Sexual Exposures Associated With Mpox Infection: California, November 2022 to June 2023.

BACKGROUND: Exposures associated with mpox infection remain imperfectly understood. METHODS: We conducted a case-control study enrolling participants who received molecular tests for mpox/orthopoxvirus in California from November 2022 through June 2023. We collected data on behaviors during a 21-day risk period before symptom onset or testing among mpox case patients and test-negative controls. RESULTS: Thirteen of 54 case patients (24.1%) and 5 of 117 controls (4.3%) reported sexual exposure to individuals they identified as potential mpox case patients ("index contacts"; odds ratio [OR], 7.7 [95% confidence interval (CI), 2.5-19.3] relative to individuals who did not report exposure to potential mpox case patients). Among these participants, 10 of 13 case patients (76.9%) and 2 of 5 controls (40.0%) reported that their index contacts were not experiencing symptoms visible to participants during sex (OR, 14.9 [95% CI, 3.6-101.8]). Only 3 of 54 case patients (5.6%) reported exposure to symptomatic index contacts. Case patients reported more anal/vaginal sex partners than did controls (adjusted OR, 2.2 [95% CI, 1.0-4.8] for 2-3 partners and 3.8 [1.7-8.8] for ≥4 partners). Male case patients with penile lesions more commonly reported insertive anal/vaginal sex than those without penile lesions (adjusted OR, 9.3 [95% CI, 1.6-54.8]). Case patients with anorectal lesions more commonly reported receptive anal sex than those without anorectal lesions (adjusted OR, 14.4 [95% CI, 1.0-207.3]). CONCLUSIONS: Sexual exposure to contacts known or suspected to have experienced mpox was associated with increased risk of infection, often when index contacts lacked apparent symptoms. Exposure to more sex partners, including those whom participants did not identify as index contacts, was associated with increased risk of infection in a site-specific manner. While participants' assessment of symptoms in partners may be imperfect, these findings suggest that individuals without visibly prominent mpox symptoms transmit infection.

Reduced Odds of Mpox-Associated Hospitalization Among Persons Who Received JYNNEOS Vaccine - California, May 2022-May 2023.

The effectiveness of 1 dose of JYNNEOS vaccine (modified vaccinia Ankara vaccine, Bavarian Nordic) against hospitalization for mpox (caused by Monkeypox virus), has been demonstrated; however, the impact of 2 doses on hospitalization risk, especially among persons infected with HIV, who are at higher risk for severe disease, is an important factor in evaluating vaccine effectiveness against mpox disease severity and Monkeypox virus infection. Surveillance data collected by the California Department of Public Health were used to evaluate whether receipt of 2 doses of JYNNEOS vaccine reduced the odds of hospitalization among persons with mpox. The odds of hospitalization among persons with mpox who had received 1 or 2 JYNNEOS doses were 0.27 (95% CI = 0.08-0.65) and 0.20 (95% CI = 0.01-0.90), respectively, compared with unvaccinated mpox patients. In mpox patients with HIV infection, the odds of hospitalization among those who had received 1 JYNNEOS vaccine dose was 0.28 (95% CI = 0.05-0.91) times that of those who were unvaccinated. No mpox-associated hospitalizations were identified among persons infected with HIV who had received 2 JYNNEOS vaccine doses. To optimize durable immunity, all eligible persons at risk for mpox, especially those infected with HIV, should complete the 2-dose JYNNEOS series.

HIV and Sexually Transmitted Infections Among Persons with Monkeypox - Eight U.S. Jurisdictions, May 17-July 22, 2022.

High prevalences of HIV and other sexually transmitted infections (STIs) have been reported in the current global monkeypox outbreak, which has affected primarily gay, bisexual, and other men who have sex with men (MSM) (1-5). In previous monkeypox outbreaks in Nigeria, concurrent HIV infection was associated with poor monkeypox clinical outcomes (6,7). Monkeypox, HIV, and STI surveillance data from eight U.S. jurisdictions* were matched and analyzed to examine HIV and STI diagnoses among persons with monkeypox and assess differences in monkeypox clinical features according to HIV infection status. Among 1,969 persons with monkeypox during May 17-July 22, 2022, HIV prevalence was 38%, and 41% had received a diagnosis of one or more other reportable STIs in the preceding year. Among persons with monkeypox and diagnosed HIV infection, 94% had received HIV care in the preceding year, and 82% had an HIV viral load of <200 copies/mL, indicating HIV viral suppression. Compared with persons without HIV infection, a higher proportion of persons with HIV infection were hospitalized (8% versus 3%). Persons with HIV infection or STIs are disproportionately represented among persons with monkeypox. It is important that public health officials leverage systems for delivering HIV and STI care and prevention to reduce monkeypox incidence in this population. Consideration should be given to prioritizing persons with HIV infection and STIs for vaccination against monkeypox. HIV and STI screening and other recommended preventive care should be routinely offered to persons evaluated for monkeypox, with linkage to HIV care or HIV preexposure prophylaxis (PrEP) as appropriate.

West Nile Virus-Associated Hospitalizations, California, 2004-2017.

BACKGROUND: West Nile virus (WNV) is the most commonly reported mosquito-borne disease in the USA. California reports more WNV disease than any other state. METHODS: We identified WNV-associated hospitalizations from 2004 through 2017 in California and estimated hospitalization incidence using Patient Discharge Data. We described demographic, geographic, and clinical characteristics of WNV hospitalizations; identified risk factors for in-hospital death; and tabulated hospitalization charges. RESULTS: From 2004 through 2017, 3109 Californians were hospitalized with WNV (median, 214 patients/year; range, 72-449). The majority were male (1983; 63.8%) and aged ≥60 years (1766; 56.8%). The highest median annual hospitalization rate (0.88 hospitalizations/100 000 persons) was in the Central Valley, followed by southern California (0.59 hospitalizations/100 000 persons). Most patients (2469; 79.4%) had ≥1 underlying condition, including hypertension, cardiovascular disease, diabetes, chronic kidney disease, or immunosuppression due to medications or disease. Median hospitalization length of stay was 12 days (interquartile range, 6-23 days). During hospitalization, 1317 (42%) patients had acute respiratory failure and/or sepsis/septic shock, 772 (24.8%) experienced acute kidney failure, and 470 (15.1%) had paralysis; 272 (8.8%) patients died. Nearly 47% (1444) of patients were discharged for additional care. During these 14 years, $838 680 664 (mean $59.9 million/year) was charged for WNV hospitalizations, 73.9% through government payers at a median charge of $142 321/patient. CONCLUSIONS: WNV-associated hospitalizations were substantial and costly in California. Hospitalization incidence was higher in males, elderly persons, and patients with underlying conditions. WNV persists as a costly and severe public health threat in California.

Thermal thresholds heighten sensitivity of West Nile virus transmission to changing temperatures in coastal California.

Temperature is widely known to influence the spatio-temporal dynamics of vector-borne disease transmission, particularly as temperatures vary across critical thermal thresholds. When temperature conditions exhibit such 'transcritical variation', abrupt spatial or temporal discontinuities may result, generating sharp geographical or seasonal boundaries in transmission. Here, we develop a spatio-temporal machine learning algorithm to examine the implications of transcritical variation for West Nile virus (WNV) transmission in the Los Angeles metropolitan area (LA). Analysing a large vector and WNV surveillance dataset spanning 2006-2016, we found that mean temperatures in the previous month strongly predicted the probability of WNV presence in pools of Culex quinquefasciatus mosquitoes, forming distinctive inhibitory (10.0-21.0°C) and favourable (22.7-30.2°C) mean temperature ranges that bound a narrow 1.7°C transitional zone (21-22.7°C). Temperatures during the most intense months of WNV transmission (August/September) were more strongly associated with infection probability in Cx. quinquefasciatus pools in coastal LA, where temperature variation more frequently traversed the narrow transitional temperature range compared to warmer inland locations. This contributed to a pronounced expansion in the geographical distribution of human cases near the coast during warmer-than-average periods. Our findings suggest that transcritical variation may influence the sensitivity of transmission to climate warming, and that especially vulnerable locations may occur where present climatic fluctuations traverse critical temperature thresholds.

Probable transfusion transmission of West Nile virus from an apheresis platelet that screened non-reactive by individual donor-nucleic acid testing.

BACKGROUND: Despite West Nile virus (WNV) blood donation screening using nucleic acid testing (NAT), donors with low viral loads not detected by mini-pool-NAT have led to transfusion transmitted (TT)-WNV infection. We describe a probable case of fatal TT-WNV infection from an individual donor (ID)-NAT non-reactive apheresis platelet donation. STUDY DESIGN AND METHODS: An apheresis platelet donation was WNV ID-NAT reactive and prior donations from the same donor were investigated. A WNV ID-NAT non-reactive apheresis platelet unit collected 26 days earlier was transfused during heart transplantation to a patient who subsequently developed WNV neuroinvasive disease and expired. The source of the recipient's WNV infection was investigated. RESULTS: Twenty-six days after collection of the suspect platelet unit, a donation from the same donor was WNV ID-NAT reactive and WNV IgM and IgG positive. In addition to the suspect platelet unit, the heart transplant recipient who developed WNV infection received 17 blood components from 24 donors. Serologic testing performed on 11 of the remaining 24 donors (46%) was WNV IgM negative. Pre-transplant recipient and heart donor samples tested WNV RNA and IgM negative. CONCLUSION: A probable case of fatal neuroinvasive TT-WNV was linked to an infectious apheresis platelet unit undetected by WNV ID-NAT. It is hypothesized that the suspect unit was collected early in the viremic period when viral RNA was below the limit-of-detection of the ID-NAT assay. Implementation of ID-NAT screening of blood donors has not entirely eliminated the risk of TT-WNV infections, which may best be addressed by pathogen inactivation technologies.

Identification and Monitoring of International Travelers During the Initial Phase of an Outbreak of COVID-19 - California, February 3-March 17, 2020.

The threat of introduction of coronavirus disease 2019 (COVID-19) into the United States with the potential for community transmission prompted U.S. federal officials in February 2020 to screen travelers from China, and later Iran, and collect and transmit their demographic and contact information to states for follow-up. During February 5-March 17, 2020, the California Department of Public Health (CDPH) received and transmitted contact information for 11,574 international travelers to 51 of 61 local health jurisdictions at a cost of 1,694 hours of CDPH personnel time. If resources permitted, local health jurisdictions contacted travelers, interviewed them, and oversaw 14 days of quarantine, self-monitoring, or both, based on CDC risk assessment criteria for COVID-19. Challenges encountered during follow-up included errors in the recording of contact information and variation in the availability of resources in local health jurisdictions to address the substantial workload. Among COVID-19 patients reported to CDPH, three matched persons previously reported as travelers to CDPH. Despite intensive effort, the traveler screening system did not effectively prevent introduction of COVID-19 into California. Effectiveness of COVID-19 screening and monitoring in travelers to California was limited by incomplete traveler information received by federal officials and transmitted to states, the number of travelers needing follow-up, and the potential for presymptomatic and asymptomatic transmission. More efficient methods of collecting and transmitting passenger data, including electronic provision of flight manifests by airlines to federal officials and flexible text-messaging tools, would help local health jurisdictions reach out to all at-risk travelers quickly, thereby facilitating timely testing, case identification, and contact investigations. State and local health departments should weigh the resources needed to implement incoming traveler monitoring against community mitigation activities, understanding that the priorities of each might shift during the COVID-19 pandemic.

Population structure of Streptococcus pneumoniae colonizing children before and after universal use of pneumococcal conjugate vaccines in Brazil: emergence and expansion of the MDR serotype 6C-CC386 lineage.

Objectives: To determine the population structure and change in drug resistance of pneumococci colonizing children before and after the introduction of the 10-valent and 13-valent pneumococcal conjugate vaccines (PCV10/13) in Brazil. Methods: We used MLST to analyse 256 pneumococcal isolates obtained from children aged <6 years before (2009-10; n = 125) and after (2014; n = 131) the introduction of the PCV10 and PCV13. Antimicrobial susceptibility and capsular types were previously determined. Results: We identified 97 different STs. Ninety (35.2%) isolates were related to international clones. The most frequent lineages were serogroup 6-CC724 (where CC stands for clonal complex) and the MDR serotype 6C-CC386 in the pre- and post-PCV10/13 periods, respectively. Penicillin-non-susceptible pneumococci (PNSP) formed 24% and 38.9% of the pre- and post-PCV10/13 isolates, respectively (P = 0.01). In the pre-PCV10/13 period, serotype 14-ST156 was the predominant penicillin-non-susceptible lineage, but it was not detected in the post-PCV10/13 period. Serotype 14-ST156 and serotype 19A-ST320 complex isolates had the highest penicillin and ceftriaxone MICs in the pre- and post-PCV10/13 periods, respectively. In turn, serotype 6C-CC386 comprised almost 30% of the PNSP and over 40% of the erythromycin-resistant isolates (MIC >256 mg/L) in the post-PCV10/13 period. Conclusions: Although PNSP strains were polyclonal, most resistant isolates belonged to a single genotype from each period. Higher erythromycin resistance prevalence (42%) in the post-PCV10/13 period was mainly attributed to MDR serotype 6C-CC386. Ongoing surveillance of pneumococcal clonal composition is important to evaluate PCV use outcomes and to identify factors other than PCVs that drive pneumococcal drug resistance evolution.

The association between community-associated Staphylococcus aureus colonization and disease: a meta-analysis.

BACKGROUND: Colonization with Staphylococcus aureus is a well-defined risk factor for disease in hospitals, which can range from minor skin infections to severe, systemic diseases. However, the generalizability of this finding has not been thoroughly investigated outside of the hospital environment. We aimed to assess the role of S. aureus colonization as a risk factor for disease in the community. METHODS: We performed a meta-analysis of observational studies and searched PubMed for articles published between December 1979 and May 23, 2016. We included cohort, cross-sectional, and case-control studies that reported quantitative estimates of both S. aureus colonization and disease statuses of all study subjects. We excluded studies on recently hospitalized subjects, long-term care facilities, surgery patients, dialysis patients, hospital staff, S. aureus outbreaks, and livestock-associated infections. Our meta-analysis was performed using random-effects analysis to obtain pooled odds ratios (ORs) to compare the odds of S. aureus disease with respect to S. aureus colonization status. RESULTS: We identified 3477 citations, of which 12 articles on 6998 subjects met the eligibility criteria. Overall, subjects colonized with S. aureus were more likely to progress to disease than those who were non-colonized: (OR 1.87, 95% CI 1.21-2.88, n = 7 studies). We observed a larger effect with methicillin-resistant S. aureus colonization (7.06, 4.60-10.84, n = 7 studies). However, the methicillin-sensitive S. aureus colonization was not associated with greater odds of disease (1.20, 0.69-2.06, n = 4 studies). Heterogeneity was present across studies in all of the subgroups: S. aureus (I2 = 95.0%, χ2 = 120.3, p < 0.001), MRSA (I2 = 92.8%, χ2 = 82.8, p = p < 0.001), and MSSA (I2 = 86.3%, χ2 = 21.8, p < 0.001). CONCLUSIONS: While the majority of papers individually support the assumption that colonization is a risk factor for S. aureus disease in the general population, there is marked heterogeneity between studies and further investigation is needed to identify the major sources of this variance. There is a shortage of literature addressing this topic in the community setting and a need for further research on colonization as a focus for disease prevention.

Risk factors for differential outcome following directly observed treatment (DOT) of slum and non-slum tuberculosis patients: a retrospective cohort study.

BACKGROUND: Brazil's National Tuberculosis Control Program seeks to improve tuberculosis (TB) treatment in vulnerable populations. Slum residents are more vulnerable to TB due to a variety of factors, including their overcrowded living conditions, substandard infrastructure, and limited access to healthcare compared to their non-slum dwelling counterparts. Directly observed treatment (DOT) has been suggested to improve TB treatment outcomes among vulnerable populations, but the program's differential effectiveness among urban slum and non-slum residents is not known. METHODS: We retrospectively compared the impact of DOT on TB treatment outcome in residents of slum and non-slum census tracts in Rio de Janeiro reported to the Brazilian Notifiable Disease Database in 2010. Patient residential addresses were geocoded to census tracts from the 2010 Brazilian Census, which were identified as slum (aglomerados subnormais -AGSN) and non-slum (non-AGSN) by the Census Bureau. Homeless and incarcerated cases as well as those geocoded outside the city's limits were excluded from analysis. RESULTS: In 2010, 6,601 TB cases were geocoded within Rio de Janeiro; 1,874 (27.4 %) were residents of AGSN, and 4,794 (72.6 %) did not reside in an AGSN area. DOT coverage among AGSN cases was 35.2 % (n = 638), while the coverage in non-AGSN cases was 26.2 % (n = 1,234). Clinical characteristics, treatment, follow-up, cure, death and abandonment were similar in both AGSN and non-AGSN TB patients. After adjusting for covariates, AGSN TB cases on DOT had 1.67 (95 % CI: 1.17, 2.4) times the risk of cure, 0.61 (95 % CI: 0.41, 0.90) times the risk of abandonment, and 0.1 (95 % CI: 0.01, 0.77) times the risk of death from TB compared to non-AGSN TB cases not on DOT. CONCLUSION: While DOT coverage was low among TB cases in both AGSN and non-AGSN communities, it had a greater impact on TB cure rate in AGSN than in non-AGSN populations in the city of Rio de Janeiro.

Tuberculosis DALY-Gap: Spatial and Quantitative Comparison of Disease Burden Across Urban Slum and Non-slum Census Tracts.

To quantitatively assess disease burden due to tuberculosis between populations residing in and outside of urban informal settlements in Rio de Janeiro, Brazil, we compared disability-adjusted life years (DALYs), or "DALY-gap." Using the 2010 Brazilian census definition of informal settlements as aglomerados subnormais (AGSN), we allocated tuberculosis (TB) DALYs to AGSN vs non-AGSN census tracts based on geocoded addresses of TB cases reported to the Brazilian Information System for Notifiable Diseases in 2005 and 2010. DALYs were calculated based on the 2010 Global Burden of Disease methodology. DALY-gap was calculated as the difference between age-adjusted DALYs/100,000 population between AGSN and non-AGSN. Total TB DALY in Rio in 2010 was 16,731 (266 DALYs/100,000). DALYs were higher in AGSN census tracts (306 vs 236 DALYs/100,000), yielding a DALY-gap of 70 DALYs/100,000. Attributable DALY fraction for living in an AGSN was 25.4%. DALY-gap was highest for males 40-59 years of age (501 DALYs/100,000) and in census tracts with <60% electricity (12,327 DALYs/100,000). DALY-gap comparison revealed spatial and quantitative differences in TB burden between slum vs non-slum census tracts that were not apparent using traditional measures of incidence and mortality. This metric could be applied to compare TB burden or burden for other diseases in mega-cities with large informal settlements for more targeted resource allocation and evaluation of intervention programs.

Hypertension in a Brazilian urban slum population.

Low- and middle-income countries account for the majority of hypertension disease burden. However, little is known about the distribution of this illness within subpopulations of these countries, particularly among those who live in urban informal settlements. A cross-sectional hypertension survey was conducted in 2003 among 5649 adult residents of a slum settlement in the city of Salvador, Brazil. Hypertension was defined as either an elevated arterial systolic (≥140 mmHg) or diastolic (≥90 mmHg) blood pressure. Sex-specific multivariable models of systolic blood pressure were constructed to identify factors associated with elevated blood pressure. The prevalence of hypertension in the population 18 years and older was 21% (1162/5649). Men had 1.2 times the risk of hypertension compared with women (95% confidence intervals (CI), 1.05, 1.36). Increasing age and lack of any schooling, particularly for women, were also significantly associated with elevated blood pressure (p < 0.05). There was also a direct association between men who were black and an elevated blood pressure. Among those who were hypertensive, 65.5% were aware of their condition, and only 36.3% of those aware were actively using anti-hypertensive medications. Men were less likely to be aware of their diagnosis or to use medications (p < 0.01 for both) than women. The prevalence of hypertension in this slum community was lower than reported frequencies in the non-slum population of Brazil and Salvador, yet both disease awareness and treatment frequency were low. Further research on hypertension and other chronic non-communicable diseases in slum populations is urgently needed to guide prevention and treatment efforts in this growing population.

High prevalence of Staphylococcus aureus and methicillin-resistant S. aureus colonization among healthy children attending public daycare centers in informal settlements in a large urban center in Brazil.

BACKGROUND: In the past decade methicillin-resistant Staphylococcus aureus (MRSA) has become increasingly prevalent in community settings. Attending a daycare center (DCC) is a known risk factor for colonization with MRSA. Brazil operates free, public DCCs for low-income families, some of which are located in census tracts defined by the Brazilian Census Bureau as informal settlements (aglomerados subnormais, AGSN). Physical and demographic characteristics of AGSNs suggest that S. aureus colonization prevalence would be higher, but little is known about the prevalence of MRSA in these settings. METHODS: We conducted a cross-sectional study to assess risk factors for S. aureus and MRSA colonization among children attending DCCs located in AGSN vs non-AGSN. Nasal swabs were collected from children aged three months to six years in 23 public DCCs in Niterói, Brazil between August 2011 and October 2012. RESULTS: Of 500 children enrolled in the study, 240 (48%) were colonized with S. aureus and 31 (6.2%) were colonized with MRSA. Children attending DCCs in AGSNs were 2.32 times more likely to be colonized with S. aureus (95% CI: 1.32, 4.08), and 3.27 times more likely to be colonized with MRSA than children attending non-AGSN DCCs (95% CI: 1.52, 7.01), adjusted for confounding variables. CONCLUSION: S. aureus and MRSA colonization prevalence among children attending DCCs in informal settlement census tracts was higher than previously reported in healthy pre-school children in Latin America. Our data suggest that transmission may occur more frequently in DCCs rather than at home, highlighting the importance of DCCs in AGSNs as potential MRSA reservoirs. This finding underscores the importance of local epidemiologic surveillance in vulnerable AGSN communities.

A comparison of social and spatial determinants of health between formal and informal settlements in a large metropolitan setting in Brazil.

Urban informal settlements are often under-recognized in national and regional surveys. A lack of quality intra-urban data frequently contributes to a one-size-fits-all public health intervention and clinical strategies that rarely address the variegated socioeconomic disparities across and within different informal settlements in a city. The 2010 Brazilian census gathered detailed population and place-based data across the country's informal settlements. Here, we examined key socio-demographic and infrastructure characteristics that are associated with health outcomes in Rio de Janeiro with the census tract as the unit of analysis. Many of the city's residents (1.39 million people, 22 % of the population) live in informal settlements. Residents of census tracts in Rio de Janeiro's urban informal areas are younger, (median age of 26 versus 35 years in formal settlements), and have less access to adequate water (96 versus 99 % of informal households), sanitation (86 versus 96 %), and electricity (67 versus 92 %). Average per household income in informal settlement census tracts is less than one third that of non-informal tracts (US\$708 versus US\$2362). Even among informal settlements in different planning areas in the same city, there is marked variation in these characteristics. Public health interventions, clinical management, and urban planning policies aiming to improve the living conditions of the people residing in informal settlements, including government strategies currently underway, must consider the differences that exist between and within informal settlements that shape place-based physical and social determinants of health.

Community-Based Participatory Research for Epidemiology, Health Equity, and Community Goals: Insights From Brazil, France, and USA.

BACKGROUND: Community-based participatory research coproduces knowledge by emphasizing bidirectional exchanges between participants, communities, and researchers. PURPOSE, RESEARCH DESIGN, AND STUDY SAMPLE: We highlight three studies in historically marginalized communities on separate continents (Richmond, CA, USA; Rio de Janeiro, Brazil; Marseille industrial zone, France) to exemplify how community-based participatory research improves research, offers tangible community benefits, and values residents more than traditional research methods. DATA ANALYSIS: We provide insights into the process of conducting meaningful community-based participatory epidemiologic research. RESULTS: In each of these communities, community-based participatory research led to high-quality research that helped inform context-appropriate policies and programs to improve health and advance health equity in these communities. CONCLUSIONS: We recommend that researchers consistently engage with community members during all phases of research so that they can engage more participants, more deeply in the research process, build local capacity, improve data collection and data quality, as well as increase our understanding of research findings to inform future applied research and practice.

Healthcare personnel with laboratory-confirmed mpox in California during the 2022 outbreak.

The California Department of Public Health (CDPH) reviewed 109 cases of healthcare personnel (HCP) with laboratory-confirmed mpox to understand transmission risk in healthcare settings. Overall, 90% of HCP with mpox had nonoccupational exposure risk factors. One occupationally acquired case was associated with sharps injury while unroofing a patient's lesion for diagnostic testing.

Comparing 7-Day Versus 6-8-Day Penicillin Treatment Intervals Among Pregnant People With Syphilis of Late or Unknown Duration: No Difference Found in Incidence of Congenital Syphilis.

Background: Guidelines recommend that pregnant patients with syphilis of late/unknown duration be treated with benzathine penicillin G, dosed as 3 weekly intramuscular injections (BPGx3) given ideally at strict 7-day intervals. Given limited pharmacokinetic data, it is unknown whether more flexible BPG treatment intervals might be effective in preventing congenital syphilis (CS). Methods: We used California surveillance data to identify birthing parent/infant dyads wherein the pregnant parent had syphilis of late/unknown duration between January 1, 2016 - June 30, 2019. We divided the dyads into 3 groups based on prenatal treatment: (1) BPGx3 at strict 7-day intervals, (2) BPGx3 at 6-8 day intervals, and (3) no/inadequate treatment. We then compared CS incidence among infants in each group. Results: We analyzed 1,092 parent/infant dyads: 607 (55.6%) in the 7-day treatment group, 70 (6.4%) in the 6-8 day treatment group, and 415 (38.0%) in the no/inadequate treatment group. The incidence proportion of infants meeting CS criteria in each group was, respectively, 5.6%, 5.7%, and 36.9%. Compared with BPGx3 at 7-day intervals, the odds of CS were 1.0 [95% CI 0.4-3.0] in the 6-8 day group and 9.8 [95% CI 6.6-14.7] in the no/inadequate treatment group. Conclusions: Prenatal BPGx3 at 6-8 days was no more likely to lead to CS in infants than 7-days. These findings hint that 6-8-day intervals might be adequate to prevent CS among pregnant people with syphilis of late/unknown duration. Consequently, it is possible that CS evaluation beyond an RPR at delivery may be unnecessary in asymptomatic infants whose parents received BPGx3 at 6-8 days.

Evaluation of the effectiveness of the California mosquito-borne virus surveillance & response plan, 2009-2018.

Local vector control and public health agencies in California use the California Mosquito-Borne Virus Surveillance and Response Plan to monitor and evaluate West Nile virus (WNV) activity and guide responses to reduce the burden of WNV disease. All available data from environmental surveillance, such as the abundance and WNV infection rates in Culex tarsalis and the Culex pipiens complex mosquitoes, the numbers of dead birds, seroconversions in sentinel chickens, and ambient air temperatures, are fed into a formula to estimate the risk level and associated risk of human infections. In many other areas of the US, the vector index, based only on vector mosquito abundance and infection rates, is used by vector control programs to estimate the risk of human WNV transmission. We built models to determine the association between risk level and the number of reported symptomatic human disease cases with onset in the following three weeks to identify the essential components of the risk level and to compare California's risk estimates to vector index. Risk level calculations based on Cx. tarsalis and Cx. pipiens complex levels were significantly associated with increased human risk, particularly when accounting for vector control area and population, and were better predictors than using vector index. Including all potential environmental components created an effective tool to estimate the risk of WNV transmission to humans in California.

Geospatial Social Determinants of Health Correlate with Disparities in Syphilis and Congenital Syphilis Cases in California.

Syphilis and congenital syphilis (CS) are increasing in California (CA). From 2015 through 2019, for example, CA cases of early syphilis among reproductive-age females (15−44) and CS each increased by >200%. Certain populations­including people experiencing homelessness, using drugs, and/or belonging to certain racial/ethnic groups­have been disproportionately impacted. We hypothesized that geospatial social determinants of health (SDH) contribute to such health inequities. To demonstrate this, we geospatially described syphilis in CA using the Healthy Places Index (HPI). The HPI is a composite index that assigns a score to each CA census tract based on eight socioeconomic characteristics associated with health (education, housing, transportation, neighborhood conditions, clean environment, and healthcare access as well as economic and social resources). We divided CA census tracts into four quartiles based on HPI scores (with the lowest quartile having the least healthy socioeconomic and environmental conditions), then used 2013−2020 CA sexually transmitted diseases surveillance data to compare overall syphilis (among adults and adolescents) and CS case counts, incidence rates (per 100,000 population or live births), and incidence rate ratios (IRRs) among these quartiles. From 2013 to 2020, across all stages of syphilis and CS, disease burden was greatest in the lowest HPI quartile and smallest in the highest quartile (8308 cases (representing 33.2% of all incidents) versus 3768 (15.1%) for primary and secondary (P&S) syphilis; 5724 (31.6%) versus 2936 (16.2%) for early non-primary non-secondary (NPNS) syphilis; 11,736 (41.9%) versus 3026 (10.8%) for late/unknown duration syphilis; and 849 (61.9%) versus 57 (4.2%) for CS; all with p < 0.001). Using the highest HPI quartile as a reference, the IRRs in the lowest quartile were 17 for CS, 4.5 for late/unknown duration syphilis, 2.6 for P&S syphilis, and 2.3 for early NPNS syphilis. We thus observed a direct relationship between less healthy conditions (per HPI) and syphilis/CS in California, supporting our hypothesis that SDH correlate with disparities in syphilis, especially CS. HPI could inform allocation of resources to: (1) support communities most in need of assistance in preventing syphilis/CS cases and (2) reduce health disparities.