Fatal Case of Heartland Virus Disease Acquired in the Mid-Atlantic Region, United States.

Heartland virus (HRTV) disease is an emerging tickborne illness in the midwestern and southern United States. We describe a reported fatal case of HRTV infection in the Maryland and Virginia region, states not widely recognized to have human HRTV disease cases. The range of HRTV could be expanding in the United States.

Advanced Materials for Energy-Water Systems: The Central Role of Water/Solid Interfaces in Adsorption, Reactivity, and Transport.

The structure, chemistry, and charge of interfaces between materials and aqueous fluids play a central role in determining properties and performance of numerous water systems. Sensors, membranes, sorbents, and heterogeneous catalysts almost uniformly rely on specific interactions between their surfaces and components dissolved or suspended in the water-and often the water molecules themselves-to detect and mitigate contaminants. Deleterious processes in these systems such as fouling, scaling (inorganic deposits), and corrosion are also governed by interfacial phenomena. Despite the importance of these interfaces, much remains to be learned about their multiscale interactions. Developing a deeper understanding of the molecular- and mesoscale phenomena at water/solid interfaces will be essential to driving innovation to address grand challenges in supplying sufficient fit-for-purpose water in the future. In this Review, we examine the current state of knowledge surrounding adsorption, reactivity, and transport in several key classes of water/solid interfaces, drawing on a synergistic combination of theory, simulation, and experiments, and provide an outlook for prioritizing strategic research directions.

Sepsis Electronic Decision Support Screen in High-Risk Patients Across Age Groups in a Pediatric Emergency Department.

OBJECTIVE: This study aimed to compare the performance of a pediatric decision support algorithm to detect severe sepsis between high-risk pediatric and adult patients in a pediatric emergency department (PED). METHODS: This is a retrospective cohort study of patients presenting from March 2017 to February 2018 to a tertiary care PED. Patients were identified as high risk for sepsis based on a priori defined criteria and were considered adult if 18 years or older. The 2-step decision support algorithm consists of (1) an electronic health record best-practice alert (BPA) with age-adjusted vital sign ranges, and (2) physician screen. The difference in test characteristics of the intervention for the detection of severe sepsis between pediatric and adult patients was assessed at 0.05 statistical significance. RESULTS: The 2358 enrolled subjects included 2125 children (90.1%) and 233 adults (9.9%). The median ages for children and adults were 3.8 (interquartile range, 1.2-8.6) and 20.1 (interquartile range, 18.2-22.0) years, respectively. In adults, compared with children, the BPA alone had significantly higher sensitivity (0.83 [95% confidence interval {CI}, 0.74-0.89] vs 0.72 [95% CI, 0.69-0.75]; P = 0.02) and lower specificity (0.11 [95% CI, 0.07-0.19] vs 0.48 [95% CI, 0.45-0.51; P < 0.001). With the addition of provider screen, sensitivity and specificity were comparable across age groups, with a lower negative predictive value in adults compared with children (0.66 [95% CI, 0.58-0.74] vs 0.77 [95% CI, 0.75-0.79]; P = 0.005). CONCLUSIONS: The BPA was less specific in adults compared with children. With the addition of provider screen, specificity improved; however, the lower negative predictive value suggests that providers may be less likely to suspect sepsis even after automated screen in adult patients. This study invites further research aimed at improving screening algorithms, particularly across the diverse age spectrum presenting to a PED.

Development and validation of a high-throughput whole cell assay to investigate Staphylococcus aureus adhesion to host ligands.

Staphylococcus aureus adhesion to the host's skin and mucosae enables asymptomatic colonization and the establishment of infection. This process is facilitated by cell wall-anchored adhesins that bind to host ligands. Therapeutics targeting this process could provide significant clinical benefits; however, the development of anti-adhesives requires an in-depth knowledge of adhesion-associated factors and an assay amenable to high-throughput applications. Here, we describe the development of a sensitive and robust whole cell assay to enable the large-scale profiling of S. aureus adhesion to host ligands. To validate the assay, and to gain insight into cellular factors contributing to adhesion, we profiled a sequence-defined S. aureus transposon mutant library, identifying mutants with attenuated adhesion to human-derived fibronectin, keratin, and fibrinogen. Our screening approach was validated by the identification of known adhesion-related proteins, such as the housekeeping sortase responsible for covalently linking adhesins to the cell wall. In addition, we also identified genetic loci that could represent undescribed anti-adhesive targets. To compare and contrast the genetic requirements of adhesion to each host ligand, we generated a S. aureus Genetic Adhesion Network, which identified a core gene set involved in adhesion to all three host ligands, and unique genetic signatures. In summary, this assay will enable high-throughput chemical screens to identify anti-adhesives and our findings provide insight into the target space of such an approach.

SARS-CoV-2 B.1.1.7 Variant Infection in Malayan Tigers, Virginia, USA.

We report infection of 3 Malayan tigers with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) B.1.1.7 (Alpha) variant at a zoologic park in Virginia, USA. All tigers exhibited respiratory signs consistent with SARS-CoV-2 infection. These findings show that tigers are susceptible to infection with the SARS-CoV-2 B.1.1.7 variant.

Coronavirus Disease among Workers in Food Processing, Food Manufacturing, and Agriculture Workplaces.

We describe coronavirus disease (COVID-19) among US food manufacturing and agriculture workers and provide updated information on meat and poultry processing workers. Among 742 food and agriculture workplaces in 30 states, 8,978 workers had confirmed COVID-19; 55 workers died. Racial and ethnic minority workers could be disproportionately affected by COVID-19.

Update: COVID-19 Among Workers in Meat and Poultry Processing Facilities - United States, April-May 2020.

Meat and poultry processing facilities face distinctive challenges in the control of infectious diseases, including coronavirus disease 2019 (COVID-19) (1). COVID-19 outbreaks among meat and poultry processing facility workers can rapidly affect large numbers of persons. Assessment of COVID-19 cases among workers in 115 meat and poultry processing facilities through April 27, 2020, documented 4,913 cases and 20 deaths reported by 19 states (1). This report provides updated aggregate data from states regarding the number of meat and poultry processing facilities affected by COVID-19, the number and demographic characteristics of affected workers, and the number of COVID-19-associated deaths among workers, as well as descriptions of interventions and prevention efforts at these facilities. Aggregate data on confirmed COVID-19 cases and deaths among workers identified and reported through May 31, 2020, were obtained from 239 affected facilities (those with a laboratory-confirmed COVID-19 case in one or more workers) in 23 states.* COVID-19 was confirmed in 16,233 workers, including 86 COVID-19-related deaths. Among 14 states reporting the total number of workers in affected meat and poultry processing facilities (112,616), COVID-19 was diagnosed in 9.1% of workers. Among 9,919 (61%) cases in 21 states with reported race/ethnicity, 87% occurred among racial and ethnic minority workers. Commonly reported interventions and prevention efforts at facilities included implementing worker temperature or symptom screening and COVID-19 education, mandating face coverings, adding hand hygiene stations, and adding physical barriers between workers. Targeted workplace interventions and prevention efforts that are appropriately tailored to the groups most affected by COVID-19 are critical to reducing both COVID-19-associated occupational risk and health disparities among vulnerable populations. Implementation of these interventions and prevention efforts† across meat and poultry processing facilities nationally could help protect workers in this critical infrastructure industry.

Reaction of NO2 with Groups IV and VI Transition Metal Oxide Clusters.

The addition of NO2 to Group IV (MO2)n and Group VI (MO3)n (n = 1-3) nanoclusters was studied using both density functional theory (DFT) and coupled cluster theory (CCSD(T)). The structures and overall binding energetics were predicted for Lewis acid-base addition without transfer of spin (a physisorption-type process) and the formation of either cluster-ONO (HONO-like or bidentate bonding) or NO3- formation where for both the spin is transferred to the metal oxide clusters (a chemisorption-type process). Only chemisorption of NO2 is predicted to be thermodynamically allowed at temperatures ≥298 K for Group IV (MO2)n clusters with the formation of surface chemisorbed NO2 being by far the most energetically favorable. The ligand binding energies (LBEs) for physisorption and chemisorption on the TiO2 nanoclusters are consistent with computational studies of the bulk solids. Chemisorption is only predicted to occur for (CrO3)n clusters in the form of a terminal nitrate containing species whereas the larger chemisorbed nitrate structures for (MoO3)n and (WO3)n were found to be metastable and unlikely to form in any appreciable amount at temperatures of 298 K and higher. NO2 is predicted to only be capable of physisorbing to (MoO3)n and (WO3)n at lower temperatures and therefore unlikely to bind NO2 at temperatures ≥298 K. Correlations between the (MO3)nNO2 ligand bond energies and the chemical properties of the parent (MO3)n clusters (Lewis acidity, ionization potentials, excitation energies, and M = O/M-O bond strengths) are described.

Psittacosis Outbreak among Workers at Chicken Slaughter Plants, Virginia and Georgia, USA, 2018.

During August-October, 2018, an outbreak of severe respiratory illness was reported among poultry slaughter plant workers in Virginia and Georgia, USA. A multiorganizational team investigated the cause and extent of illness, determined that the illness was psittacosis, and evaluated and recommended controls for health hazards in the workplace to prevent additional cases.

Human Rabies - Virginia, 2017.

On May 9, 2017, the Virginia Department of Health was notified regarding a patient with suspected rabies. The patient had sustained a dog bite 6 weeks before symptom onset while traveling in India. On May 11, CDC confirmed that the patient was infected with a rabies virus that circulates in dogs in India. Despite aggressive treatment, the patient died, becoming the ninth person exposed to rabies abroad who has died from rabies in the United States since 2008. A total of 250 health care workers were assessed for exposure to the patient, 72 (29%) of whom were advised to initiate postexposure prophylaxis (PEP). The total pharmaceutical cost for PEP (rabies immunoglobulin and rabies vaccine) was approximately $235,000. International travelers should consider a pretravel consultation with travel health specialists; rabies preexposure prophylaxis is warranted for travelers who will be in rabies endemic countries for long durations, in remote areas, or who plan activities that might put them at risk for a rabies exposures.

Exploring Attributes of High-Value Primary Care.

PURPOSE: Medicare's merit-based incentive payment system and narrowing of physician networks by health insurers will stoke clinicians' and policy makers' interest in care delivery attributes associated with value as defined by payers. METHODS: To help define these attributes, we analyzed 2009 to 2011 commercial health insurance claims data for more than 40 million preferred provider organization patients attributed to over 53,000 primary care practice sites. We identified sites ranking favorably on both quality and low total annual per capita health care spending ("high-value") and sites ranking near the median ("average-value"). Sites were selected for qualitative assessment from 64 high-value sites and 102 average-value sites with more than 1 primary care physician who delivered adult primary care and provided services to enough enrollees to permit meaningful spending and quality ranking. Purposeful sampling ensured regional diversity. Physicians experienced in primary care assessment and blinded to site rankings visited 12 high-value sites and 4 average-value sites to identify tangible attributes of care delivery that could plausibly explain a high ranking on value. RESULTS: Thirteen attributes of care delivery distinguished sites in the high-value cohort. Six attributes attained statistical significance: decision support for evidence-based medicine, risk-stratified care management, careful selection of specialists, coordination of care, standing orders and protocols, and balanced physician compensation. CONCLUSIONS: Awareness of care delivery attributes that distinguish their high-value peers may help physicians respond successfully to incentives from Medicare and private payers to lower annual health care spending and improve quality of care.

Reaction of CO2 with UO3 Nanoclusters.

Adsorption of CO2 to uranium oxide, (UO3)n, clusters was modeled using density functional theory (DFT) and coupled cluster theory (CCSD(T)). Geometries and reaction energies were predicted for carbonate formation (chemisorption) and Lewis acid-base addition of CO2 (physisorption) to these (UO3)n clusters. Chemisorption of multiple CO2 moieties was also modeled for dimer and trimer clusters. Physisorption and chemisorption were both predicted to be thermodynamically allowed for (UO3)n clusters, with chemisorption being more thermodynamically favorable than physisorption. The most energetically favored (UO3)3(CO2)m clusters contain tridentate carbonates, which is consistent with solid-state and solution structures for uranyl carbonates. The calculations show that CO2 exposure is likely to convert (UO3)n to uranyl carbonates.

Reaction of CO2 with Groups 4 and 6 Transition Metal Oxide Clusters.

Density functional theory (DFT) and coupled cluster theory (CCSD(T)) were used to study the addition of CO2 to group 4 (MO2)n and group 6 (MO3)n (n = 1, 2, 3) nanoclusters. The structures and energetics arising from Lewis acid-base addition (physisorption) and formation of CO32- (chemisorption) of CO2 to these clusters were predicted. Physisorption and chemisorption of CO2 are predicted to be thermodynamically allowed for group 4 (MO2)n clusters, with chemisorption being more favored energetically. Correlations of the ligand binding energies (LBEs) for the group 4 clusters are made with the fluoride affinities and M-O and M═O bond strengths of the clusters. The LBEs for chemisorption on the Zr and Ti clusters are consistent with published experimental and computational studies of bulk solids. Physisorption LBEs for the Ti and Zr clusters are more exothermic than the bulk values, as the cluster models allow for better relaxation at the metal sites. Chemisorption is not predicted to occur with group 6 (MO3)n clusters, as the larger chemisorbed structures were all found to be metastable. CO2 is predicted to weakly physisorb to (WO3)n with physisorption correlating with the Lewis acidity of the metal site.

Prevalence of Substance Use Among Patients of Community Health Centers in East Los Angeles and Tijuana.

BACKGROUND: Given the increased use of psychoactive substances on the United States-Mexico border, a binational study (Tijuana, Mexico-Los Angeles, USA) was conducted to identify the prevalence of substance use in primary care settings. OBJECTIVES: To compare the prevalence and characteristics of patients at risk for substance use disorders in Tijuana and East Los Angeles (LA) community clinics with special attention paid to drug use. METHODS: This was an observational, cross-sectional, analytical study, comparing substance use screening results from patients in Tijuana and LA. The settings were 2 community clinics in LA and 6 in Tijuana. Participants were 2,507 adult patients in LA and 2,890 in Tijuana eligible for WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) screening during March-October 2013. Patients anonymously self-administered the WHO ASSIST on a tablet PC in the clinic waiting rooms. RESULTS: Of eligible patients, 96.4% completed the ASSIST in Tijuana and 88.7% in LA (mean 1.34 minutes and 4.20 minutes, respectively). The prevalence of patients with moderate-to-high substance use was higher in LA than Tijuana for each substance: drugs 19.4% vs. 5.7%, alcohol 15.2% vs. 6.5%, tobacco 20.4% vs. 16.2%. LA patients born in Mexico had 2x the odds and LA patients born in the United States had 6x the odds of being a moderate-to-high drug user compared to Tijuana patients born in Mexico. CONCLUSIONS: Moderate-to-high drug use is higher in LA than in Tijuana but rates are sufficiently high in both to suggest that screening for drug use (along with alcohol and tobacco use) should be integrated into routine primary care of community clinics in both cities.

Compendium of Measures to Control Chlamydia psittaci Infection Among Humans (Psittacosis) and Pet Birds (Avian Chlamydiosis), 2017.

Psittacosis, also known as parrot fever and ornithosis, is a bacterial infection that can cause severe pneumonia and other serious health problems in humans. It is caused by Chlamydia psittaci. Reclassification of the order Chlamydiales in 1999 into 2 genera (Chlamydia and Chlamydophila) was not wholly accepted or adopted. This resulted in a reversion to the single, original genus Chlamydia, which now encompasses all 9 species including Chlamydia psittaci. During 2003-2014, 112 human cases of psittacosis were reported to the Centers for Disease Control and Prevention through the Nationally Notifiable Diseases Surveillance System. While many types of birds can be infected by C psittaci, in general, the literature suggests that human cases can most often occur after exposure to infected parrot-type birds kept as pets, especially cockatiels, parakeets, and conures. In birds, C psittaci infection is referred to as avian chlamydiosis. Infected birds shed the bacteria through feces and nasal discharges, and humans become infected from exposure to these materials. This compendium provides information about psittacosis and avian chlamydiosis to public health officials, physicians, veterinarians, the pet bird industry, and others concerned with controlling these diseases and protecting public health. The recommendations in this compendium provide standardized procedures to control C psittaci infections. This document will be reviewed and revised as necessary, and the most current version replaces all previous versions. This document was last revised in 2010. Major changes in this version include a recommendation for a shorter treatment time for birds with avian chlamydiosis, additional information about diagnostic testing, including genotyping, clearer language associated with personal protective equipment recommended for those caring for confirmed or exposed birds, and incorporating a grading scale with recommendations generally based on the United States Preventive Services Task Force's methods.

Streptococcus equi subsp. zooepidemicus infections associated with guinea pigs.

Streptococcus equi subsp. zooepidemicus is a known zoonotic pathogen. In this public health investigation conducted in Virginia, USA, in 2013, we identified a probable family cluster of S. zooepidemicus cases linked epidemiologically and genetically to infected guinea pigs. S. zooepidemicus infections should be considered in patients who have severe clinical illness and report guinea pig exposure.

Integrating Health Care for the Most Vulnerable: Bridging the Differences in Organizational Cultures Between US Hospitals and Community Health Centers.

Policymakers have increasingly promoted health services integration to improve quality and efficiency. The US health care safety net, which comprises providers of health care to uninsured, Medicaid, and other vulnerable patients, remains a largely fragmented collection of providers. We interviewed leadership from safety net hospitals and community health centers in 5 US cities (Boston, MA; Denver, CO; Los Angeles, CA; Minneapolis, MN; and San Francisco, CA) throughout 2013 on their experiences with service integration. We identify conflicts in organizational mission, identity, and consumer orientation that have fostered reluctance to enter into collaborative arrangements. We describe how smaller scale initiatives, such as capitated model for targeted populations, health information exchange, and quality improvements led by health plans, can help bridge cultural differences to lay the groundwork for developing integrated care programs.

Rabies in a Dog Imported from Egypt with a Falsified Rabies Vaccination Certificate--Virginia, 2015.

Canine rabies virus variant has been eliminated in the United States and multiple other countries. Globally, however, dogs remain the principal source for human rabies infections. The World Health Organization recommends that when dogs cross international borders, national importing authorities should require an international veterinary certificate attesting that the animal did not show signs of rabies at the time of shipment, was permanently identified, vaccinated, or revaccinated, and had been subjected to a serologic test for rabies before shipment. On June 8, 2015, an adult female dog that had recently been picked up from the streets of Cairo, Egypt, and shipped by a U.S. animal rescue organization to the United States was confirmed to have rabies by the Virginia Department of General Services Division of Consolidated Laboratory Services (DCLS). This dog was part of a large shipment of dogs and cats from Egypt that rescue organizations had distributed to multiple states for adoption. During the investigation, public health officials learned that the rabies vaccination certificate used for entry of the rabid dog into the United States had intentionally been falsified to avoid exclusion of the dog from entry under CDC's current dog importation regulations. This report underscores the ongoing risk posed by U.S. importation of domestic animals that have not been adequately vaccinated against rabies.

Safety net integration: a shared strategy for becoming providers of choice.

With the expansion of coverage as a result of federal health care reform, safety net providers are confronting a challenge to care for the underserved while also competing as a provider of choice for the newly insured. Safety net institutions may be able to achieve these goals by pursuing greater delivery system integration. We interviewed safety net hospital and community health center (CHCs) leaders in five US cities to determine what strategies these organizations are employing to promote care integration in the safety net. Although there is some experimentation with payment reform and health information exchange, safety net providers identify significant policy and structural barriers to integrating service delivery. The enhanced Medicaid payments for CHCs and the federal requirement that CHCs retain independent boards discourage these organizations from integrating with other safety net providers. Current policies are not mobilizing safety net providers to pursue integration as a way to deliver more efficient and effective care. Medicaid and other policies at the federal and state level could be revised to overcome known fragmentation in the health care safety net. This includes addressing the conflicts in financing and governance arrangements that are encouraging providers to resist integration to preserve their independence.

Self-Assembly of Hierarchical High-χ Fluorinated Block Copolymers with an Orthogonal Smectic-within-Lamellae 3 nm Sublattice and Vertical Surface Orientation.

Hierarchical structure-within-structure assemblies offer a route toward increasingly complex and multifunctional materials while pushing the limits of block copolymer self-assembly. We present a detailed study of the self-assembly of a series of fluorinated high-χ block copolymers (BCPs) prepared via postmodification of a single poly(styrene)-block-poly(glycidyl methacrylate) (S-b-G) parent polymer with the fluorinated alkylthiol pendent groups containing 1, 6, or 8 fluorinated carbons (termed trifluoro-ethanethiol (TFET), perfluoro-octylthiol (PFOT), and perfluoro-decylthiol (PFDT), respectively). Bulk X-ray scattering of thermally annealed samples demonstrates hierarchical molecular assembly with phase separation between the two blocks and within the fluorinated block. The degree of ordering within the fluorinated block is highly sensitive to synthetic variation; a lamellar sublattice was formed for S-b-GPFOT and S-b-GPFDT. Thermal analyses of S-b-GPFOT reveal that the fluorinated block exhibits liquid crystal-like ordering. The complex thin-film self-assembly behavior of an S-b-GPFOT polymer was investigated using real-space (atomic force microscopy and scanning electron microscopy) and reciprocal-space (resonant soft X-ray scattering (RSoXS), grazing incidence small- and wide-angle scattering) measurements. After thermal annealing in nitrogen or vacuum, films thicker than 1.5 times the primary lattice spacing exhibit a 90-degree grain boundary, exposing a thin layer of vertical lamellae at the free interface, while exhibiting horizontal lamellae on the preferential (polystyrene brush) substrate. RSoXS measurements reveal the near-perfect orthogonality between the primary and sublattice orientations, demonstrating hierarchical patterning at the nanoscale.