Drug Overdose Mortality by Usual Occupation and Industry: 46 U.S. States and New York City, 2020.

Objective-This report describes deaths from drug overdoses in 2020 in U.S. residents in 46 states and New York City by usual occupation and industry. Methods-Frequencies, death rates, and proportionate mortality ratios (PMRs) are presented using the 2020 National Vital Statistics System mortality data file. Data were restricted to decedents aged 16-64 for rates and 15-64 for PMRs with usual occupations and industries in the paid civilian workforce. Age-standardized drug overdose death rates were estimated for usual occupation and industry groups overall, and age-adjusted drug overdose PMRs were estimated for each usual occupation and industry group overall and by sex, race and Hispanic-origin group, type of drug, and drug overdose intent. Age-adjusted drug overdose PMRs were also estimated for individual occupations and industries. Results-Drug overdose mortality varied by usual occupation and industry. Workers in the construction and extraction occupation group (162.6 deaths per 100,000 workers, 95% confidence interval: 155.8-169.4) and construction industry group (130.9, 126.0-135.8) had the highest drug overdose death rates. The highest group-level drug overdose PMRs were observed in decedents in the construction and extraction occupation group and the construction industry group (145.4, 143.6-147.1 and 144.9, 143.2-146.5, respectively). Differences in drug overdose PMRs by usual occupation and industry group were observed within each sex, within each race and Hispanicorigin group, by drug type, and by drug overdose intent. Among individual occupations and industries, the highest drug overdose PMRs were observed in decedents who worked as fishers and related fishing occupations and in fishing, hunting, and trapping industries (193.1, 166.8-222.4 and 186.5, 161.7-214.1, respectively). Conclusions-Variation in drug overdose death rates and PMRs by usual occupation and industry in 2020 demonstrates the disproportionate burden of the ongoing drug overdose crisis on certain sectors of the U.S. workforce.

COVID-19 Mortality by Usual Occupation and Industry:46 States and New York City, United States, 2020.

Objectives-This report describes COVID-19 mortality in 2020 among U.S. residents in 46 states and New York City by usual occupation and industry.

Reported Exposures Among In-Person Workers With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in 6 States, September 2020-June 2021.

BACKGROUND: Surveillance systems lack detailed occupational exposure information from workers with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The National Institute for Occupational Safety and Health partnered with 6 states to collect information from adults diagnosed with SARS-CoV-2 infection who worked in person (outside the home) in non-healthcare settings during the 2 weeks prior to illness onset. METHODS: The survey captured demographic, medical, and occupational characteristics and work- and non-work-related risk factors for SARS-CoV-2 infection. Reported close contact with a person known or suspected to have SARS-CoV-2 infection was categorized by setting as exposure at work, exposure outside of work only, or no known exposure/did not know. Frequencies and percentages of exposure types are compared by respondent characteristics and risk factors. RESULTS: Of 1111 respondents, 19.4% reported exposure at work, 23.4% reported exposure outside of work only, and 57.2% reported no known exposure/did not know. Workers in protective service occupations (48.8%) and public administration industries (35.6%) reported exposure at work most often. More than one third (33.7%) of respondents who experienced close contact with ≥10 coworkers per day and 28.8% of respondents who experienced close contact with ≥10 customers/clients per day reported exposures at work. CONCLUSIONS: Exposure to occupational SARS-CoV-2 was common among respondents. Examining differences in exposures among different worker groups can help identify populations with the greatest need for prevention interventions. The benefits of recording employment characteristics as standard demographic information will remain relevant as new and reemerging public health issues occur.

Identifying essential critical infrastructure workers during the COVID-19 pandemic using standardized industry codes.

BACKGROUND: The Cybersecurity and Infrastructure Security Agency (CISA) produced an advisory list identifying essential critical infrastructure workers (ECIW) during the coronavirus disease 2019 (COVID-19) response. The CISA advisory list is the most common national definition of ECIW but has not been mapped to United States (U.S.) Census industry codes (CICs) to readily identify these worker populations in public health data sources. METHODS: We identified essential critical infrastructure industry designations corresponding to v4.0 of the CISA advisory list for all six-digit North American Industry Classification System (NAICS) codes and cross-walked NAICS codes to CICs. CICs were grouped as essential, non-essential, or mixed essential/non-essential according to component NAICS industries. We also obtained national estimated population sizes for NAICS and Census industries and cross-tabulated Census industry and occupation codes to identify industry-occupation pairs. RESULTS: We produced and made publicly available spreadsheets containing essential industry designations corresponding to v4.0 of the CISA advisory list for NAICS and Census industry titles and codes and population estimates by six-digit NAICS industry, Census industry, and Census industry-occupation pair. The CISA advisory list is highly inclusive and contains most industries and U.S. workers; 71.0% of Census industries comprising 80.6% of workers and 80.7% of NAICS industries comprising 87.1% of workers were designated as essential. CONCLUSIONS: We identified workers in essential critical infrastructure industries as defined by CISA using standardized industry codes. These classifications may support public health interventions and analyses related to the COVID-19 pandemic and future public health crises.

Reported exposure trends among healthcare personnel COVID-19 cases, USA, March 2020-March 2021.

BACKGROUND: Health care personnel (HCP) have experienced significant SARS-CoV-2 risk, but exposure settings among HCP COVID-19 cases are poorly characterized. METHODS: We assessed exposure settings among HCP COVID-19 cases in the United States from March 2020 to March 2021 with reported exposures (n = 83,775) using national COVID-19 surveillance data. Exposure setting and reported community incidence temporal trends were described using breakpoint estimation. Among cases identified before initiation of COVID-19 vaccination programs (n = 65,650), we used separate multivariable regression models to estimate adjusted prevalence ratios (aPR) for associations of community incidence with health care and household and/or community exposures. RESULTS: Health care exposures were the most reported (52.0%), followed by household (30.8%) and community exposures (25.6%). Health care exposures and community COVID-19 incidence showed similar temporal trends. In adjusted analyses, HCP cases were more likely to report health care exposures (aPR = 1.31; 95% CI:1.26-1.36) and less likely to report household and/or community exposures (aPR = 0.73; 95% CI:0.70-0.76) under the highest vs lowest community incidence levels. DISCUSSION: These findings highlight HCP exposure setting temporal trends and workplace exposure hazards under high community incidence. Findings also underscore the need for robust collection of work-related data in infectious disease surveillance. CONCLUSIONS: Many reported HCP cases experienced occupational COVID-19 exposures, particularly during periods of higher community COVID-19 incidence.

HIV Viral Suppression and Pre-exposure Prophylaxis in HIV and Syphilis Contact Tracing Networks: An Analysis of Disease Surveillance and Prescription Claims Data.

BACKGROUND: HIV and syphilis contact tracing networks offer efficient platforms for HIV treatment and prevention interventions, but intervention coverage within these networks has not been characterized. SETTING: HIV and syphilis sexual contact tracing networks among men who have sex with men (MSM) in North Carolina (NC). METHODS: Using surveillance data, we identified 2 types of "network events" that occurred between January 2013 and June 2017 among MSM in NC: being diagnosed with early syphilis or being named as a recent sexual contact of a person diagnosed with HIV or early syphilis. We estimated prevalent and incident HIV viral suppression among persons diagnosed with HIV before the network event, and we assessed the effect of contact tracing services on a 6-month cumulative incidence of viral suppression among previously HIV-diagnosed, virally unsuppressed persons. Using linked prescription claims data, we also evaluated prevalent and incident pre-exposure prophylaxis (PrEP) use in an insured subset of HIV-negative network members. RESULTS: Viral suppression prevalence among previously HIV-diagnosed persons was 52.6%. The 6-month cumulative incidence of viral suppression was 35.4% overall and 13.1 (95% confidence interval: 8.8 to 17.4) percentage points higher among persons reached than among those not reached by contact tracing services. Few HIV-negative persons had prevalent (5.4%) or incident (4.1%) PrEP use in the 6 months before or after network events, respectively. CONCLUSIONS: Suboptimal viral suppression and PrEP use among MSM in NC in HIV/syphilis contact tracing networks indicate a need for intensified intervention efforts. In particular, expanded services for previously HIV-diagnosed persons could improve viral suppression and reduce HIV transmission within these networks.

Required and Voluntary Occupational Use of Hazard Controls for COVID-19 Prevention in Non-Health Care Workplaces - United States, June 2020.

Certain hazard controls, including physical barriers, cloth face masks, and other personal protective equipment (PPE), are recommended to reduce coronavirus 2019 (COVID-19) transmission in the workplace (1). Evaluation of occupational hazard control use for COVID-19 prevention can identify inadequately protected workers and opportunities to improve use. CDC's National Institute for Occupational Safety and Health used data from the June 2020 SummerStyles survey to characterize required and voluntary use of COVID-19-related occupational hazard controls among U.S. non-health care workers. A survey-weighted regression model was used to estimate the association between employer provision of hazard controls and voluntary use, and stratum-specific adjusted risk differences (aRDs) among workers reporting household incomes <250% and ≥250% of national poverty thresholds were estimated to assess effect modification by income. Approximately one half (45.6%; 95% confidence interval [CI] = 41.0%-50.3%) of non-health care workers reported use of hazard controls in the workplace, 55.5% (95% CI = 48.8%-62.2%) of whom reported employer requirements to use them. After adjustment for occupational group and proximity to others at work, voluntary use was approximately double, or 22.3 absolute percentage points higher, among workers who were provided hazard controls than among those who were not. This effect was more apparent among lower-income (aRD = 31.0%) than among higher-income workers (aRD = 16.3%). Employers can help protect workers from COVID-19 by requiring and encouraging use of occupational hazard controls and providing hazard controls to employees (1).

Network Interconnectivity and Community Detection in HIV/Syphilis Contact Networks Among Men Who Have Sex With Men.

BACKGROUND: Despite persistent HIV and syphilis epidemics among men who have sex with men (MSM), the relationship between HIV and syphilis contact networks has not been well characterized. We aimed to measure interconnectivity between HIV and syphilis contact networks among MSM and identify network communities with heightened interconnectivity of the syphilis network with the HIV network. METHODS: Using contact-tracing data, we generated independent and combined HIV and syphilis networks for all MSM diagnosed with HIV or early syphilis, respectively, in North Carolina between 2015 and 2017. We treated the independent networks as layers and identified network communities, or groups of densely connected nodes, in the 2-layer network. We assessed interconnectivity by comparing the mean node degree among syphilis network members in the syphilis network alone versus the combined HIV/syphilis network, both overall and by network community. RESULTS: The syphilis network was interconnected with the HIV network, especially in network communities with younger median age, higher proportions of persons self-identifying as Black, non-Hispanic, and higher proportions of syphilis cases diagnosed at sexually transmitted disease clinics. CONCLUSIONS: Interconnected contact networks underlie HIV and syphilis epidemics among MSM, particularly among young, Black MSM. Intensified transmission prevention interventions within highly interconnected network communities may be particularly beneficial.

HIV Outbreak Control With Effective Access to Care and Harm Reduction in North Carolina, 2017-2018.

Objectives. To assess and control a potential outbreak of HIV among people who inject drugs in Western North Carolina.Methods. Disease intervention specialists offered testing for hepatitis B and hepatitis C, harm reduction materials, and linkage to care to 7 linked people recently diagnosed with HIV who also injected drugs. Contacts were offered the same services and HIV testing. HIV genotype analysis was used to characterize HIV spread. We assessed testing and care outcomes by using state surveillance information.Results. Disease intervention specialists contacted 6 of 7 linked group members and received information on 177 contacts; among 96 prioritized contacts, 42 of 96 (44%) were exposed to or diagnosed with hepatitis C, 4 of 96 (4%) had hepatitis B, and 14 of 96 (15%) had HIV (2 newly diagnosed during the investigation). HIV genotype analysis suggested recent transmission to linked group members and 1 contact. Eleven of 14 with HIV were virally suppressed following the outbreak response.Conclusions. North Carolina identified and rapidly responded to an HIV outbreak among people reporting injecting drugs. Effective HIV care, the availability of syringe exchange services, and the rapid response likely contributed to controlling this outbreak.

Prediction of HIV Transmission Cluster Growth With Statewide Surveillance Data.

BACKGROUND: Prediction of HIV transmission cluster growth may help guide public health action. We developed a predictive model for cluster growth in North Carolina (NC) using routine HIV surveillance data. METHODS: We identified putative transmission clusters with ≥2 members through pairwise genetic distances ≤1.5% from HIV-1 pol sequences sampled November 2010-December 2017 in NC. Clusters established by a baseline of January 2015 with any sequences sampled within 2 years before baseline were assessed for growth (new diagnoses) over 18 months. We developed a predictive model for cluster growth incorporating demographic, clinical, temporal, and contact tracing characteristics of baseline cluster members. We internally and temporally externally validated the final model in the periods January 2015-June 2016 and July 2016-December 2017. RESULTS: Cluster growth was predicted by larger baseline cluster size, shorter time between diagnosis and HIV care entry, younger age, shorter time since the most recent HIV diagnosis, higher proportion with no named contacts, and higher proportion with HIV viremia. The model showed areas under the receiver-operating characteristic curves of 0.82 and 0.83 in the internal and temporal external validation samples. CONCLUSIONS: The predictive model developed and validated here is a novel means of identifying HIV transmission clusters that may benefit from targeted HIV control resources.

Repeat Human Immunodeficiency Virus Testing by Transmission Risk Group and Rurality of Residence in North Carolina.

BACKGROUND: Understanding of repeat human immunodeficiency virus (HIV) testing (RHT) is limited and the impact of rural residence as a potential barrier to RHT is unknown. Rural populations are of particular interest in the Southeastern United States because of their disproportionate HIV burden. METHODS: We used HIV surveillance data from publicly funded HIV testing sites in North Carolina to assess repeat testing by transmission risk group and residential rurality in a retrospective cohort study. Linear binomial regression models were used to estimate adjusted, 1-year cumulative incidences and cumulative incidence differences comparing RHT within transmission risk populations by level of rurality. RESULTS: In our total study population of 600,613 persons, 19,275 (3.2%) and 9567 (1.6%) self-identified as men who have sex with men (MSM) and persons who inject drugs (PWID), respectively. A small minority, 13,723 (2.3%) resided in rural ZIP codes. Men who have sex with men were most likely to repeat test (unadjusted, 1-year cumulative incidence after an initial negative test, 16.4%) compared with PWID (13.2%) and persons who did not identify as either MSM or PWID (13.6%). The greatest effect of rurality was within PWID; the adjusted, 1-year cumulative incidence of RHT was 6.4 (95% confidence interval, 1.4-11.4) percentage points higher among metropolitan versus rural PWID. CONCLUSIONS: One-year cumulative incidence of RHT was low among all clients of publicly funded HIV testing sites in North Carolina, including MSM and PWID for whom annual testing is recommended. Our findings suggest a need for public health efforts to increase access to and support for RHT, particularly among rural PWID.

Pediatric Firework-Related Injuries Presenting to United States Emergency Departments, 1990-2014.

This study characterizes the epidemiology of nonfatal pediatric firework-related injuries in the United States among children and adolescents by analyzing data from the National Electronic Injury Surveillance System from 1990 through 2014. During this 25-year period, an estimated 136 991 (95% CI = 113 574-160 408) children <20 years old were treated in US emergency departments for firework-related injuries. The annual injury rate decreased significantly by 30.4% during this period. Most of those injured were male (75.7%), mean patient age was 10.6 years, and 7.6% required hospital admission. The hands (30.0%) were the most commonly injured body region, followed by head and neck (22.2%), and eyes (21.5%). Sixty percent of injuries were burns. Injuries were most commonly associated with firecrackers (26.2%), aerial devices (16.3%), and sparklers (14.3%). Consumer fireworks pose a serious injury risk to pediatric users and bystanders, and families should be encouraged to attend public firework displays rather than use consumer fireworks.

Zipline-related injuries treated in US EDs, 1997-2012.

PURPOSE: To investigate the epidemiology of zipline-related injuries in the United States. BASIC PROCEDURES: The National Electronic Injury Surveillance System database was used to examine non-fatal zipline-related injuries treated in US emergency departments (EDs) from 1997 through 2012. Sample weights were applied to calculate national estimates. MAIN FINDINGS: From 1997 through 2012, an estimated 16850 (95% CI, 13188-20512) zipline-related injuries were treated in US EDs. The annual injury rate per 1 million population increased by 52.3% from 7.64 (95% CI, 4.86-10.42) injuries in 2009 (the first year with a stable annual estimate) to 11.64 (95% CI, 7.83-15.45) injuries in 2012. Patients aged 0-9 years accounted for 45.0% of injuries, females made up 53.1% of injuries, and 11.7% of patients required hospitalization. Fractures accounted for the largest proportion of injuries (46.7%), and the upper extremities were the most commonly injured body region (44.1%). Falls were the most common mechanism of injury, accounting for 77.3% of injuries. Among cases where the location of the injury event was known, 30.8% of injuries occurred in a residential setting and 69.2% occurred in a public place. PRINCIPAL CONCLUSIONS: This study is the first to characterize the epidemiology of zipline-related injuries using a nationally representative database. The rapid increase in zipline-related injuries in recent years suggests the need for additional safety guidelines and regulations. Commercial ziplines and publicly accessible non-commercial ziplines should be subject to uniform safety standards in all states and jurisdictions across the US, and homemade ziplines should not be used.

Cow's Milk Contamination of Human Milk Purchased via the Internet.

BACKGROUND: The US Food and Drug Administration recommends against feeding infants human milk from unscreened donors, but sharing milk via the Internet is growing in popularity. Recipient infants risk the possibility of consuming contaminated or adulterated milk. Our objective was to test milk advertised for sale online as human milk to verify its human origin and to rule out contamination with cow's milk. METHODS: We anonymously purchased 102 samples advertised as human milk online. DNA was extracted from 200 µL of each sample. The presence of human or bovine mitochondrial DNA was assessed with a species-specific real-time polymerase chain reaction assay targeting the nicotinamide adenine dinucleotide (NADH) dehydrogenase subunit 5 gene. Four laboratory-created mixtures representing various dilutions of human milk with fluid cow's milk or reconstituted infant formula were compared with the Internet samples to semiquantitate the extent of contamination with cow's milk. RESULTS: All Internet samples amplified human DNA. After 2 rounds of testing, 11 samples also contained bovine DNA. Ten of these samples had a level of bovine DNA consistent with human milk mixed with at least 10% fluid cow's milk. CONCLUSIONS: Ten Internet samples had bovine DNA concentrations high enough to rule out minor contamination, suggesting a cow's milk product was added. Cow's milk can be problematic for infants with allergy or intolerance. Because buyers cannot verify the composition of milk they purchase, all should be aware that it might be adulterated with cow's milk. Pediatricians should be aware of the online market for human milk and the potential risks.