Racial and Ethnic Disaggregation of Tuberculosis Incidence and Risk Factors Among American Indian and Alaska Native Persons-United States, 2001-2020.

Objectives. To examine impacts of racial and ethnic disaggregation on the characterization of tuberculosis (TB) epidemiology among American Indian and Alaska Native (AI/AN) persons in the United States. Methods. Using data reported to the National Tuberculosis Surveillance System during 2001 to 2020, we compared annual age-adjusted TB incidence and the frequency of TB risk factors among 3 AI/AN analytic groups: non-Hispanic AI/AN alone persons, multiracial/Hispanic AI/AN persons, and all AI/AN persons (aggregate of the first 2 groups). Results. During 2009 to 2020, annual TB incidence (cases per 100 000 persons) among non-Hispanic AI/AN alone persons (range = 3.87-8.56) was on average 1.9 times higher than among all AI/AN persons (range = 1.89-4.70). Compared with non-Hispanic AI/AN alone patients with TB, multiracial/Hispanic AI/AN patients were significantly more likely to be HIV positive (prevalence ratio [PR] = 2.05) and to have been diagnosed while a resident of a correctional facility (PR = 1.71), and significantly less likely to have experienced homelessness (PR = 0.53) or died during TB treatment (PR = 0.47). Conclusions. Racial and ethnic disaggregation revealed significant differences in TB epidemiology among AI/AN analytic groups. Exclusion of multiracial/Hispanic AI/AN persons from AI/AN analytic groups can substantively affect estimates of racial and ethnic health disparities. (Am J Public Health. 2024;114(2):226-236. https://doi.org/10.2105/AJPH.2023.307498).

Using Geographic Disaggregation to Compare Tuberculosis Epidemiology Among American Indian and Alaska Native Persons-USA, 2010-2020.

BACKGROUND: American Indian and Alaska Native (AIAN) populations are frequently associated with the highest rates of tuberculosis (TB) disease of any racial/ethnic group in the USA. We systematically investigated variation in patterns and potential drivers of TB epidemiology among geographically distinct AIAN subgroups. METHODS: Using data reported to the National Tuberculosis Surveillance System during 2010-2020, we applied a geographic method of data disaggregation to compare annual TB incidence and the frequency of TB patient characteristics among AIAN persons in Alaska with AIAN persons in other states. We used US Census data to compare the prevalence of substandard housing conditions in AIAN communities in these two geographic areas. RESULTS: The average annual age-adjusted TB incidence among AIAN persons in Alaska was 21 times higher than among AIAN persons in other states. Compared to AIAN TB patients in other states, AIAN TB patients in Alaska were associated with significantly higher frequencies of multiple epidemiologic TB risk factors (e.g., attribution of TB disease to recent transmission, previous diagnosis of TB disease) and significantly lower frequencies of multiple clinical risk factors for TB disease (e.g., diagnosis with diabetes mellitus, end-stage renal disease). Occupied housing units in AIAN communities in Alaska were associated with significantly higher frequencies of multiple measures of substandard housing conditions compared to AIAN communities in other states. CONCLUSIONS: Observed differences in patient characteristics and substandard housing conditions are consistent with contrasting syndromes of TB epidemiology in geographically distinct AIAN subgroups and suggest ways that associated public health interventions could be tailored to improve efficacy.

Travel history among persons infected with SARS-CoV-2 variants of concern in the United States, December 2020-February 2021.

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

Tuberculosis Among Native Hawaiian and Other Pacific Islander Persons: United States and U.S.-Affiliated Pacific Islands, 2010-2019.

Background: In recent years, tuberculosis (TB) incidence in the United States has declined overall but remained high among Native Hawaiian and Other Pacific Islander (NH/PI) persons. Few studies have examined the epidemiology of TB among NH/PI persons, particularly in the U.S.-Affiliated Pacific Islands (USAPI). We describe TB incidence and characteristics of NH/PI patients during 2010-2019. Methods: We used data from the National Tuberculosis Surveillance System to characterize TB cases reported among NH/PI persons born in the 50 U.S. states (defined to include District of Columbia) and the USAPI. We calculated annual TB incidence among NH/PI patients, stratified by place of birth (U.S. states or USAPI). Using Asian persons born outside the United States-persons historically grouped with NH/PI persons as one racial category-as the reference, we compared demographic, clinical, and socio-behavioral characteristics of NH/PI TB patients. Results: During 2010-2019, 4359 TB cases were reported among NH/PI patients born in the U.S. states (n=205) or the USAPI (n=4154). Median annual incidence per 100,000 persons was 6.5 cases (persons born in the U.S. states) and 150.7 cases (persons born in the USAPI). The proportion of TB patients aged <15 years was higher among NH/PI persons (U.S. states: 54%, USAPI: 24%) than among Asian persons born outside the United States (1%). Conclusions: TB incidence among NH/PI persons is high, particularly among persons born in the USAPI, emphasizing the need to enhance TB prevention strategies in these communities. Interventions should be tailored toward those who experience the highest risk, including NH/PI children and adolescents.

Tuberculosis in Indigenous Persons - United States, 2009-2019.

BACKGROUND: Populations of indigenous persons are frequently associated with pronounced disparities in rates of tuberculosis (TB) disease compared to co-occurring nonindigenous populations. METHODS: Using data from the National Tuberculosis Surveillance System on TB cases in U.S.-born patients reported in the United States during 2009-2019, we calculated incidence rate ratios and risk ratios for TB risk factors to compare cases in American Indian or Alaska Native (AIAN) and Native Hawaiian or other Pacific Islander (NHPI) TB patients to cases in White TB patients. RESULTS: Annual TB incidence rates among AIAN and NHPI TB patients were on average ≥10 times higher than among White TB patients. Compared to White TB patients, AIAN and NHPI TB patients were 1.91 (95% confidence interval (CI): 1.35-2.71) and 3.39 (CI: 1.44-5.74) times more likely to have renal disease or failure, 1.33 (CI: 1.16-1.53) and 1.63 (CI: 1.20-2.20) times more likely to have diabetes mellitus, and 0.66 (CI: 0.44-0.99) and 0.19 (CI: 0-0.59) times less likely to be HIV positive, respectively. AIAN TB patients were 1.84 (CI: 1.69-2.00) and 1.48 (CI: 1.27-1.71) times more likely to report using excess alcohol and experiencing homelessness, respectively. CONCLUSION: TB among U.S. indigenous persons is associated with persistent and concerning health disparities.

Travel from the United Kingdom to the United States by a Symptomatic Patient Infected with the SARS-CoV-2 B.1.1.7 Variant - Texas, January 2021.

In December 2020, the B.1.1.7 genetic variant of SARS-CoV-2, the virus that causes COVID-19, was first reported after emergence and rapid circulation in the United Kingdom (1). Evidence suggests that the B.1.1.7 variant is more efficiently transmitted than are other SARS-CoV-2 variants, and widespread circulation could thereby increase SARS-CoV-2 infection and hospitalization rates (1,2). The first reported SARS-CoV-2 B.1.1.7 variant case in the United States was confirmed by sequencing in Colorado on December 29, 2020.* This report describes a person who traveled from the United Kingdom to the United States after experiencing COVID-19-compatible symptoms† and was eventually confirmed to be infected with the B.1.1.7 variant.

Large-scale health disparities associated with Lyme disease and human monocytic ehrlichiosis in the United States, 2007-2013.

Promoting health equity is a fundamental public health objective, yet health disparities remain largely overlooked in studies of vectorborne diseases, especially those transmitted by ticks. We sought to identify health disparities associated with Lyme disease and human monocytic ehrlichiosis, two of the most pervasive tickborne diseases within the United States. We used general linear mixed models to measure associations between county-level disease incidence and six variables representing racial/ethnic and socioeconomic characteristics of counties (percent white non-Hispanic; percent with a bachelors degree or higher; percent living below the poverty line; percent unemployed; percent of housing units vacant; per capita number of property crimes). Two ecological variables important to tick demography (percent forest cover; density of white-tailed deer) were included in secondary analyses to contextualize findings. Analyses included data from 2,695 counties in 37 states and the District of Columbia during 2007-2013. Each of the six variables was significantly associated with the incidence of one or both diseases, but the direction and magnitude of associations varied by disease. Results suggested that the incidence of Lyme disease was highest in counties with relatively higher proportions of white and more educated persons and lower poverty and crime rates; the incidence of human monocytic ehrlichiosis was highest in counties with relatively higher proportions of white and less educated persons, higher unemployment rates and lower crime rates. The percentage of housing units vacant was a strong positive predictor for both diseases with a magnitude of association comparable to those between incidence and the ecological variables. Our findings indicate that racial/ethnic and socioeconomic disparities in disease incidence appear to be epidemiologically important features of Lyme disease and human monocytic ehrlichiosis in the United States. Steps to mitigate encroachment of wild flora and fauna into areas with vacant housing might be warranted to reduce disease risk.

Work-related injuries in the Alaska logging industry, 1991-2014.

BACKGROUND: Although loggers in Alaska are at high risk for occupational injury, no comprehensive review of such injuries has been performed since the mid-1990s. We investigated work-related injuries in the Alaska logging industry during 1991-2014. METHODS: Using data from the Alaska Trauma Registry and the Alaska Occupational Injury Surveillance System, we described fatal and nonfatal injuries by factors including worker sex and age, timing and geographic location of injuries, and four injury characteristics. Annual injury rates and associated 5-year simple moving averages were calculated. RESULTS: We identified an increase in the 5-year simple moving averages of fatal injury rates beginning around 2005. While injury characteristics were largely consistent between the first 14 and most recent 10 years of the investigation, the size of logging companies declined significantly between these periods. CONCLUSIONS: Factors associated with declines in the size of Alaska logging companies might have contributed to the observed increase in fatal injury rates.

Two Outbreaks of Trichinellosis Linked to Consumption of Walrus Meat - Alaska, 2016-2017.

During 1975-2012, CDC surveillance identified 1,680 trichinellosis cases in the United States with implicated food items; among these cases, 1,219 were attributed to consumption of raw or pork products, and 461 were attributed to nonpork products. Although trichinellosis in the United States has historically been associated with consumption of pork, multiple nonporcine species of wild game also are competent hosts for Trichinella spp. and have been collectively implicated in the majority of trichinellosis cases since the late 1990s (1-4) (Figure 1). During July 2016-May 2017, the Alaska Division of Public Health (ADPH) investigated two outbreaks of trichinellosis in the Norton Sound region associated with consumption of raw or undercooked walrus (Odobenus rosmarus) meat; five cases were identified in each of the two outbreaks. These were the first multiple-case outbreaks of walrus-associated trichinellosis in Alaska since 1992 (Figure 2). Health care providers should inquire about consumption of commercially prepared and personally harvested meats when evaluating suspected trichinellosis cases, especially in areas where consumption of wild game is commonplace.

Novel Orthopoxvirus Infection in an Alaska Resident.

BACKGROUND.: Human infection by orthopoxviruses is being reported with increasing frequency, attributed in part to the cessation of smallpox vaccination and concomitant waning of population-level immunity. In July 2015, a female resident of interior Alaska presented to an urgent care clinic with a dermal lesion consistent with poxvirus infection. Laboratory testing of a virus isolated from the lesion confirmed infection by an Orthopoxvirus. METHODS.: The virus isolate was characterized by using electron microscopy and nucleic acid sequencing. An epidemiologic investigation that included patient interviews, contact tracing, and serum testing, as well as environmental and small-mammal sampling, was conducted to identify the infection source and possible additional cases. RESULTS.: Neither signs of active infection nor evidence of recent prior infection were observed in any of the 4 patient contacts identified. The patient's infection source was not definitively identified. Potential routes of exposure included imported fomites from Azerbaijan via the patient's cohabiting partner or wild small mammals in or around the patient's residence. Phylogenetic analyses demonstrated that the virus represents a distinct and previously undescribed genetic lineage of Orthopoxvirus, which is most closely related to the Old World orthopoxviruses. CONCLUSIONS.: Investigation findings point to infection of the patient after exposure in or near Fairbanks. This conclusion raises questions about the geographic origins (Old World vs North American) of the genus Orthopoxvirus. Clinicians should remain vigilant for signs of poxvirus infection and alert public health officials when cases are suspected.

Increase in Adverse Reactions Associated with Use of Synthetic Cannabinoids - Anchorage, Alaska, 2015-2016.

In July 2015, personnel in the Alaska Division of Public Health's Section of Epidemiology became aware of an increase in the number of patients being treated in Anchorage hospital emergency departments for adverse reactions associated with use of synthetic cannabinoids (SCs). SCs are a chemically diverse class of designer drugs that bind to the same cannabinoid receptors as tetrahydrocannabinol, the main psychoactive component of cannabis. A public health investigation was initiated to describe clinical outcomes, characterize the outbreak, and identify SC chemicals circulating in Anchorage. During July 15, 2015-March 15, 2016, a total of 1,351 ambulance transports to Anchorage emergency departments for adverse SC reactions were identified. A review of charts obtained from two Anchorage hospitals determined that among 167 emergency department visits for adverse SC reactions during July 15-September 30, 2015, 11 (6.6%) involved a patient who required endotracheal intubation, 17 (10.2%) involved a patient who was admitted to the intensive care unit, and 66 (39.5%) involved a patient classified as being homeless. Testing of 25 product and paraphernalia samples collected from patients at one hospital identified 11 different SC chemicals. Educational outreach campaigns focused on the considerable health risks of using SCs need to complement judicial and law enforcement actions to reduce SC use.

Habitat heterogeneity drives the host-diversity-begets-parasite-diversity relationship: evidence from experimental and field studies.

Despite a century of research into the factors that generate and maintain biodiversity, we know remarkably little about the drivers of parasite diversity. To identify the mechanisms governing parasite diversity, we combined surveys of 8100 amphibian hosts with an outdoor experiment that tested theory developed for free-living species. Our analyses revealed that parasite diversity increased consistently with host diversity due to habitat (i.e. host) heterogeneity, with secondary contributions from parasite colonisation and host abundance. Results of the experiment, in which host diversity was manipulated while parasite colonisation and host abundance were fixed, further reinforced this conclusion. Finally, the coefficient of host diversity on parasite diversity increased with spatial grain, which was driven by differences in their species-area curves: while host richness quickly saturated, parasite richness continued to increase with neighbourhood size. These results offer mechanistic insights into drivers of parasite diversity and provide a hierarchical framework for multi-scale disease research.

Pleistocene radiation of the serpentine-adapted genus Hesperolinon and other divergence times in Linaceae (Malpighiales).

PREMISE OF THE STUDY: Hesperolinon (western flax; Linaceae) is endemic to the western United States, where it is notable for its high and geographically concentrated species diversity on serpentine-derived soils and for its use as a model system in disease ecology. We used a phylogenetic framework to test a long-standing hypothesis that Hesperolinon is a neoendemic radiation. METHODS: Five plastid and two ribosomal nuclear DNA gene regions were sampled from 105 populations of Hesperolinon, including all 13 recently recognized species across their known ranges. We used these data to generate population-level phylogenies of Hesperolinon. We also generated a robustly sampled chronogram of Linaceae using an eight-gene, 100-taxon supermatrix calibrated using fossil Linum pollen and a published chronogram of Malpighiales. KEY RESULTS: Most diversification in Hesperolinon has taken place in the past 1-2 million yr, much more recently than previous estimates. Only the earliest-diverging species, H. drymarioides, was resolved as a clade. Denser taxon and gene sampling generally support previously proposed relationships within Linaceae, but with more recent diversification of key clades. CONCLUSIONS: Hesperolinon is an excellent example of edaphic neoendemism, in support of Raven and Axelrod's hypothesis for the genus. Dense population-level sampling reveals a complex of incipient species, with clades poorly aligned with traditional morphological circumscriptions, likely due in part to continued gene flow. The diversification of Linaceae is more recent than previously estimated, and other recent radiations (e.g., Hugonia) warrant further study.

Expanding Range of Amblyomma americanum and Simultaneous Changes in the Epidemiology of Spotted Fever Group Rickettsiosis in the United States.

Spotted fever group (SFG) Rickettsia species are etiologic agents of a wide range of human infections from asymptomatic or mild infections to severe, life-threatening disease. In the United States, recent passive surveillance for SFG rickettsiosis shows an increased incidence and decreased severity of reported cases. The reasons for this are not well understood; however, we hypothesize that less pathogenic rickettsiae are causing more human infections, while the incidence of disease caused by more pathogenic rickettsiae, particularly Rickettsia rickettsii, is relatively stable. During the same period, the range of Amblyomma americanum has expanded. Amblyomma americanum is frequently infected with "Candidatus Rickettsia amblyommii", a SFG Rickettsia of unknown pathogenicity. We tested our hypothesis by modeling incidence rates from 1993 to 2013, hospitalization rates from 1981 to 2013, and case fatality rates from 1981 to 2013 regressed against the presence of A. americanum, the decade of onset of symptoms, and the county of residence. Our results support the hypothesis, and we show that the expanding range of A. americanum is associated with changes in epidemiology reported through passive surveillance. We believe epidemiological and acarological data collected on individual cases from enhanced surveillance may further elucidate the reasons for the changing epidemiology of SFG rickettsiosis.

Modeling the Present and Future Geographic Distribution of the Lone Star Tick, Amblyomma americanum (Ixodida: Ixodidae), in the Continental United States.

The Lone star tick (Amblyomma americanum L.) is the primary vector for pathogens of significant public health importance in North America, yet relatively little is known about its current and potential future distribution. Building on a published summary of tick collection records, we used an ensemble modeling approach to predict the present-day and future distribution of climatically suitable habitat for establishment of the Lone star tick within the continental United States. Of the nine climatic predictor variables included in our five present-day models, average vapor pressure in July was by far the most important determinant of suitable habitat. The present-day ensemble model predicted an essentially contiguous distribution of suitable habitat extending to the Atlantic coast east of the 100th western meridian and south of the 40th northern parallel, but excluding a high elevation region associated with the Appalachian Mountains. Future ensemble predictions for 2061-2080 forecasted a stable western range limit, northward expansion of suitable habitat into the Upper Midwest and western Pennsylvania, and range contraction along portions of the Gulf coast and the lower Mississippi river valley. These findings are informative for raising awareness of A. americanum-transmitted pathogens in areas where the Lone Star tick has recently or may become established.

Variation in Baiting Intensity Among CO2-Baited Traps Used to Collect Hematophagous Arthropods.

Hematophagous arthropods transmit the etiological agents of numerous diseases and as a result are frequently the targets of sampling to characterize vector and pathogen populations. Arguably, the most commonly used sampling approach involves traps baited with carbon dioxide. We report results of a laboratory study in which the performance of carbon dioxide-baited traps was evaluated using measures of baiting intensity, the amount of carbon dioxide released per unit time during trap deployment. We evaluated the effects of trap design, carbon dioxide source, and wind speed on baiting intensity and documented significant effects of these factors on the length of sampling (time to baiting intensity = 0), maximum baiting intensity, and variation in baiting intensity during experimental trials. Among the three dry ice-baited trap types evaluated, traps utilizing insulated beverage coolers as dry ice containers sampled for the longest period of time, had the lowest maximum but most consistent baiting intensity within trials and were least sensitive to effects of wind speed and dry ice form (block vs. pellet) on baiting intensity. Results of trials involving traps baited with carbon dioxide released from pressurized cylinders suggested that this trap type had performance comparable to dry ice-baited insulated cooler traps but at considerably higher cost.

Spatial distribution of counties in the continental United States with records of occurrence of Amblyomma americanum (Ixodida: Ixodidae).

In addition to being a major nuisance biter, the lone star tick, Amblyomma americanum (L.), is increasingly recognized as an important vector of pathogens affecting humans, domestic animals, and wildlife. Despite its notoriety, efforts have been lacking to define the spatial occurrence ofA. americanum in the continental United States with precision beyond that conveyed in continental-scale distribution maps. Here we present a county-level distribution map for A. americanum generated by compiling collection records obtained from a search of the published literature and databases managed by the USDA, U.S. National Tick Collection, and Walter Reed Biosystematics Unit. Our decadal and cumulative maps, which visually summarize 18,121 collections made between 1898 and 2012, show that A. americanum is either established (> or = six ticks or -two life stages) or reported (

Socioeconomic gradients in sexually transmitted diseases: a geographic information system-based analysis of poverty, race/ethnicity, and gonorrhea rates in California, 2004-2006.

OBJECTIVES: We quantified the relationship between gonorrheal infection rates in California and a measure of poverty status and investigated how this relationship and the spatial dispersion of cases varied among the 4 dominant racial/ethnic groups in the state. METHODS: We geocoded gonorrhea cases reported in California between 2004 and 2006, and estimated the poverty status of each case by using the percentage of residents living below poverty in the census tract of residence. We calculated infection rates for African American, Asian, Hispanic, and White cases in each of 4 poverty strata. We mapped cases to visualize the patterns of spatial dispersion associated with each race/ethnicity-poverty combination. RESULTS: There was a strong positive relationship between poverty and infection, but racial/ethnic disparities in infection, driven by a disproportionate level of gonorrhea among African Americans, eclipsed this differential. The degree of spatial aggregation varied substantially among groups and was especially pronounced for African Americans with gonorrhea in the highest poverty category. CONCLUSIONS: Prevention efforts should target low-income neighborhood "hot spots" to reach the largest numbers of cases, particularly among African Americans.

Edaphic quality and plant-pathogen interactions: effects of soil calcium on fungal infection of a serpentine flax.

Spatial variation in the frequency and outcome of interspecific interactions is thought to play a central role in shaping geographic patterns of biodiversity. Previous empirical studies and modeling exercises suggest that negative species interactions should occur with greater frequency and intensity in high-quality/low-stress environments. I tested this hypothesis through a four-year epidemiological study of interactions between the plant Hesperolinon californicum and the pathogenic rust fungus Melampsora lini. By virtue of its association with serpentine soils, H. californicum is exposed to edaphic conditions that are stressful to most plants. Notable among these is the low availability of calcium, an element that plays critically important roles in the immune responses of plants to attacking pathogens. As a serpentine generalist, however, H. californicum grows in soils with a wide range of calcium concentrations, and this should lead to differences in the frequency and/or severity of rust infection among host populations. I investigated geographic variation in disease pressure by conducting annual surveys in 16 populations spanning the host's distribution and representing a range of soil calcium concentrations. Results indicated that plants growing in more stressful low-calcium soils experienced higher rates of rust infection, suggesting that soil calcium may modulate host susceptibility in a manner opposite to that predicted by the a priori hypothesis. Epidemiological surveys further revealed a latitudinal cline in disease prevalence, with high infection rates in northern host populations decreasing gradually toward the south. Studies of the fitness effects of disease demonstrated that rust infection caused significant reductions in host survival and fecundity, and there was evidence of a demographic feedback between infection prevalence and host density across survey years.