.61-3.91; paternal aOR, 2.11; 95% CI, 1.54-2.88), and parents born outside the United States (maternal aOR, 1.29; 95% CI, 1.06-1.57; paternal aOR, 1.92; 95% CI, 1.53-2.41). Maternal health conditions associated with increased odds of anotia/microtia included obesity (aOR, 1.31; 95% CI, 1.06-1.61) and pre-pregnancy diabetes (type I aOR, 9.89; 95% CI, 5.46-17.92; type II aOR, 4.70; 95% CI, 2.56-8.63). Reduced odds were observed for black mothers (aOR, 0.57; 95% CI, 0.38-0.85) and mothers reporting daily intake of folic acid-containing supplements (aOR, 0.59; 95% CI, 0.46-0.76).
Conclusion: We identified several risk factors for anotia/microtia, some of which have been previously reported (e.g., diabetes) and others which we investigate for perhaps the first time (e.g., binge drinking) that warrant further investigation. Our findings point to some potentially modifiable risk factors and provide further leads toward understanding the etiology of anotia/microtia.

Kirby RS1, Mai CT2, Wingate MS3, et al. Prevalence of selected birth defects by maternal nativity status, United States, 1999-2007. Birth Defects Res. 2019 Jul 1;111(11):630-639. Epub 2019 Mar 28. doi.org/10.1002/bdr2.1489
Objectives: We investigated differences in the prevalence of major birth defects by maternal nativity within racial/ethnic groups for 27 major birth defects.
Methods: Data from 11 population-based birth defects surveillance systems in the United States including almost 13 million live births (approximately a third of U.S. births) during 1999-2007 were pooled. We calculated prevalence estimates for each birth defect for five racial/ethnic groups. Using Poisson regression, crude and adjusted prevalence ratios (aPRs) were also calculated using births to US-born mothers as the referent group in each racial/ethnic group.
Results: Approximately 20% of case mothers and 26% of all mothers were foreign-born. Elevated aPRs for infants with foreign-born mothers were found for spina bifida and trisomy 13, 18, and 21, while lower prevalence patterns were found for pyloric stenosis, gastroschisis, and hypospadias.
Conclusions: This study demonstrates that birth defect prevalence varies by nativity within race/ethnic groups, with elevated prevalence ratios for some specific conditions and lower prevalence for others. More detailed analyses focusing on a broader range of maternal behaviors and characteristics are required to fully understand the implications of our findings.

Abara WE, Trujillo L, Broz D, et al. Age-related differences in past or present HCV infection among people who inject drugs - national HIV behavioral surveillance, eight U.S Cities, 2015. J Infect Dis. 2019 Jul 2;220(3):377-385. Epub 27 March 2019. doi: 10.1093/infdis/jiz142
Background: Historically, older people who inject drugs (PWID) have had the highest hepatitis C burden, however, young PWID account for recent increases in HCV infection. We assessed factors associated with past or present HCV infection (HCV antibody-positive) among young (≤35 years) and older PWID (>35 years).
Methods: Using Poisson regression, we calculated adjusted prevalence ratios (aPR) to examine socio-demographic and past 12-month injection risk behaviors associated with HCV infection.
Results: Of 4,094 PWID, 55.2% were HCV antibody-positive (anti-HCV). Among young PWID, anti-HCV prevalence was 42.1% and associated with ≤high school diploma/GED (aPR=1.17, 95%CI=1.03-1.32), receptive syringe sharing (aPR=1.37, 95%CI=1.21-1.56), sharing injection equipment (aPR=1.16, 95%CI=1.01-1.35), arrest history (aPR=1.14, 95%CI=1.02-1.29), and injecting speedball (aPR=1.37, 95%CI=1.16-1.61). Among older PWID, anti-HCV prevalence was 62.2% and associated with ≤high school diploma/GED (aPR= 1.08, 95%CI=1.02-1.15), sharing injection equipment (aPR=1.08, 95% CI=1.02-1.15), high injection frequency (aPR=1.16, 95%CI=1.01-1.34), and injecting speedball (aPR=1.09, 95%CI=1.01-1.16).
Conclusions: Anti-HCV positivity prevalence is high and associated with risky injection practices. Almost half of young PWID were anti-HCV positive. Improving access to direct-acting antiviral treatment, syringe service programs, and medication-assisted therapy is critical to reducing HCV transmission risk and infection burden, particularly among young PWID who are more likely to be newly infected.

White JT, Kovar E, Chambers TM, et al. Hypospadias risk from maternal residential exposure to heavy metal hazardous air pollutants. Int J Environ Res Public Health. 2019;16(6):930. Epub 2019 Mar 15. doi: 10.3390/ijerph16060930
Objective: Investigate whether residential prenatal exposure to heavy metal hazardous air pollutants (HMHAPs) is associated with an increased risk of hypospadias.
Methods: Data on non-syndromic hypospadias cases (n = 8981) and control patients delivered in Texas were obtained from the Texas Birth Defects Registry and matched 1:10 by birth year. Average exposure concentrations of HMHAPs were obtained from the 2005 U.S. Environmental Protection Agency National-Scale Air Toxics Assessment and categorized into quintiles. Odds ratios and 95% confidence intervals were estimated. STROBE reporting guidelines were followed.
Results: We observed associations between hypospadias and prenatal HMHAP exposure. Manganese demonstrated a significantly increased risk of hypospadias at the medium, medium-high, and high exposure quintiles; lead in the medium-high and high exposure quintiles. Cadmium, mercury, and nickel demonstrated a significant inverted "U-shaped" association for exposures with significant associations in the medium and medium-high quintiles but not in the medium-low and high quintiles. Arsenic and chromium demonstrated a significant bivalent association for risk of hypospadias in a lower quintile as well as a higher quintile with non-significant intermediate quintiles.
Conclusions: Using data from one of the world's largest active surveillance birth defects registries, we identified significant associations between hypospadias and HMHAP exposures. These results should be used in counseling for maternal demographic risk factors as well as avoidance of heavy metals and their sources.

Lindsey NP, Porse CC, Potts E, et al. Postnatally acquired Zika virus disease among children, United States, 2016-2017. Clin Infect Dis. 2020;70(2):227-231. Epub 2019 Mar 11.  doi: 10.1093/cid/ciz195
Background: The clinical findings among children with postnatally acquired Zika virus disease are not well characterized. We describe and compare clinical signs and symptoms for children aged <18 years.
Methods: Zika virus disease cases were included if they met the national surveillance case definition, had illness onset in 2016 or 2017, resided in a participating state, and were reported to CDC. Pediatric cases were aged <18 years; congenital and perinatal infections were excluded. Pediatric cases were matched to adult cases (18‒49 years). Clinical information was compared between younger and older pediatric cases and between children and adults.
Results: A total of 141 pediatric Zika virus disease cases were identified; none experienced neurologic disease. Overall, 28 (20%) were treated in an emergency department, 1 (<1%) was hospitalized; none died. Of the four primary clinical signs and symptoms associated with Zika virus disease, 133 (94%) children had a rash, 104 (74%) fever, 67 (48%) arthralgia, and 51 (36%) conjunctivitis. Fever, arthralgia, and myalgia were more common in older children (12‒17 years) than younger children (1‒11 years). Arthralgia, arthritis, edema, and myalgia were more common in adults compared to children.
Conclusions: This report supports previous findings that Zika virus disease is generally mild in children. The most common symptoms are similar to other childhood infections, and clinical findings and outcomes are similar to those in adults. Healthcare providers should consider a diagnosis of Zika virus infection in children with fever, rash, arthralgia, or conjunctivitis, who reside in or have traveled to an area where Zika virus transmission is occurring.

Kapoor R, Kancherla V, Cao Y, et al. Prevalence and descriptive epidemiology of infantile hypertrophic pyloric stenosis in the United States: A multistate, population-based retrospective study, 1999-2010. Birth Defects Res. 2019 Feb 1; 111(3):159-169. Epub 2018 Dec 13. doi: 10.1002/bdr2.1439 
Background: Antecedents for infantile hypertrophic pyloric stenosis (IHPS) vary across studies; therefore, we conducted a multistate, population-based retrospective study of the prevalence and descriptive epidemiology of IHPS in the United States (US).
Methods: Data for IHPS cases (n = 29,554) delivered from 1999-2010 and enumerated from 11 US population-based birth defect surveillance programs, along with data for live births (n = 14,707,418) delivered within the same birth period and jurisdictions, were analyzed using Poisson regression to estimate IHPS prevalence per 10,000 live births. Additional data on deliveries from 1999-2005 from seven of these programs were analyzed using multivariable logistic regression to estimate adjusted prevalence ratios (aPR)s and 95% confidence intervals (CI)s for selected infant and parental characteristics.
Results: Overall, IHPS prevalence from 1999-2010 was 20.09 (95% CI = 19.87, 20.32) per 10,000 live births, with statistically significant increases from 2003-2006 and decreases from 2007-2010. Compared to their respective referents, aPRs were higher in magnitude for males, preterm births, and multiple births, but lower for birth weights <2,500 g. The aPRs for all cases increased with decreasing parental age, maternal education, and maternal parity, but decreased for parental race/ethnicity other than non-Hispanic White. Estimates restricted to isolated cases or stratified by infant sex were similar to those for all cases.
Conclusions: This study covers one of the largest samples and longest temporal period examined for IHPS in the US. Similar to findings reported in Europe, estimates suggest that IHPS prevalence has decreased recently in the US. Additional analyses supported associations with several infant and parental characteristics.

Benjamin RH, Mitchell LE, Canfield MA, et al. Fish consumption before pregnancy and pregnancy outcomes in the National Birth Defects Prevention Study, 1997-2011. Public Health Nutr. 2019 Feb;22(2):336-343. Epub 2018 Oct 17. doi: 10.1017/S1368980018002641
Objective: To evaluate the relationships between maternal fish consumption and pregnancy outcomes in a large, population-based sample of women in the USA.
Design: We collected average fish consumption before pregnancy using a modified version of the semi-quantitative Willett FFQ. We estimated adjusted OR (aOR) and 95 % CI for associations between different levels of fish consumption and preterm birth (&lt;37 weeks), early preterm birth (&lt;32 and &lt;35 weeks), and small-for-gestational-age infants (SGA; &lt;10th percentile).
Setting: The National Birth Defects Prevention Study (NBDPS).
Subjects: Control mother-infant pairs with estimated delivery dates between 1997 and 2011 (n 10 919).
Results: No significant associations were observed between fish consumption and preterm birth or early preterm birth (aOR = 0·7-1·0 and 0·7-0·9, respectively). The odds of having an SGA infant were elevated (aOR = 2·1; 95 % CI 1·2, 3·4) among women with daily fish consumption compared with women consuming fish less than once per month. No associations were observed between other levels of fish consumption and SGA (aOR = 0·8-1·0).
Conclusions: High intake of fish was associated with twofold higher odds of having an SGA infant, while moderate fish consumption before pregnancy was not associated with preterm or SGA. Our study, like many other studies in this area, lacked information regarding preparation methods and the specific types of fish consumed. Future studies should incorporate information on nutrient and contaminant contents, preparation methods, and biomarkers to assess these relationships.

Endres BT1, Begum K1, Sun H2, et al. Epidemic Clostridioides difficile ribotype 027 lineages: comparisons of Texas versus worldwide strains. Open Forum Infect Dis. 2019 Feb 9;6(2):ofz013. doi: 10.1093/ofid/ofz013
Background: The epidemic Clostridioides difficile ribotype 027 strain resulted from the dissemination of 2 separate fluoroquinolone-resistant lineages: FQR1 and FQR2. Both lineages were reported to originate in North America; however, confirmatory large-scale investigations of C difficile ribotype 027 epidemiology using whole genome sequencing has not been undertaken in the United States.
Methods: Whole genome sequencing and single-nucleotide polymorphism (SNP) analysis was performed on 76 clinical ribotype 027 isolates obtained from hospitalized patients in Texas with C difficile infection and compared with 32 previously sequenced worldwide strains. Maximum-likelihood phylogeny based on a set of core genome SNPs was used to construct phylogenetic trees investigating strain macro- and microevolution. Bayesian phylogenetic and phylogeographic analyses were used to incorporate temporal and geographic variables with the SNP strain analysis.
Results: Whole genome sequence analysis identified 2841 SNPs including 900 nonsynonymous mutations, 1404 synonymous substitutions, and 537 intergenic changes. Phylogenetic analysis separated the strains into 2 prominent groups, which grossly differed by 28 SNPs: the FQR1 and FQR2 lineages. Five isolates were identified as pre-epidemic strains. Phylogeny demonstrated unique clustering and resistance genes in Texas strains indicating that spatiotemporal bias has defined the microevolution of ribotype 027 genetics.
Conclusions: Clostridioides difficile ribotype 027 lineages emerged earlier than previously reported, coinciding with increased use of fluoroquinolones. Both FQR1 and FQR2 ribotype 027 epidemic lineages are present in Texas, but they have evolved geographically to represent region-specific public health threats.

Hoang TT, Lei Y, Mitchell LE, et al. Maternal lactase polymorphism (rs4988235) is associated with neural tube defects in offspring in the National Birth Defects Prevention Study. J Nutr. 2019 Feb 1;149(2):295-303. Epub 2019 Jan 24. doi: 10.1093/jn/nxy246
Background: The risk of neural tube defect (NTD)-affected pregnancies is reduced with adequate folic acid intake during early pregnancy. However, NTDs have been observed among the offspring of women with adequate folic acid intake. Some of these women are possibly not absorbing enough folic acid. Because lactase deficiency can lead to poor nutrient absorption, we hypothesized that lactase-deficient women will be at increased risk of having offspring with NTDs.
Objective: We examined the association between maternal rs4988235 (a lactase deficiency genetic marker) and NTDs in offspring.
Methods: We conducted a case-control study using data from the National Birth Defects Prevention Study, United States, 1997-2009, restricting to non-Hispanic white (NHW) and Hispanic women. Cases were women with an offspring with an NTD (n = 378 NHW, 207 Hispanic), and controls were women with an offspring without a birth defect (n = 461 NHW, 165 Hispanic). Analyses were conducted separately by race/ethnicity, using logistic regression. Women with the CC genotype were categorized as being lactase deficient. To assess potential effect modification, analyses were stratified by lactose intake, folic acid supplementation, dietary folate, and diet quality.
Results: Among NHW women, the odds of being lactase deficient were greater among cases compared with controls (OR: 1.37; 95% CI: 1.02, 1.82). Among Hispanic women, the odds of being lactase deficient were significantly lower among cases compared with controls (OR: 0.50, 95% CI: 0.33, 0.77). The association differed when stratified by lactose intake in NHW women (higher odds among women who consumed ≥12 g lactose/1000 kcal) and by dietary folate in Hispanic women (opposite direction of associations). The association did not differ when stratified by folic acid supplementation or diet quality.
Conclusions: Our findings suggest that maternal lactase deficiency is associated with NTDs in offspring. However, we observed opposite directions of effect by race/ethnicity that could not be definitively explained.

Shewale JB, Ganduglia Cazaban CM, Waller DK, Mitchell LE, Langlois PH, Agopian AJ. Microcephaly inpatient hospitalization and potential Zika outbreak in Texas: A cost and predicted economic burden analysis. Travel Med Infect Dis. 2019 Jul-Aug;30:67-72. Epub 2019 Jan 9. doi: 10.1016/j.tmaid.2019.01.001
Objective: Estimate inpatient hospitalization costs for patients with microcephaly, and predict cost increases due to a potential Zika virus outbreak.
Methods: We identified Texas-wide inpatient hospitalization discharge records (2008-2015), for newborns and non-newborns with microcephaly. We estimated the cost of each hospitalization by applying cost-to-charge ratios to the actual hospitalization charge. For comparison, newborn visits for patients without microcephaly were also identified, and hospital costs were compared between patients with and without microcephaly. We estimated costs for microcephaly during the first year of life following a Zika outbreak (possible 1-50% increase in birth prevalence) in Texas.
Results: There were 8005 microcephaly hospitalizations ($203,899,042; total cost). The median admission cost for newborns with microcephaly (N = 1393) was higher compared to those without microcephaly ($6751 vs $725, p < 0.001). Microcephaly hospitalizations of newborns had a lower median cost compared to non-newborns ($6751 vs $9754, p < 0.001). Based on these observed hospitalization costs, we estimated that a potential Zika virus outbreak in Texas could result in an additional $1-6 million per year for hospitalizations.
Conclusion: Hospitalizations of patients with microcephaly are associated with high costs. An increase in microcephaly prevalence due to a Zika outbreak in Texas could have a considerable impact on healthcare costs.

Haidar A, Ranjit N, Saxton D, Hoelscher DM. Perceived parental and peer social support is associated with healthier diets in adolescents. J Nutr Educ Behav. 2019 Jan;51(1):23-31. doi: 10.1016/j.jneb.2018.10.003
Objective: Investigate associations between perceived parental/peer support for a healthy diet and adolescent dietary behaviors using data from the 2009-2011 School Physical Activity and Nutrition (SPAN) survey.
Design: A secondary analysis of SPAN, a cross-sectional statewide study using a validated self-administered questionnaire, assessed obesity-related behaviors.
Setting: Probability-based sample of Texas 8th- and 11th-grade students.
Participants: A total of 6,716 8th- and 11th-grade students.
Main outcome measures: Obtained by self-report and included sugary beverage consumption, fruit and vegetable intake, and SPAN healthy eating score.
Analysis: Multiple logistic regression and linear regression were used to determine associations, controlling for demographic variables.
Results: For every 1-point increase in parental support (range, 0-12), adolescents had 1.19 times higher odds of consuming ≥1 fruits or vegetables/d (P < .001) and 1.1 times lower odds of consuming ≥2 sugary beverages/d (P < .05), and had a SPAN healthy eating score (range, -100 to 100) that was 1.6 points higher (P < .001). For every 1-point increase in peer support, adolescents had 1.14 times higher odds of consuming ≥1 fruits and vegetables/d (P < .001) and a higher SPAN healthy eating score (P < .05).
Conclusions and implications: Parental/peer support was associated with healthier dietary behaviors. Future research could conduct pre-post intervention studies to determine whether an increase in parental/peer support is associated with positive changes in healthier eating.