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Gay, bisexual, and other men who have sex with men (MSM) have been disproportionately affected during the 2022 U.S. monkeypox outbreak, with Black or African American (Black) MSM being the most affected demographic group (1). As of September 28, 2022, Georgia had reported 1,784 monkeypox cases; 98% of which occurred in males and 77% among Black persons (2). As of September 13, 2022, 60% of reported cases were among persons with HIV infection, and 50% of persons with monkeypox had a sexually transmitted infection within the past year (3). Because of racial disparities in the incidence of monkeypox cases and a large proportion of cases among MSM in Georgia, early vaccination beginning in July focused on improving equitable access by establishing new and leveraging existing partnerships with community-based organizations that serve affected populations, including persons with HIV infection. Despite these efforts, disparities persisted because of high demand and limited vaccine supply. The Georgia Department of Public Health (DPH) requested CDC support for a vaccine pilot and received an additional allocation of 5,500 doses of JYNNEOS vaccine for administration at events leading up to and throughout a Black gay Pride festival in Atlanta, a multiday event held Labor Day weekend (September 2-5, 2022). The event celebrates lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and other (LGBTQIA+) communities of color and hosts more than 125,000 attendees each year. Before the festival (as of August 24), 17,546 persons had been vaccinated in Georgia, of whom 96% were male, 34% aged 25-36 years, 44% Black, and 8% Hispanic or Latino (Hispanic) (4).

Objective: Contact tracing has been used in China and several other countries in the WHO Western Pacific Region as part of the COVID-19 response. We describe COVID-19 cases and the number of contacts traced and quarantined per case as part of COVID-19 emergency public health response activities in China. Methods: We abstracted publicly available, online aggregated data published in daily COVID-19 situational reports by China’s National Health Commission and provincial health commissions between 20 January and 29 February 2020. The number of new contacts traced by report date was computed as the difference between total contacts traced in consecutive reports. A proxy for the number of contacts traced per case was computed as the number of new contacts traced divided by the number of new cases. Results: During the study period, China reported 80 968 new COVID-19 cases and 659 899 contacts. In Hubei Province, there were 67 608 cases and 264 878 contacts, representing 83% and 40% of the total, respectively. Non-Hubei provinces reported tracing 1.5 times more contacts than Hubei Province; the weekly number of contacts traced per case was also higher in non-Hubei provinces than in Hubei Province and increased from 17.2 in epidemiological week 4 to 115.7 in epidemiological week 9. Discussion: More contacts per case were reported from areas and periods with lower COVID-19 case counts. With other non-pharmaceutical interventions used in China, contact tracing and quarantining large numbers of potentially infected contacts probably contributed to reducing SARS-CoV-2 transmission.

Hepatitis C virus (HCV) infection is common in the United States and leads to significant morbidity, mortality, and economic costs. Simplified screening recommendations and highly effective direct-acting antivirals for HCV present an opportunity to eliminate HCV. The objective of this study was to increase testing, linkage to care, treatment, and cure of HCV. This was an observational, prospective, population-based intervention program carried out between September 2014 and September 2018 and performed in three community health centers, three large multiclinic health care systems, and an HCV patient education and advocacy group in King County, WA. There were 232,214 patients included based on criteria of documented HCV-related diagnosis code, positive HCV laboratory test or prescription of HCV medication, and seen at least once at a participating clinical site in the prior year. Electronic health record (EHR) prompts and reports were created. Case management linked patients to care. Primary care providers received training through classroom didactics, an online curriculum, specialty clinic shadowing, and a telemedicine program. The proportion of baby boomer patients with documentation of HCV testing increased from 18% to 54% during the project period. Of 77,577 baby boomer patients screened at 87 partner clinics, 2,401 (3%) were newly identified HCV antibody positive. The number of patients staged for treatment increased by 391%, and those treated increased by 1,263%. Among the 79% of patients tested after treatment, 95% achieved sustained virologic response. Conclusion: A combination of EHR-based health care system interventions, active linkage to care, and clinician training contributed to a tripling in the number of patients screened and a more than 10-fold increase of those treated. The interventions are scalable and foundational to the goal of HCV elimination.

BACKGROUND: Data are limited on the economic burden of seasonal influenza in China. We estimated the cost due to influenza illness among children < 5-year-old in Suzhou, China. METHODS: This study adopted a societal perspective to estimate direct medical cost, direct non-medical cost, and indirect cost related to lost productivity. Data to calculate costs and rates of three influenza illness outcomes (non-medically attended, outpatient and hospitalization) were collected from prospective community-based cohort studies and hospital-based enhanced laboratory-confirmed influenza surveillance in Suzhou during the 2011/12 to 2016/17 influenza seasons. We used mean cost-per-episode, annual incidence rates of episodes of each outcome, and annual population size to estimate the total annual economic burden of influenza illnesses among children < 5-year-old for Suzhou. All costs were reported in 2017 U.S. dollars. RESULTS: The mean cost-per-episode (standard deviation) was $9.92 (13.26) for non-medically attended influenza, $161.05 (176.98) for influenza outpatient illnesses, and $1425.95 (603.59) for influenza hospitalizations. By applying the annual incidence rates to the population size, we estimated an annual total of 4,919 episodes of non-medically attended influenza, 21,994 influenza outpatient, and 2,633 influenza hospitalization. Total annual economic burden of influenza to society among children < 5-year-old in Suzhou was $7.37 (95% confidence interval, 6.9–7.8) million, with estimated costs for non-medically attended influenza of $49,000 (46,000–52,000), influenza outpatients $3.5 (3.3–3.8) million, and influenza hospitalizations $3.8 (3.6–3.9) million. Among outpatients, the indirect cost was 36.3% ($1.3 million) of total economic burden, accounting for 21,994 days of lost productivity annually. Among inpatients, the indirect cost was 22.1% ($829,000), accounting for 18,431 days of lost productivity annually. CONCLUSIONS: Our findings show that influenza in children < 5-year-oldcauses substantial societal economic burden in Suzhou, China. Assessing the potential economic benefit of increasing influenza vaccination coverage in this population is warranted.

In 2014, trained health care provider capacity was insufficient to deliver care to an estimated 70,000 persons in Maryland with chronic hepatitis C virus (HCV) infection. The goal of Maryland Community Based Programs to Test and Cure Hepatitis C, a public health implementation project, was to improve HCV treatment access by expanding the workforce. Sharing the Cure (STC) was a package of services deployed 10/1/14 to 9/30/18 that included enhanced information technology and public health infrastructure, primary care provider training, and practice transformation. Nine primary care sites enrolled. HCV clinical outcomes were documented among individuals who presented for care at sites and met criteria for HCV testing including risk factor or birth cohort (born between 1945 and 1965) based testing. Fifty-three providers completed the STC training. STC providers identified 3,237 HCV antibody positive patients of which 2,624 (81%) were RNA+. Of those HCV RNA+, 1,739 (66%) were staged, 932 (36%) were prescribed treatment, 838 (32%) started treatment, 721 (28%) completed treatment, and 543 (21%) achieved cure. Among 1,739 patients staged, 693 (40%) patients had a liver fibrosis assessment score < F2, rendering them ineligible for treatment under Maryland Medicaid guidelines. HCV RNA testing among HCV antibody positive people increased from 40% (baseline) to 95% amongst STC providers. Of 554 patients with virologic data reported, 543 (98%) achieved cure. Primary care practices can effectively serve as HCV treatment centers to expand treatment access. However, criteria by insurance providers in Maryland was a major barrier to treatment.

An estimated 4.1 million people in the United States are infected with hepatitis C virus (HCV). In 2014, the Hepatitis C Community Alliance to Test and Treat (HepCCATT) collaborative was formed to address hepatitis C in Chicago. From 2014 to 2017, the HepCCATT Case Management Program case managed 181 HCV-infected people and performed on-site capacity building at a 6-site community health center (CHC) that produced codified protocols, which were translated into a telehealth program to build capacity within CHCs to deliver hepatitis C care. HepCCATT's innovative approach to addressing multilevel barriers is a potential model for increasing access to hepatitis C care and treatment.

Hepatitis C virus (HCV) infection is a public health threat. The electronic health record (EHR) can be used to monitor patients along the HCV cure cascade and highlight opportunities for interventions to improve cascade outcomes. We developed an HCV patient registry using data from Grady Health System's (GHS) EHR and performed a cross-sectional analysis of 72 745 GHS patients who received anti-HCV testing from 2004 to 2016. We created a testing cascade: (1) anti-HCV reactive, (2) HCV RNA tested and (3) HCV RNA detectable; and a cure cascade: (1) HCV RNA detectable, (2) engaged in care, (3) treatment prescribed, (4) sustained virologic response (SVR) tested and (5) SVR documented. A total of 9893 (14%) had reactive anti-HCV tests of 72 745 patients tested, 5109 (52%) of these had HCV RNA tested, and 4224 (43%) were HCV RNA detectable. A total of 2738 (65%) of 4224 with detectable RNA were engaged in care, 909 (22%) were prescribed antiviral therapy, and 354 (8%) achieved SVR. Factors associated with HCV treatment included cirrhosis, tobacco use, depression, diabetes, obesity, alcohol use, male gender, black race and Medicare insurance. Uninsured patients were significantly less likely to be prescribed HCV treatment. In conclusion, using EHR data, we identified high anti-HCV prevalence and noted gaps in HCV RNA testing, linkage to care and treatment. The EHR can be used to evaluate the effectiveness of targeted interventions to overcome these gaps.

BACKGROUND Data on influenza incidence during pregnancy in China are limited. METHODS From October 2015 to September 2018, we conducted active surveillance for acute respiratory illness (ARI) among women during pregnancy. Nurses conducted twice weekly phone and text message follow-up upon enrollment until delivery to identify new episodes of ARI. Nasal and throat swabs were collected ≤10 days from illness onset to detect influenza. RESULTS In total, we enrolled 18 724 pregnant women median aged 28 years old, 37% in first trimester, 48% in second trimester, and 15% in third trimester, with seven self-reported influenza vaccination during pregnancy. In the 18-week epidemic period during October 2015 to September 2016, influenza incidence was 0.7/100 person-months (95% CI: 0.5-0.9). In the cumulative 29-week-long epidemic during October 2016 to September 2017, influenza incidence was 1.0/100 person-months (95% CI: 0.8-1.2). In the 11-week epidemic period during October 2017 to September 2018, influenza incidence was 2.1/100 person-months (95% CI: 1.9-2.4). Influenza incidence was similar by trimester. More than half of the total influenza illnesses had no elevated temperature and cough. Most influenza-associated ARIs were mild, and

Background: Data on influenza incidence during pregnancy in China are limited. Methods: From October 2015–September 2018, we conducted active surveillance for acute respiratory illness (ARI) among women during pregnancy. Nurses conducted twice weekly phone and text message follow-up upon enrollment until delivery to identify new episodes of ARI. Nasal and throat swabs were collected ≤10 days from illness onset to detect influenza. Results: In total, we enrolled 18,724 pregnant women median aged 28yo, 37% in first trimester, 48% in second trimester and 15% in third trimester, with 7 self-reported vaccination during pregnancy. In the 18-week epidemic period during October 2015–September 2016, influenza incidence was 0.7/100 person-months (95% CI:0.5–0.9). In the 29-week epidemic during October 2016–September 2017, influenza incidence was 1.0/100 person-months (95% CI:0.8–1.2). In the 11-week epidemic period during October 2017–September 2018, influenza incidence was 2.1/100 person-months (95% CI:1.9–2.4). Influenza incidence was similar by trimester. More than half of the total influenza illnesses had no elevated temperature and cough. Most influenza-associated ARIs were mild, and

Almost 100 years after the 1918 influenza pandemic, China experienced its largest, most widespread epidemic of human infections with avian influenza A (H7N9), the influenza virus with the greatest pandemic potential of all influenza viruses assessed to date by the United States Centers for Disease Control and Prevention’s Influenza Risk Assessment Tool. This historical review describes how China was affected by the 1918, 1958, 1968, and 2009 influenza pandemics, records milestones in China’s capacity to detect and respond to influenza threats, and identifies remaining challenges for pandemic preparedness. This review suggests that past influenza pandemics have improved China’s national capabilities such that China has become a global leader in influenza detection and response. Further enhancing China’s pandemic preparedness to address remaining challenges requires government commitment and increased investment in China’s public health and healthcare systems.

The structure of electronic medical record data prevents easy population-level monitoring of hepatitis C virus (HCV) treatment uptake and cure. Using an HCV registry from a public hospital system in Atlanta, Georgia, we developed multiple algorithms that use serial HCV RNA test results as proxy measures for initiation of direct-acting antiviral (DAA) treatment and sustained virological response (SVR). We calculated sensitivity and positive predictive values (PPVs) by comparing the algorithms with the DAA initiation and SVR results from the registry. From December 2013 to August 2016, 1,807 persons actively infected with HCV were identified in the registry. Of those, 698 initiated DAA treatment on the basis of medical record abstraction; of 442 patients with treatment start and/or end dates, 314 had documented SVR. Treatment algorithm 2 (a detectable HCV RNA result followed by 2 sequential HCV RNA test results) and treatment algorithm 5 (a detectable HCV RNA result followed by 2 sequential HCV RNA test results >6 weeks apart) had the highest sensitivity (87% and 85%, respectively) and PPV (80% and 82%, respectively) combinations. Four SVR algorithms relied on fulfilling treatment algorithm definitions and having an undetectable HCV RNA test result ≥12 weeks after the last HCV RNA result; sensitivity for all 4 algorithms was 79%, and PPV was 92%-93%. Algorithms using serial quantitative HCV RNA results can serve as proxy measures for evaluating population-level DAA treatment and SVR outcomes.

AIM To investigate hepatitis C virus (HCV) testing recommendations from the United States and other high-income countries. METHODS A comprehensive search for current HCV testing recommendations from the top quartile of United Nations Human Development Index (HDI) countries (very high HDI) was performed using Google and reviewed from May 1 - October 30, 2014 and re-reviewed April 1 - October 2, 2017. RESULTS Of the 51 countries identified, 16 had HCV testing recommendations from a government body or recommendations issued collaboratively between a government and a medical organization. Of these 16 countries, 15 had HCV testing recommendations that were primarily risk-based and highlight behaviors, exposures, and conditions that are associated with HCV transmission in that region. In addition to risk-based testing, the HCV Guidance Panel (United States) incorporates recommendations for a one-time test for individuals born during 1945-1965 (the birth cohort) without prior ascertainment of risk into their guidance. In addition to the United States, six other countries either have an age-based testing recommendation or recommend one-time testing for all adults independent of risk factors typical of the region. CONCLUSION This review affirmed the similarities of the HCV Guidance Panel’s guidance with those of recommendations from very high HDI countries.

ObjectiveAlthough contact tracing is generally not used to control influenza pandemics, China and several countries in the Western Pacific Region employed contact tracing as part of COVID-19 response activities. To improve understanding on the use of contact tracing for COVID-19 emergency public health response activities, we describe reported COVID-19 contacts traced and quarantined in China and a proxy for number of reported contacts traced per reported case.MethodsWe abstracted publicly available online aggregate data reported from China’s National Health Commission and provincial health commissions’ COVID-19 daily situational reports for January 20–February 29, 2020. The number of new contacts traced by report date was computed as the difference between total contacts traced on consecutive reports. A proxy for the number of contacts traced per case was computed as the number of new contacts traced divided by the number of new cases.ResultsDuring January 20–February 29, 2020, China reported 80,968 new COVID-19 cases (Hubei Province = 67,608 [83%]), and 659,899 contacts traced (Hubei Province = 265,617 [40%]). Non-Hubei provinces reported more contacts traced per case than Hubei Province; this difference increased over time.DiscussionAlong with other NPI used in China, contact tracing likely contributed to reducing SARS-CoV-2 transmission by quarantining a large number of potentially infected contacts. Despite reporting only 15% of total cases, non-Hubei provinces had 1.5 times more reported contacts traced compared to Hubei Province. Contract tracing may have been more complete in areas and periods with lower case counts.

Background There are few estimates of vaccination-averted influenza-associated illnesses in China. Methods We used a mathematical model and Monte Carlo algorithm to estimate numbers and 95% confidence intervals (CI) of influenza-associated outcomes (hospitalization, illness, and medically-attended (MA) illness) averted by vaccination among children aged 6–59 months in Suzhou from October 2011–September 2016. Influenza illnesses included non-hospitalized MA influenza illnesses and non-MA influenza illnesses. The numbers of influenza-associated outcomes averted by vaccination were the difference between the expected burden if there were no vaccination given and the observed burden with vaccination. The model incorporated the disease burden estimated based on surveillance data from Suzhou University Affiliated Children’s Hospital (SCH) and data from health utilization surveys conducted in the catchment area of SCH, age-specific estimates of influenza vaccination coverage in Suzhou from the Expanded Program on Immunization database, and influenza vaccine effectiveness estimates from previous publications. Averted influenza estimations were presented as absolute numbers and in terms of the prevented fraction (PF). A hypothetical scenario with 50% coverage (but identical vaccine effectiveness) over the study period was also modeled. Results In ~250,000 children, influenza vaccination prevented an estimated 731 (CI: 549–960) influenza hospitalizations (PF: 6.2% of expected, CI: 5.8–6.6%) and 10,024 (7593–12,937) influenza illnesses (PF: 6.5%, 6.4–6.7%), of which 8342 (6338–10,768) were MA (PF: 6.6%, 6.4–6.7%) from 2011 to 2016. The PFs declined each year along with decreasing influenza vaccination coverage. If 50% of the study population had been vaccinated over time, the estimated numbers of averted cases during the study period would have been 4059 (3120–5762) influenza hospitalizations (PF: 27.2%, 26.4–27.9%) and 56,215 (42,925–78,849) influenza illnesses (PF: 28.5%, 28.3–28.7%), of which 46,596 (35,662–65,234) would be MA (PF: 28.5%, 28.3–28.7%). Conclusion Influenza vaccination is estimated to have averted influenza-associated illness outcomes even with low coverage in children aged 6–59 months in Suzhou. Increasing influenza vaccination coverage in this population could further reduce illnesses and hospitalizations.

Introduction: With the goal of eliminating hepatitis C virus (HCV) as a public health problem in Washington State, Public Health–Seattle & King County (PHSKC) designed a Hepatitis C Virus Test and Cure (HCV-TAC) data system to integrate surveillance, clinical, and laboratory data into a comprehensive database. The intent of the system was to promote identification, treatment, and cure of HCV-infected persons (ie, HCV care cascade) using a population health approach. Materials and Methods: The data system automatically integrated case reports received via telephone and fax from health care providers and laboratories, hepatitis test results reported via electronic laboratory reporting, and data on laboratory and clinic visits reported by 6 regional health care systems. PHSKC examined patient-level laboratory test results and established HCV case classification using Council of State and Territorial Epidemiologists criteria, classifying patients as confirmed if they had detectable HCV RNA. Results: The data enabled PHSKC to report the number of patients at various stages along the HCV care cascade. Of 7747 HCV RNA-positive patients seen by a partner site, 5377 (69%) were assessed for severity of liver fibrosis, 3932 (51%) were treated, and 2592 (33%) were cured. Practice Implications: Data supported local public heath surveillance and HCV program activities. The data system could serve as a foundation for monitoring future HCV prevention and control programs.

Background During the 2014-2015 US influenza season, 320 cases of non-mumps parotitis (NMP) among residents of 21 states were reported to the Centers for Disease Control and Prevention (CDC). We conducted an epidemiologic and laboratory investigation to determine viral etiologies and clinical features of NMP during this unusually large occurrence. Methods NMP was defined as acute parotitis or other salivary gland swelling of >2 days duration in a person with a mumps- negative laboratory result. Using a standardized questionnaire, we collected demographic and clinical information. Buccal samples were tested at the CDC for selected viruses, including mumps, influenza, human parainfluenza viruses (HPIVs) 1-4, adenoviruses, cytomegalovirus, Epstein-Barr virus (EBV), herpes simplex viruses (HSVs) 1 and 2, and human herpes viruses (HHVs) 6A and 6B. Results Among the 320 patients, 65% were male, median age was 14.5 years (range, 0-90), and 67% reported unilateral parotitis. Commonly reported symptoms included sore throat (55%) and fever (48%). Viruses were detected in 210 (71%) of 294 NMP patients with adequate samples for testing, ≥2 viruses were detected in 37 samples, and 248 total virus detections were made among all samples. These included 156 influenza A(H3N2), 42 HHV6B, 32 EBV, 8 HPIV2, 2 HPIV3, 3 adenovirus, 4 HSV-1, and 1 HSV-2. Influenza A(H3N2), HHV6B, and EBV were the most frequently codetected viruses. Conclusions Our findings suggest that, in addition to mumps, clinicians should consider respiratory viral (influenza) and herpes viral etiologies for parotitis, particularly among patients without epidemiologic links to mumps cases or outbreaks.

Monitoring hepatitis B surveillance data is important for evaluating progress towards global hepatitis B elimination goals. Accurate classification of acute and chronic hepatitis infections is essential for assessing program effectiveness. We evaluated hepatitis B case-reporting at six hospitals in Fujian, Hainan and Gansu provinces in 2015 to assess the accuracy of case classification. We linked National Notifiable Disease Reporting System (NNDRS) HBV case-reports with hospital information systems and extracted information on age, gender, admission ward and viral hepatitis diagnosis from medical records. To assess accuracy, we compared NNDRS reported case-classifications with the national HBV case definitions. Multivariable logistic regression was used to identify factors associated with misclassification. Of the 1420 HBV cases reported to NNDRS, 23 (6.5%) of the 352 acute reports and 648 (60.7%) of the 1068 chronic reports were correctly classified. Of the remaining, 318 (22.4%) were misclassified and 431 (30.4%) could not be classified due to the lack of supporting information. Based on the multivariable analysis, HBV cases reported from Hainan (aOR = 1.8; 95% CI: 1.3–2.4) and Gansu (aOR = 12.7; 95% CI: 7.7–20.1) along with reports from grade 2 hospitals (aOR = 1.6; 95% CI:1.2–2.2) and those from non-HBV related departments (aOR = 5.3; 95% CI: 4.1–7.0) were independently associated with being ‘misclassified’ in NNDRS. We identified discrepancies in the accuracy of HBV case-reporting in the project hospitals. Onsite training on the use of anti-HBc IgM testing as well as on HBV case definitions and reporting procedures are needed to accurately assess program effectiveness and ensure case-patients are referred to appropriate treatment and care. Routine surveillance evaluations such as this can be useful for improving data quality and monitoring program effectiveness.

Background Live attenuated influenza vaccine (LAIV) is safe in healthy children ⩾2 years. The original clinical trials excluded individuals with underlying conditions; however, post-marketing data suggest LAIV may be safe for these populations. Methods We analyzed MarketScan Commercial Claims Databases from 2010 to 2012 to describe hospitalizations within 14 days of vaccination among LAIV recipients. We evaluated LAIV recipients aged 2–18 years and defined underlying conditions by presence of inpatient or outpatient ICD-9 code during the previous calendar year. We excluded asthma and immunocompromising conditions. We defined risk windows as 1–7 days and 8–14 days after vaccination; the control period was 12–4 days prior to and 15–23 days after vaccination. We conducted a self-controlled case series analysis using a conditional Poisson regression model to estimate incidence-rate ratios (IRR). Results 1,216,123 children aged 2–18 years received LAIV from 2010 to 2012. 634 children met our inclusion criteria and were hospitalized during the observation period (12 days prior to vaccination to 23 days after vaccination). Of those hospitalized, 72 (11.4%) had non-asthma, non-immunocompromising underlying conditions. Children with non-asthma, non-immunocompromising underlying conditions had an all-cause hospitalization IRR of 1.1 (95% CI 0.6–2.0, p = 0.83) in the 1–7 day risk period and 0.9 (95% CI 0.4–1.7, p = 0.67) in the 8–14 day risk period. Children with no underlying conditions had an all-cause hospitalization IRR of 0.9 (0.8–1.2, p = 0.60) in the 1–7 day risk period and 1.1 (95% CI 0.9–1.3, p = 0.53) in the 8–14 day risk period. There were no differences in all-cause hospitalization risk in individuals with non-asthma, non-immunocompromising underlying conditions compared to those without underlying conditions in the 1–7 day (p = 0.88) or 8–14 day (p = 0.24) risk period. Conclusions We found no evidence of differences in post-LAIV hospitalization risk among children with non-asthma, non-immunocompromising underlying conditions compared to healthy children.

Hepatitis C (HCV) and HIV have common modes of transmission but information about HCV transmission risk, prevention, and treatment among persons with coinfection is lacking. The Medical Monitoring Project produces nationally representative estimates describing adults with diagnosed HIV in the United States. Using medical record data recorded during 6/2013-5/2017, we identified persons with detectable HCV RNA documented during the past 24 months. Among persons with coinfection, we described HCV transmission risk factors and receipt of HCV prevention services during the past 12 months and prescription of HCV treatment during the past 24 months. Overall, 4.9% had documented active HCV coinfection, among whom 30.2% were men who have sex with men (MSM), 6.7% reported injection drug use, and 62.1% were prescribed HCV treatment. Among MSM, 45.5% reported condomless anal sex and 42.3% received free condoms. Among persons who used drugs, 30.8% received drug or alcohol counseling, and among persons who injected drugs, 79.2% received sterile syringes. Among persons with HIV/HCV coinfection, recent drug injection was uncommon and most received sterile syringes. However, 1 in 3 were MSM, of whom half reported recent HCV sexual transmission risk behaviors. More than one-third of those with coinfection were not prescribed curative HCV treatment.

Background We sought to assess reporting in China’s Pneumonia of Unknown Etiology (PUE) passive surveillance system for emerging respiratory infections and to identify ways to improve the PUE surveillance system’s detection of respiratory infections of public health significance. Methods From February 29–May 29, 2016, we actively identified and enrolled patients in two hospitals with acute respiratory infections (ARI) that met all PUE case criteria. We reviewed medical records for documented exposure history associated with respiratory infectious diseases, collected throat samples that were tested for seasonal and avian influenza, and interviewed clinicians regarding reasons for reporting or not reporting PUE cases. We described and analyzed the proportion of PUE cases reported and clinician awareness of and practices related to the PUE system. Results Of 2619 ARI admissions in two hospitals, 335(13%) met the PUE case definition; none were reported. Of 311 specimens tested, 18(6%) were seasonal influenza virus-positive; none were avian influenza-positive.

Introduction The Cherokee Nation Comprehensive Cancer Control Program collaborated with the Cherokee Nation Hepatitis C Virus (HCV) Elimination Program within Cherokee Nation’s Health Services to plan and implement activities to increase knowledge and awareness of liver cancer prevention among health care providers and the Cherokee Nation community. From August 2017 to April 2018, the 2 programs implemented liver cancer prevention interventions that focused on education of health care providers and community members. We used descriptive statistics to analyze data collected from a brief, retrospective pre–post survey for each intervention. We assessed overall awareness and knowledge of liver cancer and ability and intention to address it on a scale of 1 to 5. Project Extension for Community Healthcare Outcomes didactic sessions resulted in a 1.1-point improvement, provider education workshops resulted in a 1.4-point improvement, and presentations at community coalition meetings resulted in a 1.7-point improvement. Our study shows that HCV interventions can be used by public health and medical professionals interested in controlling HCV and related diseases such as liver cancer.

Background Hepatitis B virus (HBV) infection testing among persons with hepatitis C virus (HCV) infection is necessary to appropriately care for these patients, yet uptake of HBV testing and vaccination in this population is suboptimal. Methods In a retrospective cohort analysis, we describe the prevalence of hepatitis B testing, linkage to hepatitis B care, and hepatitis B vaccination in patients with HCV infection within a large urban safety-net health system. Using a registry of HCV-infected patients with patient-level electronic health record data, that included demographic, clinical, and laboratory information from 2004 to 2016 from Grady Health System in Atlanta, GA, we describe (1) The prevalence of hepatitis B testing (hepatitis B surface antigen [HBsAg], core antibody [anti-HBc], surface antibody [anti-HBs]); (2) The proportion of HBsAg-positive persons receiving HBV DNA and e-antigen (HBeAg) as indicators for linkage to hepatitis B-directed care; and (3) The proportion of persons receiving hepatitis B vaccine. Results Of 4224 HCV-infected patients, 3629 (86%) had test results for HBsAg and 43 (1.2%) were HBsAg-positive. Of 2342 (55%) with test results for all three HBV serological markers, median age was 60 years, 67% were male, and 83% were African-American, 789 (34%) anti-HBc positive only, 678 (29%) anti-HBc/anti-HBs positive, 190 (8.1%) anti-HBs positive only, and 642 (27%) were HBV-susceptible. Of HBsAg-positive patients, 21% received HBV DNA and 40% HBeAg testing. The proportion of HBV-susceptible patients receiving at least 1 dose of hepatitis B vaccine was 322/642 (50%). Conclusions In a large cohort of HCV-infected patients, we found a high prevalence of current or past HBV infection, but there were gaps in complete hepatitis B testing, hepatitis B-directed care, and hepatitis B vaccination. Strategies are needed to increase hepatitis B testing, linkage to care, and administration of the hepatitis B vaccine for HCV-infected persons in this healthcare system.

INTRODUCTION: Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are risk factors for hepatocellular carcinoma, a type of primary liver cancer, and are most prevalent in people born 1945–1965. Relatively little information is available for liver cancer prevention, compared to other cancers. In this review, we provide a summary of current promising public health practices for liver cancer prevention from the literature, as well as liver cancer-related initiatives in the National Comprehensive Cancer Control Program (NCCCP). METHODS: Two types of source materials were analyzed for this review: published literature (2005-present), and current cancer plans from the NCCCP (2005–2022). A search strategy was developed to include a review of several scientific databases. Of the 73 articles identified as potentially eligible, 20 articles were eligible for inclusion in the review. Eligible articles were abstracted using a data abstraction tool. Three independent keyword searches on 65 NCCCP plans were conducted. Keyword searches within each of the plans to identify activities related to liver cancer were conducted. Relevant information was abstracted from the plans and saved in a data table. RESULTS: Of the 20 eligible articles, 15 articles provided information on interventions related to liver cancer and hepatitis B or hepatitis C prevention. All 15 of the intervention articles were related to hepatitis; 13 were hepatitis B-focused, two were hepatitis C-focused, and 14 focused on Asian/Pacific Islander American populations. The independent keyword search of NCCCP plans produced 46 results for liver, 27 results for hepatitis, and 52 results for alcohol. Two plans included activities related to liver cancer. Twenty-four plans included activities related to hepatitis. DISCUSSION: A majority of the intervention articles published focused on HBV infection in Asian/Pacific Islander American populations, and a small percentage of NCCCP plans included liver-related content. The findings from this review will inform the development of an Action Plan on liver cancer prevention for the NCCCP, which will assist programs with the adoption and uptake of promising practices for the prevention of liver cancer.

The country of Georgia initiated an ambitious national hepatitis C elimination program. To facilitate elimination, a national hospital hepatitis C screening program was launched in November 2016, offering all inpatients screening for HCV infection. This analysis assesses the effectiveness of the first year of the screening program to identify HCV-infected persons and link them to care. Data from Georgia's electronic Health Management Information System and ELIMINATION-C treatment database were analyzed for patients aged ≥18 years hospitalized from November 1, 2016 to October 31, 2017. We described patient characteristics and screening results and compared linked-to-care patients to those not linked to care, defined as having a test for viremia following an HCV antibody (anti-HCV) positive hospital screening. Of 291,975 adult inpatients, 252,848 (86.6%) were screened. Of them, 4.9% tested positive, with a high of 17.4% among males aged 40-49. Overall, 19.8% of anti-HCV+ patients were linked to care, which differed by sex (20.6% for males vs. 18.4% for females; p = .019), age (23.9% for age 50-59 years vs. 10.7% for age ≥ 70 years; p .0001), and length of hospitalization (21.8% among patients hospitalized for 1 day vs. 16.1% for those hospitalized 11+ days; p = .023). Redundant screening is a challenge; 15.6% of patients were screened multiple times and 27.6% of anti-HCV+ patients had a prior viremia test. This evaluation demonstrates that hospital-based screening programs can identify large numbers of anti-HCV+ persons, supporting hepatitis C elimination. However, low linkage-to-care rates underscore the need for screening programs to be coupled with effective linkage strategies.

Background During the 2014-2015 influenza season in the United States, 256 cases of influenza-associated parotitis were reported from 27 states. We conducted a case-control study and laboratory investigation to further describe this rare clinical manifestation of influenza. Methods During February 2015-April 2015, we interviewed 50 cases (with parotitis) and 124 ill controls (without parotitis) with laboratory-confirmed influenza; participants resided in 11 states and were matched by age, state, hospital admission status, and specimen collection date. Influenza viruses were characterized using real-time polymerase chain reaction and next-generation sequencing. We compared cases and controls using conditional logistic regression. Specimens from additional reported cases were also analyzed. Results Cases, 73% of whom were aged

Adjusting for diagnostic test sensitivity enables more accurate and timely comparisons over time., Diagnostic test sensitivity affects rate estimates for laboratory-confirmed influenza–associated hospitalizations. We used data from FluSurv-NET, a national population-based surveillance system for laboratory-confirmed influenza hospitalizations, to capture diagnostic test type by patient age and influenza season. We calculated observed rates by age group and adjusted rates by test sensitivity. Test sensitivity was lowest in adults >65 years of age. For all ages, reverse transcription PCR was the most sensitive test, and use increased from 65 years. After 2009, hospitalization rates adjusted by test sensitivity were ≈15% higher for children 65 years of age. Test sensitivity adjustments improve the accuracy of hospitalization rate estimates.

Restrictive policies on access to new, curative hepatitis C treatments represent a substantial barrier to treating patients infected with hepatitis C. This case series demonstrates challenges experienced by patients and practitioners in accessing these treatments and highlights several strategies for navigating the treatment preauthorization process.

This review highlights key studies and recently published data, policies, and recommendations related to hepatitis C virus (HCV) epidemiology, transmission, and treatment.HCV is a leading cause of liver-related deaths, cirrhosis, and hepatocellular carcinoma. Since 2011 and accelerating since 2013, new, safe, tolerable, and curative therapies have considerably altered clinical and public health frameworks related to the prevention, control and clinical management of HCV. Nevertheless, there are several populations in the United States that are important to consider because of disparities in HCV prevalence and transmission risk. Adults born during 1945-1965 have an estimated anti-HCV antibody prevalence of ~3%, which is six times higher than among other adults, are often unaware of their infections, and are at increased risk of having HCV-associated morbidity and mortality from decades of chronic infection. Since the early 2000s, increasing incidence of acute HCV infections among young, white, non-urban people who inject drugs have been reported. Despite promising therapeutic advances, significant challenges remain for reducing HCV-associated morbidity and mortality.The high burden of HCV and significant health consequences associated with chronic infection make HCV a critical public health priority. Advances in HCV treatment have created new opportunities for reducing HCV-associated morbidity and mortality. These treatments are safe, well-tolerated, and highly effective; however, benefits cannot be realized without a significant increase in the number of persons tested for HCV so that all chronically infected individuals can be aware of their diagnosis and linked to appropriate clinical care.

Public health investigations can require intensive collaboration between numerous governmental and nongovernmental organizations. We describe an investigation involving several governmental and nongovernmental partners that was successfully planned and performed in an organized, comprehensive, and timely manner with several governmental and nongovernmental partners.

Background Acute lower respiratory tract infections (LRTI) are a frequent cause of hospitalization and mortality in South Africa; however, existing respiratory severity scores may underestimate mortality risk in HIV-infected adults in resource limited settings. A simple predictive clinical score for low-resource settings could aid healthcare providers in the management of patients hospitalized with LRTI. Methods We analyzed 1,356 LRTI hospitalizations in adults aged ≥18 years enrolled in Severe Acute Respiratory Illness (SARI) surveillance in three South African hospitals from January 2010 to December 2011. Using demographic and clinical data at admission, we evaluated potential risk factors for in-hospital mortality. We evaluated three existing respiratory severity scores, CURB-65, CRB-65, and Classification Tree Analysis (CTA) Score assessing for discrimination and calibration. We then developed a new respiratory severity score using a multivariable logistic regression model for in-hospital mortality and assigned points to risk factors based on the coefficients in the multivariable model. Finally we evaluated the model statistically using bootstrap resampling techniques. Results Of the 1,356 patients hospitalized with LRTI, 101 (7.4%) died while hospitalized. The CURB-65, CRB-65, and CTA scores had poor calibration and demonstrated low discrimination with c-statistics of 0.594, 0.548, and 0.569 respectively. Significant risk factors for in-hospital mortality included age ≥ 45 years (A), confusion on admission (C), HIV-infection (H), and serum blood urea nitrogen >7 mmol/L (U), which were used to create the seven-point ACHU clinical predictor score. In-hospital mortality, stratified by ACHU score was: score ≤1, 2.4%, score 2, 6.4%, score 3, 11.9%, and score ≥ 4, 29.3%. Final models showed good discrimination (c-statistic 0.789) and calibration (chi-square 1.6, Hosmer-Lemeshow goodness-of-fit p-value = 0.904) and discriminated well in the bootstrap sample (average optimism of 0.003). Conclusions Existing clinical predictive scores underestimated mortality in a low resource setting with a high HIV burden. The ACHU score incorporates a simple set a risk factors that can accurately stratify patients ≥18 years of age with LRTI by in-hospital mortality risk. This score can quantify in-hospital mortality risk in an HIV-endemic, resource-limited setting with limited clinical information and if used to facilitate timely treatment may improve clinical outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s12890-017-0368-8) contains supplementary material, which is available to authorized users.

Chikungunya spread throughout the Dominican Republic (DR) after the first identified laboratory-confirmed cases were reported in April 2014. In June 2014, a U.S.-based service organization operating in the DR reported chikungunya-like illnesses among several staff. We assessed the incidence of chikungunya virus (CHIKV) and dengue virus (DENV) infection and illnesses and evaluated adherence to mosquito avoidance measures among volunteers/staff deployed in the DR who returned to the United States during July-August 2014. Investigation participants completed a questionnaire that collected information on demographics, medical history, self-reported illnesses, and mosquito exposures and avoidance behaviors and provided serum for CHIKV and DENV diagnostic testing by reverse transcription polymerase chain reaction and IgM enzyme-linked immunosorbent assay. Of 102 participants, 42 (41%) had evidence of recent CHIKV infection and two (2%) had evidence of recent DENV infection. Of the 41 participants with evidence of recent CHIKV infection only, 39 (95%) reported fever, 37 (90%) reported rash, and 37 (90%) reported joint pain during their assignment. All attended the organization's health trainings, and 89 (87%) sought a pretravel health consultation. Most (∼95%) used insect repellent; however, only 30% applied it multiple times daily and < 5% stayed in housing with window/door screens. In sum, CHIKV infections were common among these volunteers during the 2014 chikungunya epidemic in the DR. Despite high levels of preparation, reported adherence to mosquito avoidance measures were inconsistent. Clinicians should discuss chikungunya with travelers visiting areas with ongoing CHIKV outbreaks and should consider chikungunya when diagnosing febrile illnesses in travelers returning from affected areas.

The Ebola virus disease (Ebola) outbreak in West Africa has claimed approximately 11,300 lives (1), and the magnitude and course of the epidemic prompted many nonaffected countries to prepare for Ebola cases imported from affected countries. In October 2014, CDC and the Department of Homeland Security (DHS) implemented enhanced entry risk assessment and management at five U.S. airports: John F. Kennedy (JFK) International Airport in New York City (NYC), O'Hare International Airport in Chicago, Newark Liberty International Airport in New Jersey, Hartsfield-Jackson International Airport in Atlanta, and Dulles International Airport in Virginia (2). Enhanced entry risk assessment began at JFK on October 11, 2014, and at the remaining airports on October 16 (3). On October 21, DHS exercised its authority to direct all travelers flying into the United States from an Ebola-affected country to arrive at one of the five participating airports. At the time, the Ebola-affected countries included Guinea, Liberia, Mali, and Sierra Leone. On October 27, CDC issued updated guidance for monitoring persons with potential Ebola virus exposure (4), including recommending daily monitoring of such persons to ascertain the presence of fever or symptoms for a period of 21 days (the maximum incubation period of Ebola virus) after the last potential exposure; this was termed "active monitoring." CDC also recommended "direct active monitoring" of persons with a higher risk for Ebola virus exposure, including health care workers who had provided direct patient care in Ebola-affected countries. Direct active monitoring required direct observation of the person being monitored by the local health authority at least once daily (5). This report describes the operational structure of the NYC Department of Health and Mental Hygiene's (DOHMH) active monitoring program during its first 6 months (October 2014-April 2015) of operation. Data collected on persons who required direct active monitoring are not included in this report.

To describe and compare the clinical characteristics, outcomes, and etiology of pneumonia among children hospitalized with community-acquired pneumonia (CAP) with neurologic disorders, non-neurologic underlying conditions, and no underlying conditions.Children18 years old hospitalized with clinical and radiographic CAP were enrolled at 3 US children's hospitals. Neurologic disorders included cerebral palsy, developmental delay, Down syndrome, epilepsy, non-Down syndrome chromosomal abnormalities, and spinal cord abnormalities. We compared the epidemiology, etiology, and clinical outcomes of CAP in children with neurologic disorders with those with non-neurologic underlying conditions, and those with no underlying conditions using bivariate, age-stratified, and multivariate logistic regression analyses.From January 2010-June 2012, 2358 children with radiographically confirmed CAP were enrolled; 280 (11.9%) had a neurologic disorder (52.1% of these individuals also had non-neurologic underlying conditions), 934 (39.6%) had non-neurologic underlying conditions only, and 1144 (48.5%) had no underlying conditions. Children with neurologic disorders were older and more likely to require intensive care unit (ICU) admission than children with non-neurologic underlying conditions and children with no underlying conditions; similar proportions were mechanically ventilated. In age-stratified analysis, children with neurologic disorders were less likely to have a pathogen detected than children with non-neurologic underlying conditions. In multivariate analysis, having a neurologic disorder was associated with ICU admission for children ≥2 years of age.Children with neurologic disorders hospitalized with CAP were less likely to have a pathogen detected and more likely to be admitted to the ICU than children without neurologic disorders.

This virus is unlikely to have spread substantially among humans in Vietnam, Thailand, Cambodia, and Laos., During February 2013–March 2015, a total of 602 human cases of low pathogenic avian influenza A(H7N9) were reported; no autochthonous cases were reported outside mainland China. In contrast, since highly pathogenic avian influenza A(H5N1) reemerged during 2003 in China, 784 human cases in 16 countries and poultry outbreaks in 53 countries have been reported. Whether the absence of reported A(H7N9) outside mainland China represents lack of spread or lack of detection remains unclear. We compared epidemiologic and virologic features of A(H5N1) and A(H7N9) and used human and animal influenza surveillance data collected during April 2013–May 2014 from 4 Southeast Asia countries to assess the likelihood that A(H7N9) would have gone undetected during 2014. Surveillance in Vietnam and Cambodia detected human A(H5N1) cases; no A(H7N9) cases were detected in humans or poultry in Southeast Asia. Although we cannot rule out the possible spread of A(H7N9), substantial spread causing severe disease in humans is unlikely.

Background During spring 2014, two large influenza outbreaks occurred among cruise ship passengers and crew on trans-hemispheric itineraries. Methods Passenger and crew information for both ships was obtained from components of the ship medical records. Data included demographics, diagnosis of influenza-like illness (ILI) or acute respiratory illness (ARI), illness onset date, passenger cabin number, crew occupation, influenza vaccination history, and rapid influenza diagnostic test (RIDT) result, if performed. Results In total, 3.7% of passengers and 3.1% of crew on Ship A had medically attended acute respiratory illness (MAARI). On Ship B, 6.2% of passengers and 4.7% of crew had MAARI. In both outbreaks, passengers reported illness prior to the ship's departure. Influenza activity was low in the places of origin of the majority of passengers and both ships' ports of call. The median age of affected passengers on both ships was 70 years. Diagnostic testing revealed three different co-circulating influenza viruses [influenza A(H1N1)pdm09, influenza A(H3N2), and influenza B] on Ship A and one circulating influenza virus (influenza B) on Ship B. Both ships voluntarily reported the outbreaks to the Centers for Disease Control and Prevention (CDC) and implemented outbreak response plans including isolation of sick individuals and antiviral treatment and prophylaxis. Conclusions Influenza activity can become widespread during cruise ship outbreaks and can occur outside of traditional influenza seasons. Comprehensive outbreak prevention and control plans, including prompt antiviral treatment and prophylaxis, may mitigate the impact of influenza outbreaks on cruise ships.

(See the Editorial Commentary by Shah on pages 1361–3.) Transmission of tuberculosis in healthcare settings poses a risk to vulnerable patients and healthcare workers. In the 1990s, multiple nosocomial outbreaks affecting patients and healthcare workers in the United States were attributed to delayed diagnosis and inadequate respiratory protections in hospitals [1–4]. In response, the US Centers for Disease Control and Prevention issued “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities,” recommending administrative measures for systematically screening patients for active tuberculosis, use of personal respiratory protection devices by healthcare workers, and respiratory isolation of patients presenting with signs and symptoms of tuberculosis pending serial negative microscopic examination of sputum smears for acid-fast bacilli (AFB) [5]. These principles have proven effective in reducing the frequency and duration of exposure to patients with infectious tuberculosis in emergency departments and inpatient facilities [6–15]. Unfortunately, this approach is inefficient at identifying tuberculosis patients in low-burden settings. Rapid diagnostic algorithms based on clinical symptoms are nonspecific, and sputum smear microscopy requires several days to complete and is insufficiently sensitive to detect all cases of infectious tuberculosis [16–19]. Furthermore, negative-pressure respiratory isolation facilities are costly and the need for airborne precautions can delay tests and procedures done in hospital areas without this capability. In addition, patients may experience opportunity costs such as lost income, lost housing if residing in shelters, and lost positions in substance abuse and behavioral treatment programs. They may also experience stigma [20]. These costs and delays are unnecessary for most patients, as only a small proportion of those placed in respiratory isolation actually have tuberculosis. A rapid testing strategy allowing patients who test negative to be removed from respiratory isolation more quickly would benefit patients and healthcare facilities. In 2008, Campos et al found that performing the GenProbe M. tuberculosis direct nucleic acid amplification test (NAAT) (Hologic, San Diego, California) on a single sputum sample could differentiate inpatients with from those without infectious tuberculosis as accurately and up to 2 days sooner than serial sputum smear microscopy [21]. Unfortunately, this strategy has not been further evaluated nor widely implemented, in part because of concerns about cost, uncertain reliability, and limited impact on clinical decisions [22–28]. Recently, however, there has been renewed interest in molecular testing following US Food and Drug Administration (FDA) approval of a novel, semiautomated NAAT, GeneXpert MTB/RIF (Cepheid MTB/RIF, Sunnyvale, California; hereafter referred to as “Xpert”), for diagnosis of active pulmonary tuberculosis, based on its high sensitivity and specificity for smear-positive tuberculosis and moderate sensitivity for smear-negative tuberculosis [29, 30]. Several recent analyses suggest that use of NAATs in general, and particularly of Xpert, could be cost saving compared with serial sputum microscopy for triage of inpatients into and out of respiratory isolation during evaluation for active pulmonary tuberculosis [22, 23, 31, 32]. Here, we add to that evidence with prospective observational data on the diagnostic accuracy and predicted turnaround time for Xpert in an inpatient setting in a low-burden country. We use these data to estimate the potential impact of Xpert on respiratory isolation usage.

Background: Respiratory isolation of inpatients during evaluation for TB is a slow and costly process in low-burden settings. Xpert MTB/RIF (Xpert) is a novel molecular test for tuberculosis (TB) that is faster and more sensitive but substantially more expensive than smear microscopy. No previous studies have examined the costs of molecular testing as a replacement for smear microscopy in this setting. Methods: We conducted an incremental cost–benefit analysis comparing the use of a single negative Xpert versus two negative sputum smears to release consecutive adult inpatients with presumed TB from respiratory isolation at an urban public hospital in the United States. We estimated all health-system costs and patient outcomes related to Xpert implementation, diagnostic evaluation, isolation, hospitalization, and treatment. We performed sensitivity and probabilistic uncertainty analyses to determine at what threshold the Xpert strategy would become cost-saving. Results: Among a hypothetical cohort of 234 individuals undergoing evaluation for presumed active TB annually, 6.4% had culture-positive TB. Compared to smear microscopy, Xpert reduced isolation bed utilization from an average of 2.7 to 1.4 days per patient, leading to a 48% reduction in total annual isolation bed usage from 632 to 328 bed-days. Xpert saved an average of $2,278 (95% uncertainty range $1582–4570) per admission, or $533,520 per year, compared with smear microscopy. Conclusions: Molecular testing for TB could provide substantial savings to hospitals in high-income countries by reducing respiratory isolation usage and overall length of stay.