Epidemiologic and Clinical Features of Children and Adolescents Aged <18 Years with Monkeypox - United States, May 17-September 24, 2022.

Data on monkeypox in children and adolescents aged <18 years are limited (1,2). During May 17­September 24, 2022, a total of 25,038 monkeypox cases were reported in the United States,† primarily among adult gay, bisexual, and other men who have sex with men (3). During this period, CDC and U.S. jurisdictional health departments identified Monkeypox virus (MPXV) infections in 83 persons aged <18 years, accounting for 0.3% of reported cases. Among 28 children aged 0­12 years with monkeypox, 64% were boys, and most had direct skin-to-skin contact with an adult with monkeypox who was caring for the child in a household setting. Among 55 adolescents aged 13­17 years, most were male (89%), and male-to-male sexual contact was the most common presumed exposure route (66%). Most children and adolescents with monkeypox were non-Hispanic Black or African American (Black) (47%) or Hispanic or Latino (Hispanic) (35%). Most (89%) were not hospitalized, none received intensive care unit (ICU)­level care, and none died. Monkeypox in children and adolescents remains rare in the United States. Ensuring equitable access to monkeypox vaccination, testing, and treatment is a critical public health priority. Vaccination for adolescents with risk factors and provision of prevention information for persons with monkeypox caring for children might prevent additional infections.

Epidemiologic and Clinical Characteristics of Monkeypox Cases - United States, May 17-July 22, 2022.

Monkeypox, a zoonotic infection caused by an orthopoxvirus, is endemic in parts of Africa. On August 4, 2022, the U.S. Department of Health and Human Services declared the U.S. monkeypox outbreak, which began on May 17, to be a public health emergency (1,2). After detection of the first U.S. monkeypox case), CDC and health departments implemented enhanced monkeypox case detection and reporting. Among 2,891 cases reported in the United States through July 22 by 43 states, Puerto Rico, and the District of Columbia (DC), CDC received case report forms for 1,195 (41%) cases by July 27. Among these, 99% of cases were among men; among men with available information, 94% reported male-to-male sexual or close intimate contact during the 3 weeks before symptom onset. Among the 88% of cases with available data, 41% were among non-Hispanic White (White) persons, 28% among Hispanic or Latino (Hispanic) persons, and 26% among non-Hispanic Black or African American (Black) persons. Forty-two percent of persons with monkeypox with available data did not report the typical prodrome as their first symptom, and 46% reported one or more genital lesions during their illness; 41% had HIV infection. Data suggest that widespread community transmission of monkeypox has disproportionately affected gay, bisexual, and other men who have sex with men and racial and ethnic minority groups. Compared with historical reports of monkeypox in areas with endemic disease, currently reported outbreak-associated cases are less likely to have a prodrome and more likely to have genital involvement. CDC and other federal, state, and local agencies have implemented response efforts to expand testing, treatment, and vaccination. Public health efforts should prioritize gay, bisexual, and other men who have sex with men, who are currently disproportionately affected, for prevention and testing, while addressing equity, minimizing stigma, and maintaining vigilance for transmission in other populations. Clinicians should test patients with rash consistent with monkeypox,† regardless of whether the rash is disseminated or was preceded by prodrome. Likewise, although most cases to date have occurred among gay, bisexual, and other men who have sex with men, any patient with rash consistent with monkeypox should be considered for testing. CDC is continually evaluating new evidence and tailoring response strategies as information on changing case demographics, clinical characteristics, transmission, and vaccine effectiveness become available.§.

Impact of close interpersonal contact on COVID-19 incidence: Evidence from 1 year of mobile device data.

Close contact between people is the primary route for transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). We quantified interpersonal contact at the population level using mobile device geolocation data. We computed the frequency of contact (within 6 feet) between people in Connecticut during February 2020 to January 2021 and aggregated counts of contact events by area of residence. When incorporated into a SEIR-type model of COVID-19 transmission, the contact rate accurately predicted COVID-19 cases in Connecticut towns. Contact in Connecticut explains the initial wave of infections during March to April, the drop in cases during June to August, local outbreaks during August to September, broad statewide resurgence during September to December, and decline in January 2021. The transmission model fits COVID-19 transmission dynamics better using the contact rate than other mobility metrics. Contact rate data can help guide social distancing and testing resource allocation.

Automated Digital Notification of COVID-19 Diagnoses Through Text and Email Messaging - North Carolina, December 2020-January 2021.

During October 3, 2020-January 9, 2021, North Carolina experienced a 400% increase in daily reported COVID-19 cases (1). To handle the increased number of cases and rapidly notify persons receiving a positive SARS-CoV-2 test result (patients), North Carolina state and local health departments moved from telephone call notification only to telephone call plus automated text and email notification (digital notification) beginning on December 24, 2020. Overall, among 200,258 patients, 142,975 (71%) were notified by telephone call or digital notification within the actionable period (10 days from their diagnosis date)* during January 2021, including at least 112,543 (56%) notified within 24 hours of report to North Carolina state and local health departments, a significantly higher proportion than the 25,905 of 175,979 (15%) notified within 24 hours during the preceding month (p<0.001). Differences in text notification by age, race, and ethnicity were observed. Automated digital notification is a feasible, rapid and efficient method to support timely outreach to patients, provide guidance on how to isolate, access resources, inform close contacts, and increase the efficiency of case investigation staff members.

Impact of close interpersonal contact on COVID-19 incidence: evidence from one year of mobile device data.

Close contact between people is the primary route for transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). We sought to quantify interpersonal contact at the population-level by using anonymized mobile device geolocation data. We computed the frequency of contact (within six feet) between people in Connecticut during February 2020 - January 2021. Then we aggregated counts of contact events by area of residence to obtain an estimate of the total intensity of interpersonal contact experienced by residents of each town for each day. When incorporated into a susceptible-exposed-infective-removed (SEIR) model of COVID-19 transmission, the contact rate accurately predicted COVID-19 cases in Connecticut towns during the timespan. The pattern of contact rate in Connecticut explains the large initial wave of infections during March-April, the subsequent drop in cases during June-August, local outbreaks during August-September, broad statewide resurgence during September-December, and decline in January 2021. Contact rate data can help guide public health messaging campaigns to encourage social distancing and in the allocation of testing resources to detect or prevent emerging local outbreaks more quickly than traditional case investigation. ONE SENTENCE SUMMARY: Close interpersonal contact measured using mobile device location data explains dynamics of COVID-19 transmission in Connecticut during the first year of the pandemic.

Physical Activity Facilitators and Barriers Among Retired Women in North Carolina: A Qualitative Study.

BACKGROUND Women are less likely than men to be physically active and more likely to reduce their physical activity as they age. The objective of this research was to understand barriers that might prevent North Carolina women from being physically active after retirement as well as aspects of retirement that might facilitate a more physically active lifestyle to inform intervention strategies applicable to retired women.METHOD Semi-structured interviews were conducted with 15 recently retired women living in North Carolina. Interviews were recorded and transcribed. Content analysis was used to identify themes related to barriers and facilitators of physical activity after retirement.RESULTS Six themes were identified. One theme was the development of leisure-time physical activity habits over the lifespan. Five other themes described how physical activity after retirement was influenced by prior occupational physical activity, concurrent life transitions (e.g., becoming a caregiver), health, social support, and the community environment.LIMITATIONS Women in this study were active participants in community organizations, which might make their experiences unique from those of women who are not engaged with their communities. However, similarities in themes in this and other qualitative studies corroborate the broader transferability of findings.CONCLUSION Interventions to promote physical activity among retired North Carolina women should consider emphasizing health benefits of physical activity and improving walking environments and access to physical activity facilities. Local residents should be involved in intervention design to address unique barriers among women who retire from physically demanding jobs or become caregivers.

Anhydrous Ammonia Chemical Release - Lake County, Illinois, April 2019.

On April 25, 2019, a farm tractor towing two 2-ton ammonia tanks on a county road in Lake County, Illinois, experienced a mechanical failure that resulted in the release of anhydrous ammonia, a colorless, pungent, irritating gas that can cause severe respiratory and ocular damage (1). Approximately 80% of anhydrous ammonia produced in the United States is used as a fertilizer in agriculture (1). Eighty-three persons, including first responders, motorists, and neighborhood residents, were evaluated at area hospitals because of exposure to the gas. Two weeks after the release, the Agency for Toxic Substances and Disease Registry (ATSDR) and CDC's National Center for Environmental Health (NCEH) collaborated with the Lake County Health Department and the Illinois Department of Public Health on an investigation using ATSDR's Assessment of Chemical Exposures program to describe the release, review the emergency response, and determine health effects associated with the exposure. First responders, community residents, and hospital personnel reported communication challenges related to the nature of the gas release and effective protective measures. Among the 83 persons evaluated at six area hospitals for effects of the chemical release, 14 (17%) were hospitalized, including eight (10%) who were admitted to the intensive care unit (ICU), seven (8%) of whom required endotracheal intubation and mechanical ventilation; no deaths occurred. In addition, ICU health care providers experienced symptoms of secondary exposure. The National Institute for Occupational Safety and Health's Emergency Responder Health Monitoring and Surveillance Program has specific recommendations and tools to protect responders during all phases of a response (2). Hospitals also need to review institutional policies and procedures for chemical mass casualty events, including decontamination (3). Prompt and correct identification of hazardous material (hazmat) events, and clear communication among responding entities, including on-scene and hospital responders, is important to ensure effective response after a chemical release.

Sepsis Attributed to Bacterial Contamination of Platelets Associated with a Potential Common Source - Multiple States, 2018.

During May-October 2018, four patients from three states experienced sepsis after transfusion of apheresis platelets contaminated with Acinetobacter calcoaceticus-baumannii complex (ACBC) and Staphylococcus saprophyticus; one patient died. ACBC isolates from patients' blood, transfused platelet residuals, and two environmental samples were closely related by whole genome sequencing. S. saprophyticus isolates from two patients' blood, three transfused platelet residuals, and one hospital environmental sample formed two whole genome sequencing clusters. This whole genome sequencing analysis indicated a potential common source of bacterial contamination; investigation into the contamination source continues. All platelet donations were collected using apheresis cell separator machines and collection sets from the same manufacturer; two of three collection sets were from the same lot. One implicated platelet unit had been treated with pathogen-inactivation technology, and two had tested negative with a rapid bacterial detection device after negative primary culture. Because platelets are usually stored at room temperature, bacteria in contaminated platelet units can proliferate to clinically relevant levels by the time of transfusion. Clinicians should monitor for sepsis after platelet transfusions even after implementation of bacterial contamination mitigation strategies. Recognizing adverse transfusion reactions and reporting to the platelet supplier and hemovigilance systems is crucial for public health practitioners to detect and prevent sepsis associated with contaminated platelets.

Temporal trends in validated ischaemic stroke hospitalizations in the USA.

BACKGROUND: Accurate assessment of the burden of stroke, a major cause of disability and death, is crucial. We aimed to estimate rates of validated ischaemic stroke hospitalizations in the USA during 1998-2011. METHODS: We used the Atherosclerosis Risk in Communities (ARIC) study cohort's adjudicated stroke data for participants aged ≥55 years, to construct validation models for each International Classification of Diseases (ICD)-code group and patient covariates. These models were applied to the Nationwide Inpatient Sample (NIS) data to estimate the probability of validated ischaemic stroke for each eligible hospitalization. Rates and trends in NIS using ICD codes vs estimates of validated ischaemic stroke were compared. RESULTS: After applying validation models, the estimated annual average rate of validated ischaemic stroke hospitalizations in the USA during 1998-2011 was 3.37 [95% confidence interval (CI): 3.31, 3.43) per 1000 person-years. Validated rates declined during 1998-2011 from 4.7/1000 to 2.9/1000; however, the decline was limited to 1998-2007, with no further decline subsequently through 2011. Validation models showed that the false-positive (∼23% of strokes) and false-negative rates of ICD-9-CM codes in primary position for ischaemic stroke approximately cancel. Therefore, estimates of ischaemic stroke hospitalizations did not substantially change after applying validation models. CONCLUSIONS: Overall, ischaemic stroke hospitalization rates in the USA have declined during 1998-2007, but no further decline was observed from 2007 to 2011. Validated ischaemic stroke hospitalizations estimates were similar to published estimates of hospitalizations with ischaemic stroke ICD codes in primary position. Validation of national discharge data using prospective chart review data is important to estimate the accuracy of reported burden of stroke.

Correlates of changes in walking during the retirement transition: The Multi-Ethnic Study of Atherosclerosis.

Retirement from employment involves disruption in daily routines and has been associated with positive and negative changes in physical activity. Walking is the most common physical activity among older Americans. The factors that influence changes in walking after retirement are unknown. The study objective was to identify correlates of within-person change in recreational walking (for leisure) and transport walking (to get places) during the retirement transition among a multi-ethnic cohort of adults (N = 928) from six US communities. Correlates were measured at the individual (e.g., gender), interpersonal (e.g., social support), and community (e.g., density of walking destinations) levels at study exams between 2000 and 2012. Comparing pre- and post-retirement measures (average 4.5 years apart), 50% of participants increased recreational walking by 60 min or more per week, 31% decreased by 60 min or more per week, and 19% maintained their recreational walking. Forty-one percent of participants increased transport walking by 60 min or more per week, 40% decreased by 60 min or more per week, and 19% maintained their transport walking after retirement. Correlates differed for recreational and transport walking and for increases compared to decreases in walking. Self-rated health, chronic conditions, and perceptions of the neighborhood walking environment were associated with changes in both types of walking after retirement. Further, some correlates differed by gender and retirement age. Findings can inform the targeting of interventions to promote walking during the retirement transition.

Physical Activity, Sedentary Behavior, and Retirement: The Multi-Ethnic Study of Atherosclerosis.

INTRODUCTION: Physical activity and sedentary behavior are major risk factors for chronic disease. These behaviors may change at retirement, with implications for health in later life. The study objective was to describe longitudinal patterns of moderate to vigorous and domain-specific physical activity and TV watching by retirement status. METHODS: Participants in the Multi-Ethnic Study of Atherosclerosis (n=6,814) were recruited from six U.S. communities and were aged 45-84 years at baseline. Retirement status and frequency and duration of domain-specific physical activity (recreational walking, transport walking, non-walking leisure activity, caregiving, household, occupational/volunteer) and TV watching were self-reported at four study exams (2000 to 2012). Fixed effect linear regression models were used to describe longitudinal patterns in physical activity and TV watching by retirement status overall and stratified by socioeconomic position. Analyses were conducted in 2017. RESULTS: Of 4,091 Multi-Ethnic Study of Atherosclerosis participants not retired at baseline, 1,012 (25%) retired during a median of 9 years follow-up. Retirement was associated with a 10% decrease (95% CI= -15%, -5%) in moderate to vigorous physical activity and increases of 13% to 29% in recreational walking, household activity, and TV watching. Among people of low socioeconomic position, the magnitude of association was larger for moderate to vigorous physical activity. Among people of high socioeconomic position, the magnitude of association was larger for non-walking leisure and household activity. CONCLUSIONS: The retirement transition was associated with changes in physical activity and TV watching. To inform intervention development, future research is needed on the determinants of behavior change after retirement, particularly among individuals of low socioeconomic position.

Correlates of US adult physical activity and sedentary behavior patterns.

OBJECTIVES: Physical activity and sedentary behavior patterns may be differentially associated with socio-demographic and health measures. We explored correlates of day-to-day patterns over a week in accelerometer measured physical activity and sedentary behavior to inform intervention development. DESIGN: Cross-sectional study. METHODS: National Health and Nutrition Examination Survey (NHANES) adult participants (≥20 years) in 2003-2006 wore an accelerometer for 1 week. Accelerometer data from 7236 participants were used to derive latent classes describing day-to-day patterns over a week of physical activity and sedentary behavior. Correlates of each pattern were identified using multinomial logistic regression from 21 potential variables grouped into four domains: socio-demographic, acculturation, cardiovascular, and health history. RESULTS: Older age, female sex, higher body mass index, and history of chronic disease were consistently associated with lower odds of being in a more active compared to the least active class. In contrast, being employed, speaking Spanish at home, and having better self-rated health were associated with higher odds of being in a more active compared to the least active class. CONCLUSIONS: Correlates of physical activity and sedentary behavior patterns were identified from all domains (socio-demographic, acculturation, cardiovascular, and health history). Most correlates that were positively associated with physical activity were negatively associated with sedentary behavior. Better understanding of the correlates of physical activity and sedentary behavior patterns can inform interventions to promote physical activity and reduce sedentary behavior.

Park characteristics, use, and physical activity: A review of studies using SOPARC (System for Observing Play and Recreation in Communities).

The System for Observing Play and Recreation in Communities (SOPARC) can obtain information on park users and their physical activity using momentary time sampling. We conducted a literature review of studies using the SOPARC tool to describe the observational methods of each study, and to extract public park use overall and by demographics and physical activity levels. We searched PubMed, Embase, and SPORTDiscus for full-length observational studies published in English in peer-reviewed journals through 2014. Twenty-four studies from 34 articles were included. The number of parks observed per study ranged from 3 to 50. Most studies observed parks during one season. The number of days parks were observed ranged from 1 to 16, with 16 studies observing 5 or more days. All studies included at least one weekday and all but two included at least one weekend day. Parks were observed from 1 to 14times/day, with most studies observing at least 4 times/day. All studies included both morning and afternoon observations, with one exception. There was a wide range of park users (mean 1.0 to 152.6 people/park/observation period), with typically more males than females visiting parks and older adults less than other age groups. Park user physical activity levels varied greatly across studies, with youths generally more active than adults and younger children more active than adolescents. SOPARC was adapted to numerous settings and these review results can be used to improve future studies using the tool, demonstrate ways to compare park data, and inform park promotions and programming.

Disparities in physical activity resource availability in six US regions.

OBJECTIVE: We conducted an ecological study to determine physical activity resource availability overall and by sociodemographic groups in parts of six states (CA, IL, MD, MN, NC, NY). METHODS: Data on parks and recreational facilities were collected from 3 sources in 2009-2012. Three measures characterized park and recreational facility availability at the census tract level: presence of ≥1 resource, number of resources, and resource kernel density. Associations between resource availability and census tract characteristics (predominant racial/ethnic group, median income, and proportion of children and older adults) were estimated using linear, binomial, and zero-inflated negative binomial regression in 2014. Pooled and stratified analyses were conducted. RESULTS: The study included 7139 census tracts, comprising 9.5% of the 2010 US population. Overall the availability of parks and recreational facilities was lower in predominantly minority relative to non-Hispanic white census tracts. Low-income census tracts and those with a higher proportion of children had an equal or greater availability of park resources but fewer recreational facilities. Stratification revealed substantial variation in resource availability by site. CONCLUSION: The availability of physical activity resources varied by sociodemographic characteristics and across regions. Improved knowledge of resource distribution can inform strategies to provide equitable access to parks and recreational facilities.

Measuring Physical Activity in Outdoor Community Recreational Environments: Implications for Research, Policy, and Practice.

Chronic diseases such as cardiovascular disease (CVD) are major contributors to escalating health care costs in the USA. Physical activity is an important protective factor against CVD, and the National Prevention Strategy recognizes active living (defined as a way of life that integrates physical activity into everyday routines) as a priority for improving the nation's health. This paper focuses on developing more inclusive measures of physical activity in outdoor community recreational environments, specifically parks and trails, to enhance their usability for at-risk populations such as persons with mobility limitations. We develop an integrated conceptual framework for measuring physical activity in outdoor community recreational environments, describe examples of evidence-based tools for measuring physical activity in these settings, and discuss strategies to improve measurement of physical activity for persons with mobility limitations. Addressing these measurement issues is critically important to making progress towards national CVD goals pertaining to active community environments.

Psychometric properties of the modified RESIDE physical activity questionnaire among low-income overweight women.

OBJECTIVES: This study explored the criterion-related validity and test-retest reliability of the modified RESIDential Environment physical activity questionnaire and whether the instrument's validity varied by body mass index, education, race/ethnicity, or employment status. DESIGN: Validation study using baseline data collected for randomized trial of a weight loss intervention. METHODS: Participants recruited from health departments wore an ActiGraph accelerometer and self-reported non-occupational walking, moderate and vigorous physical activity on the modified RESIDential Environment questionnaire. We assessed validity (n=152) using Spearman correlation coefficients, and reliability (n=57) using intraclass correlation coefficients. RESULTS: When compared to steps, moderate physical activity, and bouts of moderate/vigorous physical activity measured by accelerometer, these questionnaire measures showed fair evidence for validity: recreational walking (Spearman correlation coefficients 0.23-0.36), total walking (Spearman correlation coefficients 0.24-0.37), and total moderate physical activity (Spearman correlation coefficients 0.18-0.36). Correlations for self-reported walking and moderate physical activity were higher among unemployed participants and women with lower body mass indices. Generally no other variability in the validity of the instrument was found. Evidence for reliability of RESIDential Environment measures of recreational walking, total walking, and total moderate physical activity was substantial (intraclass correlation coefficients 0.56-0.68). CONCLUSIONS: Evidence for questionnaire validity and reliability varied by activity domain and was strongest for walking measures. The questionnaire may capture physical activity less accurately among women with higher body mass indices and employed participants. Capturing occupational activity, specifically walking at work, may improve questionnaire validity.

Validity of hospital discharge diagnosis codes for stroke: the Atherosclerosis Risk in Communities Study.

BACKGROUND AND PURPOSE: Characterizing International Classification of Disease 9th Revision, Clinical Modification (ICD-9-CM) code validity is essential given widespread use of hospital discharge databases in research. Using the Atherosclerosis Risk in Communities (ARIC) Study, we estimated the accuracy of ICD-9-CM stroke codes. METHODS: Hospitalizations with ICD-9-CM codes 430 to 438 or stroke keywords in the discharge summary were abstracted for ARIC cohort members (1987-2010). A computer algorithm and physician reviewer classified definite and probable ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Using ARIC classification as a gold standard, we calculated the positive predictive value (PPV) and sensitivity of ICD-9-CM codes grouped according to the American Heart Association/American Stroke Association (AHA/ASA) 2013 categories and an alternative code grouping for comparison. RESULTS: Thirty-three percent of 4260 hospitalizations were validated as strokes (1251 ischemic, 120 intracerebral hemorrhage, 46 subarachnoid hemorrhage). The AHA/ASA code groups had PPV 76% and 68% sensitivity compared with PPV 72% and 83% sensitivity for the alternative code groups. The PPV of the AHA/ASA code group for ischemic stroke was slightly higher among blacks, individuals <65 years, and at teaching hospitals. Sensitivity was higher among older individuals and increased over time. The PPV of the AHA/ASA code group for intracerebral hemorrhage was higher among blacks, women, and younger individuals. PPV and sensitivity varied across study sites. CONCLUSIONS: A new AHA/ASA discharge code grouping to identify stroke had similar PPV and lower sensitivity compared with an alternative code grouping. Accuracy varied by patient characteristics and study sites.