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The world is not on track to meet Sustainable Development Goal 6.1 to provide universal access to safely managed drinking water by 2030. Removal of priority microbial contaminants by disinfection is one aspect of ensuring water is safely managed. Passive chlorination (also called in-line chlorination) represents one approach to disinfecting drinking water before or at the point of collection (POC), without requiring daily user input or electricity. In contrast to manual household chlorination methods typically implemented at the point of use (POU), passive chlorinators can reduce the user burden for chlorine dosing and enable treatment at scales ranging from communities to small municipalities. In this review, we synthesized evidence from 27 evaluations of passive chlorinators (in 19 articles, 3 NGO reports, and 5 theses) conducted across 16 countries in communities, schools, health care facilities, and refugee camps. Of the 27 passive chlorinators we identified, the majority (22/27) were solid tablet or granular chlorine dosers, and the remaining devices were liquid chlorine dosers. We identified the following research priorities to address existing barriers to scaled deployment of passive chlorinators: (i) strengthening local chlorine supply chains through decentralized liquid chlorine production, (ii) validating context-specific business models and financial sustainability, (iii) leveraging remote monitoring and sensing tools to monitor real-time chlorine levels and potential system failures, and (iv) designing handpump-compatible passive chlorinators to serve the many communities reliant on handpumps as a primary drinking water source. We also propose a set of reporting indicators for future studies to facilitate standardized evaluations of the technical performance and financial sustainability of passive chlorinators. In addition, we discuss the limitations of chlorine-based disinfection and recognize the importance of addressing chemical contamination in drinking water supplies. Passive chlorinators deployed and managed at-scale have the potential to elevate the quality of existing accessible and available water services to meet "safely managed" requirements.

Background We used data from the Sentinel Enhanced Dengue Surveillance System (SEDSS) to describe influenza trends in southern Puerto Rico during 2012‐2018 and compare them to trends in the United States. Methods Patients with fever onset ≤ 7 days presenting were enrolled. Nasal/oropharyngeal swabs were tested for influenza A and B viruses by PCR. Virologic data were obtained from the US World Health Organization (WHO) Collaborating Laboratories System and the National Respiratory and Enteric Virus Surveillance System (NREVSS). We compared influenza A and B infections identified from SEDSS and WHO/NREVSS laboratories reported by US Department of Health and Human Services (HHS) region using time series decomposition methods, and analysed coherence of climate and influenza trends by region. Results Among 23,124 participants, 9% were positive for influenza A and 5% for influenza B. Influenza A and B viruses were identified year‐round, with no clear seasonal patterns from 2012 to 2015 and peaks in December‐January in 2016‐2017 and 2017‐2018 seasons. Influenza seasons in HHS regions were relatively synchronized in recent years with the seasons in Puerto Rico. We observed high coherence between absolute humidity and influenza A and B virus in HHS regions. In Puerto Rico, coherence was much lower in the early years but increased to similar levels to HHS regions by 2017‐2018. Conclusions Influenza seasons in Puerto Rico have recently become synchronized with seasons in US HHS regions. Current US recommendations are for everyone 6 months and older to receive influenza vaccination by the end of October seem appropriate for Puerto Rico.

OBJECTIVE: Asthma carries a high burden of disease for residents of Puerto Rico. We conducted this study to better understand asthma-related healthcare use and to examine potential asthma triggers. METHODS: We characterized asthma-related healthcare use in 2013 by demographics, region, and date using outpatient, hospital, and emergency department (ED) insurance claims with a primary diagnostic ICD-9-CM code of 493.XX. We examined environmental asthma triggers, including outdoor allergens (i.e., mold and pollen), particulate pollution, and influenza-like illness. Analyses included descriptive statistics and Poisson time-series regression. RESULTS: During 2013, there were 550,655 medical asthma claims reported to the Puerto Rico Healthcare Utilization database, representing 148 asthma claims/1,000 persons; 71% of asthma claims were outpatient visits, 19% were hospitalizations, and 10% were ED visits. Females (63%), children aged ≤9 years (77% among children), and adults aged ≥45 years (80% among adults) had the majority of asthma claims. Among health regions, Caguas had the highest asthma claim-rate at 142/1,000 persons (overall health region claim-rate = 108). Environmental exposures varied across the year and demonstrated seasonal patterns. Metro health region regression models showed positive associations between increases in mold and particulate matter

The appearance of first-degree atrioventricular block and mitral annulus calcification in an end-stage renal failure patient with elevated parathyroid hormone levels should raise the suspicion of metastatic cardiac calcification. Measures should be taken to normalize the parathyroid hormone, calcium, and phosphorus levels to limit the progression of atrioventricular block. Exploration or removal of parathyroid glands should be considered if heart block worsens.

Continuity of key water, sanitation, and hygiene (WASH) infrastructure and WASH practices—for example, hand hygiene—are among several critical community preventive and mitigation measures to reduce transmission of infectious diseases, including COVID-19 and other respiratory diseases. WASH guidance for COVID-19 prevention may combine existing WASH standards and new COVID-19 guidance. Many existing WASH tools can also be modified for targeted WASH assessments during the COVID-19 pandemic. We partnered with local organizations to develop and deploy tools to assess WASH conditions and practices and subsequently implement, monitor, and evaluate WASH interventions to mitigate COVID-19 in low- and middle-income countries in Latin America and the Caribbean and Africa, focusing on healthcare, community institution, and household settings and hand hygiene specifically. Employing mixed-methods assessments, we observed gaps in access to hand hygiene materials specifically despite most of those settings having access to improved, often onsite, water supplies. Across countries, adherence to hand hygiene among healthcare providers was about twice as high after patient contact compared to before patient contact. Poor or non-existent management of handwashing stations and alcohol-based hand rub (ABHR) was common, especially in community institutions. Markets and points of entry (internal or external border crossings) represent congregation spaces, critical for COVID-19 mitigation, where globally-recognized WASH standards are needed. Development, evaluation, deployment, and refinement of new and existing standards can help ensure WASH aspects of community mitigation efforts that remain accessible and functional to enable inclusive preventive behaviors.

Approximately 56 million school-aged children (aged 5-17 years) resumed education in the United States in fall 2020.* Analysis of demographic characteristics, underlying conditions, clinical outcomes, and trends in weekly coronavirus disease 2019 (COVID-19) incidence during March 1-September 19, 2020 among 277,285 laboratory-confirmed cases in school-aged children in the United States might inform decisions about in-person learning and the timing and scaling of community mitigation measures. During May-September 2020, average weekly incidence (cases per 100,000 children) among adolescents aged 12-17 years (37.4) was approximately twice that of children aged 5-11 years (19.0). In addition, among school-aged children, COVID-19 indicators peaked during July 2020: weekly percentage of positive SARS-CoV-2 test results increased from 10% on May 31 to 14% on July 5; SARS-CoV-2 test volume increased from 100,081 tests on May 31 to 322,227 on July 12, and COVID-19 incidence increased from 13.8 per 100,000 on May 31 to 37.9 on July 19. During July and August, test volume and incidence decreased then plateaued; incidence decreased further during early September and might be increasing. Percentage of positive test results decreased during August and plateaued during September. Underlying conditions were more common among school-aged children with severe outcomes related to COVID-19: among school-aged children who were hospitalized, admitted to an intensive care unit (ICU), or who died, 16%, 27%, and 28%, respectively, had at least one underlying medical condition. Schools and communities can implement multiple, concurrent mitigation strategies and tailor communications to promote mitigation strategies to prevent COVID-19 spread. These results can provide a baseline for monitoring trends and evaluating mitigation strategies.

As of September 21, 2020, the coronavirus disease 2019 (COVID-19) pandemic had resulted in more than 6,800,000 reported U.S. cases and more than 199,000 associated deaths.* Early in the pandemic, COVID-19 incidence was highest among older adults (1). CDC examined the changing age distribution of the COVID-19 pandemic in the United States during May-August by assessing three indicators: COVID-19-like illness-related emergency department (ED) visits, positive reverse transcription-polymerase chain reaction (RT-PCR) test results for SARS-CoV-2, the virus that causes COVID-19, and confirmed COVID-19 cases. Nationwide, the median age of COVID-19 cases declined from 46 years in May to 37 years in July and 38 in August. Similar patterns were seen for COVID-19-like illness-related ED visits and positive SARS-CoV-2 RT-PCR test results in all U.S. Census regions. During June-August, COVID-19 incidence was highest in persons aged 20-29 years, who accounted for >20% of all confirmed cases. The southern United States experienced regional outbreaks of COVID-19 in June. In these regions, increases in the percentage of positive SARS-CoV-2 test results among adults aged 20-39 years preceded increases among adults aged ≥60 years by an average of 8.7 days (range = 4-15 days), suggesting that younger adults likely contributed to community transmission of COVID-19. Given the role of asymptomatic and presymptomatic transmission (2), strict adherence to community mitigation strategies and personal preventive behaviors by younger adults is needed to help reduce their risk for infection and subsequent transmission of SARS-CoV-2 to persons at higher risk for severe illness.

Background Little is known about the prevalence or incidence of Zika virus (ZIKV) infection in settings affected by the 2015–2016 Zika pandemic and associated risk factors. We assessed these factors among household contacts of patients with ZIKV disease enrolled in a cohort study in Puerto Rico during 2016–2017. Methods Household contacts of index case patients completed a questionnaire and gave specimens for real-time polymerase chain reaction (RT-PCR) and immunoglobulin M enzyme-linked immunosorbent assay testing to detect ZIKV infection. We measured the prevalence of ZIKV infection among contacts and associated individual and household factors, examined sexual transmission using a sexual-networks approach, and assessed incident infection among initially uninfected household contacts 2–4 months later. Results Of 366 contacts, 34.4% had evidence of ZIKV infection at enrollment, including 11.2% by RT-PCR. Having open doors and windows that were either screened (prevalence ratio [PR], 2.1 [95% confidence interval {CI}, 1.2–3.6]) or unscreened (PR, 2.5 [95% CI, 1.5–4.1]) was associated with increased prevalence. Sexual partners were more likely to both be RT-PCR positive relative to other relationships (odds ratio, 2.2 [95% CI, 1.1–4.5]). At follow-up, 6.1% of contacts had evidence of incident infection. Conclusions This study identified sexual contact as a risk factor for ZIKV infection. Persons living with ZIKV-infected individuals should be a focus of public health efforts.

OBJECTIVE: Asthma affects 6 million children in the United States. Most people can control their asthma symptoms with effective care, management, and appropriate medical treatment. Information on the relationship between asthma control and quality of life indicators and health care use among school-age children is limited. METHODS: Using the 2006–2010 combined Behavior Risk Factor Surveillance System Asthma Call-back Survey child data, we examined asthma control and asthma attack status among school-age (aged 5–17 years) children with asthma from 35 states and the District of Columbia. Multivariable logistic regression models were used to assess if having uncontrolled asthma and having ≥1 asthma attacks affect quality of life (activity limitation and missed school days) and healthcare use (emergency department [ED] visits and hospitalizations). RESULTS: About one-third (36.5%) of the 8,484 respondents with current asthma had uncontrolled asthma and 56.8% reported ≥1 asthma attack in the past year. Having uncontrolled asthma and having ≥1 asthma attack were significantly associated with activity limitation (aPR=1.43 and 1.74, respectively), missed school (1.45 and 1.68), ED visits (2.05 and 4.78), and hospitalizations (2.38 and 3.64). Long-term control (LTC) medication use was higher among respondents with uncontrolled asthma (61.3%) than respondents with well-controlled asthma (33.5%). CONCLUSIONS: Having uncontrolled asthma is associated with reduced quality of life and increased health care use. However, only 61.3% of respondents with uncontrolled asthma use LTC medications. Increasing use of LTC medications among children with uncontrolled asthma could help improve quality of life and reduce health care use.

Background: Over 40% of the world's population relies on solid fuels for heating and cooking. Use of improved biomass cookstoves (ICS) has the potential to reduce household air pollution (HAP). Objectives: As part of an evaluation to identify ICS for use in Kenya, we collected indoor air and personal air samples to assess differences between traditional cookstoves (TCS) and ICS. Methods: We conducted a cross-over study in 2012 in two Kenyan villages; up to six different ICS were installed in 45 households during six two-week periods. Forty-eight hour kitchen measurements of fine particulate matter (PM2.5) and carbon monoxide (CO) were collected for the TCS and ICS. Concurrent personal CO measurements were conducted on the mother and one child in each household. We performed descriptive analysis and compared paired measurements between baseline (TCS only) and each ICS. Results: The geometric mean of 48-hour baseline PM2.5 and CO concentrations in the kitchen was 586 μg/m3 (95% CI: 460, 747) and 4.9 ppm (95% CI: 4.3, 5.5), respectively. For each ICS, the geometric mean kitchen air pollutant concentration was lower than the TCS: median reductions were 38.8% (95% CI: 29.5, 45.2) for PM2.5 and 27.1% (95% CI: 17.4, 40.3) for CO, with statistically significant relationships for four ICS. We also observed a reduction in personal exposures to CO with ICS use. Conclusions: We observed a reduction in mean 48-hour PM2.5 and CO concentrations compared to the TCS; however, concentrations for both pollutants were still consistently higher than WHO air quality guidelines. Our findings illustrate that ICS tested in real-world settings can reduce exposures to HAP, but implementation of cleaner fuels and related stove technologies may also be necessary to optimize public health benefits. Keywords: Cookstove, Household air pollution, Particulate matter, Carbon monoxide

International audience; Since the 2007 Zika epidemic in the Micronesian state of Yap, it has been apparent that not all people infected with Zika virus (ZIKV) experience symptoms. However, the proportion of infections that result in symptoms remains unclear. Existing estimates have varied in their interpretation of symptoms due to other causes and the case definition used, and they have assumed perfect test sensitivity and specificity. Using a Bayesian model and data from ZIKV serosurveys in Yap (2007), French Polynesia (2013-2014), and Puerto Rico (2016), we found that assuming perfect sensitivity and specificity generally led to lower estimates of the symptomatic proportion. Incorporating reasonable assumptions for assay sensitivity and specificity, we estimated that 27% (95% credible interval (CrI): 15, 37) (Yap), 44% (95% CrI: 26, 66) (French Polynesia), and 50% (95% CrI: 34, 92) (Puerto Rico) of infections were symptomatic, with variation due to differences in study populations, study designs, and case definitions. The proportion of ZIKV infections causing symptoms is critical for surveillance system design and impact assessment. Here, we accounted for key uncertainties in existing seroprevalence data and found that estimates for the symptomatic proportion ranged from 27% to 50%, suggesting that while the majority of infections are asymptomatic or mildly symptomatic, symptomatic infections might be more common than previously estimated.

Background: Ebola virus disease (EVD) is highly transmissible and has a high mortality rate. During outbreaks, EVD can spread across international borders. Inadequate hand hygiene places healthcare workers (HCWs) at increased risk for healthcare-associated infections, including EVD. In high-income countries, alcohol-based hand rub (ABHR) can improve hand hygiene compliance among HCWs in healthcare facilities (HCF). We evaluated local production and district-wide distribution of a WHO-recommended ABHR formulation and associations between ABHR availability in HCF and HCW hand hygiene compliance. Methods: The evaluation included 30 HCF in Kabarole District, located in Western Uganda near the border with the Democratic Republic of the Congo, where an EVD outbreak has been ongoing since August 2018. We recorded baseline hand hygiene practices before and after patient contact among 46 healthcare workers across 20 HCFs in August 2018. Subsequently, in late 2018, WHO/UNICEF distributed commercially produced ABHR to all 30 HCFs in Kabarole as part of Ebola preparedness efforts. In February 2019, our crossover evaluation distributed 20 L locally produced ABHR to each of 15 HCFs. From June 24–July 5, 2019, we performed follow-up observations of hand hygiene practices among 68 HCWs across all 30 HCFs. We defined hand hygiene as handwashing with soap or using ABHR. We conducted focus groups with healthcare workers at baseline and follow-up. Results: We observed hand hygiene compliance before and after 203 and 308 patient contacts at baseline and follow-up, respectively. From baseline to follow-up, hand hygiene compliance before patient contact increased for ABHR use (0% to 17%) and handwashing with soap (0% to 5%), for a total increase from 0% to 22% (P < .0001). Similarly, hand hygiene after patient contact increased from baseline to follow-up for ABHR use (from 3% to 55%), and handwashing with soap decreased (from 12% to 7%), yielding a net increase in hand hygiene compliance after patient contact from 15% to 62% (P < .0001). Focus groups found that HCWs prefer ABHR to handwashing because it is faster and more convenient. Conclusions: In an HCF in Kabarole District, the introduction of ABHR appeared to improve hand hygiene compliance. However, the confirmation of 3 EVD cases in Uganda 120 km from Kabarole District 2 weeks before our follow-up hand hygiene observations may have influenced healthcare worker behavior and hand hygiene compliance. Local production and district-wide distribution of ABHR is feasible and may contribute to improved hand hygiene compliance among healthcare workers.Funding: NoneDisclosures: Mohammed Lamorde, Contracted Research - Janssen Pharmaceutica, ViiV, Mylan

BackgroundAfter Zika virus (ZIKV) emerged in the Americas, laboratory-based surveillance for arboviral diseases in Puerto Rico was adapted to include ZIKV disease.Methods and findingsSuspected cases of arboviral disease reported to Puerto Rico Department of Health were tested for evidence of infection with Zika, dengue, and chikungunya viruses by RT-PCR and IgM ELISA. To describe spatiotemporal trends among confirmed ZIKV disease cases, we analyzed the relationship between municipality-level socio-demographic, climatic, and spatial factors, and both time to detection of the first ZIKV disease case and the midpoint of the outbreak. During November 2015-December 2016, a total of 71,618 suspected arboviral disease cases were reported, of which 39,717 (55.5%; 1.1 cases per 100 residents) tested positive for ZIKV infection. The epidemic peaked in August 2016, when 71.5% of arboviral disease cases reported weekly tested positive for ZIKV infection. Incidence of ZIKV disease was highest among 20-29-year-olds (1.6 cases per 100 residents), and most (62.3%) cases were female. The most frequently reported symptoms were rash (83.0%), headache (64.6%), and myalgia (63.3%). Few patients were hospitalized (1.2%), and 13 (ConclusionsDuring the ZIKV epidemic in Puerto Rico, 1% of residents were reported to public health authorities and had laboratory evidence of ZIKV disease. Transmission was first detected in urban areas of eastern Puerto Rico, where transmission also peaked earlier. These trends suggest that ZIKV was first introduced to Puerto Rico in the east before disseminating throughout the island.

Hurricane Maria made landfall in Puerto Rico on September 20, 2017, causing major damage to infrastructure and severely limiting access to potable water, electric power, transportation, and communications. Public services that were affected included operations of the Puerto Rico Department of Health (PRDOH), which provides critical laboratory testing and surveillance for diseases and other health hazards. PRDOH requested assistance from CDC for the restoration of laboratory infrastructure, surveillance capacity, and diagnostic testing for selected priority diseases, including influenza, rabies, leptospirosis, salmonellosis, and tuberculosis. PRDOH, CDC, and the Association of Public Health Laboratories (APHL) collaborated to conduct rapid needs assessments and, with assistance from the CDC Foundation, implement a temporary transport system for shipping samples from Puerto Rico to the continental United States for surveillance and diagnostic and confirmatory testing. This report describes the initial laboratory emergency response and engagement efforts among federal, state, and nongovernmental partners to reestablish public health laboratory services severely affected by Hurricane Maria. The implementation of a sample transport system allowed Puerto Rico to reinitiate priority infectious disease surveillance and laboratory testing for patient and public health interventions, while awaiting the rebuilding and reinstatement of PRDOH laboratory services.

A prospective cohort of women with reverse transcription polymerase chain reaction (RT-PCR) confirmed Zika virus infection aged 18–39 years in Puerto Rico found that pregnant women have about a 3-fold longer estimated median detection of Zika virus RNA in serum, which can increase definitive diagnosis of infection and facilitate timely and appropriate clinical management.

Background During the outbreak of Zika virus (ZIKV) disease in Puerto Rico in 2016, nonpregnant women aged 20-39 years were disproportionately identified with ZIKV disease. We used household-based cluster investigations to determine whether this disparity was associated with age- or sex-dependent differences in the rate of ZIKV infection or reported symptoms. Methods Participation was offered to residents of households within a 100-m radius of the residences of a convenience sample of 19 laboratory-confirmed ZIKV disease cases. Participants answered a questionnaire and provided specimens for diagnostic testing by reverse transcription-polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA). Results Among 367 study participants, 114 (31.1%) were laboratory positive for ZIKV infection, of whom 30% reported a recent illness (defined as self-reported rash or arthralgia) attributable to ZIKV infection. Age and sex were not associated with ZIKV infection. Female sex (adjusted prevalence ratio [aPR], 2.28; 95% confidence interval [CI], 1.40, 3.67), age

Zika virus is a flavivirus transmitted primarily by Aedes species mosquitoes; symptoms of infection include rash, arthralgia, fever, and conjunctivitis.*,† Zika virus infection during pregnancy can cause microcephaly and other serious brain anomalies (1), and in rare cases, Zika virus infection has been associated with Guillain-Barre syndrome (2) and severe thrombocytopenia (3). This report describes the incidence of reported symptomatic Zika virus disease in the U.S. territory of Puerto Rico by age and sex. During November 1, 2015-October 20, 2016, 62,500 suspected Zika virus disease cases were reported to the Puerto Rico Department of Health (PRDH); 29,345 (47%) were confirmed by reverse transcription-polymerase chain reaction (RT-PCR) testing, or were presumptively diagnosed based on serological testing. The highest incidence among confirmed or presumptive cases occurred among persons aged 20-29 years (1,150 cases per 100,000 residents). Among 28,219 (96.2%) nonpregnant patients with confirmed or presumptive Zika virus disease, incidence was higher among women (936 per 100,000 population) than men (576 per 100,000) for all age groups ≥20 years, and the majority (61%) of reported Zika virus disease cases occurred in females. Among suspected Zika virus disease cases in nonpregnant adults aged ≥40 years, the percentage that tested positive among females (52%) was higher than that among males (47%) (p

SYNOPSIS Over the last two decades, experts have reported a rising number of deaths caused by chronic kidney disease (CKD) along the Pacific coast of Central America, from southern Mexico to Costa Rica. However, this specific disease is not associated with traditional causes of CKD, such as aging, diabetes, or hypertension. Rather, this disease is a chronic interstitial nephritis termed chronic kidney disease of nontraditional etiology (CKDnT). According to the Pan American Health Organization (PAHO) mortality database, there are elevated rates of deaths related to kidney disease in many of these countries, with the highest rates being reported in El Salvador and Nicaragua. This condition has been identified in certain agricultural communities, predominantly among male farmworkers. Since CKD surveillance systems in Central America are under development or nonexistent, experts and governmental bodies have recommended creating standardized case definitions for surveillance purposes to monitor and characterize this epidemiological situation. A group of experts from Central American ministries of health, the U.S. Centers for Disease Control and Prevention (CDC), and PAHO held a workshop in Guatemala to discuss CKDnT epidemiologic case definitions. In this paper, we propose that CKD in general be identified by the standard definition internationally accepted and that a suspect case of CKDnT be defined as a person age < 60 years with CKD, without type 1 diabetes mellitus, hypertensive diseases, and other well-known causes of CKD. A probable case of CKDnT is defined as a suspect case with the same findings confirmed three or more months later.

Zika virus is a flavivirus transmitted primarily by Aedes aegypti and Aedes albopictus mosquitoes, and infection can be asymptomatic or result in an acute febrile illness with rash (1). Zika virus infection during pregnancy is a cause of microcephaly and other severe birth defects (2). Infection has also been associated with Guillain-Barre syndrome (GBS) (3) and severe thrombocytopenia (4,5). In December 2015, the Puerto Rico Department of Health (PRDH) reported the first locally acquired case of Zika virus infection. This report provides an update to the epidemiology of and public health response to ongoing Zika virus transmission in Puerto Rico (6,7). A confirmed case of Zika virus infection is defined as a positive result for Zika virus testing by reverse transcription-polymerase chain reaction (RT-PCR) for Zika virus in a blood or urine specimen. A presumptive case is defined as a positive result by Zika virus immunoglobulin M (IgM) enzyme-linked immunosorbent assay (MAC-ELISA)* and a negative result by dengue virus IgM ELISA, or a positive test result by Zika IgM MAC-ELISA in a pregnant woman. An unspecified flavivirus case is defined as positive or equivocal results for both Zika and dengue virus by IgM ELISA. During November 1, 2015-July 7, 2016, a total of 23,487 persons were evaluated by PRDH and CDC Dengue Branch for Zika virus infection, including asymptomatic pregnant women and persons with signs or symptoms consistent with Zika virus disease or suspected GBS; 5,582 (24%) confirmed and presumptive Zika virus cases were identified. Persons with Zika virus infection were residents of 77 (99%) of Puerto Rico's 78 municipalities. During 2016, the percentage of positive Zika virus infection cases among symptomatic males and nonpregnant females who were tested increased from 14% in February to 64% in June. Among 9,343 pregnant women tested, 672 had confirmed or presumptive Zika virus infection, including 441 (66%) symptomatic women and 231 (34%) asymptomatic women. One patient died after developing severe thrombocytopenia (4). Evidence of Zika virus infection or recent unspecified flavivirus infection was detected in 21 patients with confirmed GBS. The widespread outbreak and accelerating increase in the number of cases in Puerto Rico warrants intensified vector control and personal protective behaviors to prevent new infections, particularly among pregnant women.

Household air pollution (HAP) contributes to 3.5–4 million annual deaths globally. Recent interventions using improved cookstoves (ICS) to reduce HAP have incorporated temperature sensors as stove use monitors (SUMs) to assess stove use. We deployed SUMs in an effectiveness study of 6 ICSs in 45 Kenyan rural homes. Stove were installed sequentially for 2 weeks and kitchen air monitoring was conducted for 48 hours during each 2-week period. We placed SUMs on the ICSs and traditional cookstoves (TCS) and the continuous temperature data were analyzed using an algorithm to examine the number of cooking events, days of exclusive use of ICS, and how stove use patterns affect HAP. Stacking, defined as using both a TCS and an ICS in the same day, occurred on 40% of the study days, and exclusive use of the ICS occurred on 25% of study days. When researchers were not present, ICS use declined, which can have implications for long-term stove adoption in these communities. Continued use of TCSs was also associated with higher HAP levels. SUMs are a valuable tool for characterizing stove use and provide additional information to interpret HAP levels measured during ICS intervention studies.

Background Identifying factors associated with time-to-loss of Zika virus (ZIKV) RNA in serum and semen is important to inform diagnostic testing and prevention recommendations. CDC currently recommends RT-PCR testing of serum up to two weeks after symptom onset. We evaluated such associations among participants of the Zika virus Persistence (ZiPer) study in Puerto Rico. Methods Patients presenting for care with Zika-like illness and ZIKV RNA detected by RT-PCR in serum or urine (index cases) were offered study participation. Index cases’ household members were offered study participation, and those with detectable ZIKV RNA were eligible for the prospective cohort. Serum and semen were collected weekly for the first month, and biweekly thereafter for participants with detectable ZIKV RNA in any fluid and at 2, 4, and 6 months post-enrollment for all others. We used chi-squared and Fischer’s exact tests to assess if detecting ZIKV RNA in specific specimens at any point was associated with sex, age, Zika-like symptoms (rash, fever, arthralgia, or conjunctivitis), or pregnancy. We performed Weibull regression models to estimate time-to-loss of ZIKV RNA in days post symptom onset (DPO) and evaluated associations between covariates and duration of detection. Results Among 295 participants, 260 (88.1%) had ZIKV RNA detected in serum at any point. Participants aged ≥18 years (n = 244) had a significantly longer median time-to-loss of ZIKV RNA in serum than participants aged < 18 years (n = 50) (13.1 vs. 7.8 DPO, respectively; P = 0.003) (Figure 1). Among women aged 18–39 years (n = 60), pregnant women (n = 9) had a significantly longer median time-to-loss of ZIKV RNA in serum than non-pregnant women (n = 51) (37.4 vs. 15.5 DPO, respectively; P = 0.0005) (Figure 2). The proportion of men who had detectable ZIKV RNA in semen at any point was significantly higher among men with conjunctivitis (47 of 82) than among men without conjunctivitis (3 of 14) (P = 0.01). No other associations were significant. Conclusion Time-to-loss of ZIKV RNA in serum was longer among adults than children, and conjunctivitis was associated with detecting ZIKV RNA in semen. This study provides evidence that time-to-loss of ZIKV RNA is longer among pregnant women than non-pregnant women. Findings may inform the recommended period to test pregnant women for ZIKV using RT-PCR. Disclosures All authors: No reported disclosures.

From 2000 to 2011, the rate of death from unintentional drug poisoning in the USA more than doubled from 4.1 per 100,000 to 10.6 per 100,000, respectively [1]. Further, from 1999 to 2011, drug overdose deaths involving opioids quadrupled from 4030 to 16,917 [1]. Nationally, since 2009, more people have died each year from drug poisoning than from motor vehicle crashes [1]. In fact, overdose is the leading cause of adult unintentional injury death in Rhode Island, which is one of 30 states where overdose mortality exceeded motor vehicle collision mortality in 2010 [2]. The major driver of the increase in drug overdose deaths is pharmaceutical opioids. In 2010, 60 % of the unintentional drug poisoning deaths in the USA were caused by pharmaceuticals, and 75 % of the fatal pharmaceutical overdoses were caused by opioids [3]. Nationally, heroin use doubled from 2003 to 2012, and from 2002 to 2011, drug poisoning deaths involving heroin more than doubled from 2089 to 4397, respectively [4, 5]. In Rhode Island, overdose deaths caused by illicit drugs increased so much during 2011–2013 that it overtook fatal pharmaceutical overdoses, which remained steady during the same time period [6]. Fentanyl (N-(1-(2-phenethyl)-4-piperidinyl-N-phenyl-propanamide) is a synthetic opioid first synthesized by Janssen Pharmaceuticals in the 1960s and used medicinally since 1968. It is estimated to be between 80 and 100 times more potent than morphine [7, 8] and has over 200 chemical derivatives, some of which have been used recreationally or implicated in heroin adulteration in the past. The first fentanyl derivatives synthesized in the early 1970s showed similar pharmacokinetics but significantly different potencies. By the early 1980s, clandestinely produced synthetic fentanyl and fentanyl derivatives were becoming available on the black market [7, 9]. The speed of onset and potency of these drugs made them attractive to opioid users but also made them more dangerous. Fentanyl derivatives can be a few to hundreds of times more potent than heroin, and if users unknowingly obtain and administer packages sold as heroin but containing a more potent fentanyl derivative, this can lead to inadvertent overdose and death [10]. Several epidemics of overdose deaths caused by illicitly manufactured fentanyl- and fentanyl derivative-adulterated heroin have occurred in the USA since the 1970s, leaving more than 1000 dead in their wakes. The first epidemic was identified in California in 1978 and was associated with a compound later identified as the fentanyl analog 3-methylfentanyl, branded by the street name “China White.” This drug is several hundred times more potent than morphine and accounted for more than 100 deaths in California [7–9, 11]. This same drug resurfaced in 1988 in Pennsylvania, where it was implicated in the deaths of 16 persons [12, 13]. In 1991, covertly manufactured fentanyl was sold as heroin on the streets of New York City in small envelopes labeled “Tango and Cash.” Because of difficulties in cutting the drug, these samples contained highly variable amounts of fentanyl and their use resulted in 12 deaths [14]. More recently, from 2005 to 2007, an outbreak of fentanyl-contaminated heroin caused 1013 deaths across several states [15]. The Rhode Island State Health Laboratory preliminarily identified acetyl fentanyl, a fentanyl analog, as the cause of ten overdose deaths during March–April 2013. Acetyl fentanyl (N-phenyl-N-[1-(2-phenylethyl)-4-piperidinyl]-acetamide, monohydrochloride) is an illicit synthetic opioid that is four to five times more potent than heroin; it is not FDA approved, not prescribed by physicians, and not commercially available. The objectives of this investigation were to (1) determine if these drug overdose deaths represented an increase above baseline, (2) characterize the acetyl fentanyl overdose decedents, and (3) identify potential risk factors for acetyl fentanyl overdose death relative to those for other illicit drug overdose deaths.