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DSHS Authors: 2020 Research Articles by DSHS Staff

The following list includes peer-reviewed research articles that have been written by staff of the Texas Department of State Health Services. For more information about these articles or for a full-text copy, please contact the Medical and Research Library by email at library@dshs.texas.gov by calling 512-776-7559.

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2020 Articles (in date order with 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 who 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. 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:
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 (Leishmaniamexicana 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 (Dampfomyiaanthophora (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 (Leishmaniamexicana 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 (contributor, COVID-19 State, Tribal, Local, and Territorial Response Team). 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. 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 (contributor, Antimicrobial-Resistant Neisseriameningitidis Team). Detection of Ciprofloxacin-Resistant, β-Lactamase-Producing Neisseria eningitidis 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 ,10 diagnosed with cancer, 539,567 diagnosed with birth defects, and 2124 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:
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 Cdifficile 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 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.

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Last updated April 19, 2021