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DSHS Authors: 2019 Research Articles by DSHS Staff

The following list includes peer-reviewed research articles that have been written by staff of the Texas Department of State Health Services. For more information about these articles or for a full-text copy, please contact the Medical and Research Library by email at library@dshs.texas.gov by calling 512-776-7559.

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2019 Articles (in date order with most recent first)

Mai CT, Isenburg JL, Canfield MA, et al. National population-based estimates for major birth defects, 2010-2014. Birth Defects Res. 2019 Nov 1;111(18):1420-1435. Epub 2019 Oct 3.  doi: 10.1002/bdr2.1589
Using the National Birth Defects Prevention Network (NBDPN) annual data report, U.S. national prevalence estimates for major birth defects are developed based on birth cohort 2010-2014.
Methods: Data from 39 U.S. population-based birth defects surveillance programs (16 active case-finding, 10 passive case-finding with case confirmation, and 13 passive without case confirmation) were used to calculate pooled prevalence estimates for major defects by case-finding approach. Fourteen active case-finding programs including at least live birth and stillbirth pregnancy outcomes monitoring approximately one million births annually were used to develop national prevalence estimates, adjusted for maternal race/ethnicity (for all conditions examined) and maternal age (trisomies and gastroschisis). These calculations used a similar methodology to the previous estimates to examine changes over time.
Results: The adjusted national birth prevalence estimates per 10,000 live births ranged from 0.62 for interrupted aortic arch to 16.87 for clubfoot, and 19.93 for the 12 critical congenital heart defects combined. While the birth prevalence of most birth defects studied remained relatively stable over 15 years, an increasing prevalence was observed for gastroschisis and Down syndrome. Additionally, the prevalence for atrioventricular septal defect, tetralogy of Fallot, omphalocele, and trisomy 18 increased in this period compared to the previous periods. Active case-finding programs generally had higher prevalence rates for most defects examined, most notably for anencephaly, anophthalmia/microphthalmia, trisomy 13, and trisomy 18.
Conclusion: National estimates of birth defects prevalence provide data for monitoring trends and understanding the impact of these conditions. Increasing prevalence rates observed for selected conditions warrant further examination.

Hodo CL, Bañuelos RM, Edwards EE, Wozniak EJ, Hamer SA. Pathology and discrete typing unit associations of Trypanosoma cruzi infection in coyotes (Canis latrans) and raccoons (Procyon lotor) of Texas, USA. J Wildl Dis. 2020 Jan;56(1):134-144. Epub 2019 Sep 30. doi:10.7589/2019-03-071 
Trypanosoma cruzi is a vector-borne, protozoal parasite of mammals. Infected humans, dogs (Canis lupus familiaris), and nonhuman primates may remain asymptomatic or may develop Chagas disease, most commonly characterized by lymphoplasmacytic myocarditis with myocardial degeneration and fibrosis, ultimately resulting in heart failure. Although wildlife species have important roles as sylvatic reservoirs, investigations into the pathology of T. cruzi in wildlife are limited to a few studies documenting histologic lesions in opossums (Didelphis spp.) and raccoons (Procyon lotor). Pathology in coyotes (Canis latrans) has not, to our knowledge, been described, despite their recognition as a reservoir and close genetic relationship to domestic dogs. Our objectives were to perform a detailed, comparative cardiac pathology study of sympatric, naturally infected coyotes and raccoons, to characterize the overall T. cruzi infection prevalence in the heart and blood of each species via PCR, and to identify infecting discrete typing units (DTUs). We sampled hunter-harvested coyotes (n=120) and raccoons (n=24) in a 28 county region of central and south Texas. Raccoons were significantly more likely to have positive PCR results (P<0.001) with a prevalence of 63% (15/24), comprising DTU TcIV exclusively, with mild to no evidence of cardiac pathology. In contrast, coyotes had a lower infection prevalence (8%, 10/120), comprising DTU TcI exclusively, with lymphoplasmacytic myocarditis observed in four of the six PCR-positive animals. Many raccoons had PCR-positive blood and heart tissue simultaneously, supporting previous reports that raccoons maintain parasitemia into chronic stages of infection; in contrast, none of the PCR-positive coyotes were positive in both heart and blood. Our findings demonstrate marked differences in T. cruzi infection dynamics between coyotes and raccoons, with important implications for reservoir potential and their role in transmission cycles.

Goel N, Morris JK, Tucker D, et al. Trisomy 13 and 18-Prevalence and mortality-A multi-registry population based analysis. Am J Med Genet A. 2019;179(12):2382-2392. Epub 2019 Sep 30. doi.org/10.1002/ajmg.a.61365
The aim of the study is to determine the prevalence, outcomes, and survival (among live births [LB]), in pregnancies diagnosed with trisomy 13 (T13) and 18 (T18), by congenital anomaly register and region. Twenty-four population- and hospital-based birth defects surveillance registers from 18 countries, contributed data on T13 and T18 between 1974 and 2014 using a common data-reporting protocol. The mean total birth prevalence (i.e., LB, stillbirths, and elective termination of pregnancy for fetal anomalies [ETOPFA]) in the registers with ETOPFA (n = 15) for T13 was 1.68 (95% CI 1.3-2.06), and for T18 was 4.08 (95% CI 3.01-5.15), per 10,000 births. The prevalence varied among the various registers. The mean prevalence among LB in all registers for T13 was 0.55 (95%CI 0.38-0.72), and for T18 was 1.07 (95% CI 0.77-1.38), per 10,000 births. The median mortality in the first week of life was 48% for T13 and 42% for T18, across all registers, half of which occurred on the first day of life. Across 16 registers with complete 1-year follow-up, mortality in first year of life was 87% for T13 and 88% for T18. This study provides an international perspective on prevalence and mortality of T13 and T18. Overall outcomes and survival among LB were poor with about half of live born infants not surviving first week of life; nevertheless about 10% survived the first year of life. Prevalence and outcomes varied by country and termination policies. The study highlights the variation in screening, data collection, and reporting practices for these conditions.

Choi G, Stingone JA, Desrosiers TA, et al. Maternal exposure to outdoor air pollution and congenital limb deficiencies in the National Birth Defects Prevention Study. Environ Res. 2019 Sep 10;179(Pt A):108716. Epub 2019 Sep 10. doi: 10.1016/j.envres.2019.108716
Background: Congenital limb deficiencies (CLDs) are a relatively common group of birth defects whose etiology is mostly unknown. Recent studies suggest maternal air pollution exposure as a potential risk factor.
Aim: To investigate the relationship between ambient air pollution exposure during early pregnancy and offspring CLDs.
Methods: The study population was identified from the National Birth Defects Prevention Study, a population-based multi-center case-control study, and consisted of 615 CLD cases and 5,701 controls with due dates during 1997 through 2006. Daily averages and/or maxima of six criteria air pollutants (particulate matter <2.5 μm [PM2.5], particulate matter <10 μm [PM10], nitrogen dioxide [NO2], sulfur dioxide [SO2], carbon monoxide [CO], and ozone [O3]) were averaged over gestational weeks 2-8, as well as for individual weeks during this period, using data from EPA air monitors nearest to the maternal address. Logistic regression was used to estimate odds ratios (aORs) and 95% confidence intervals (CIs) adjusted for maternal age, race/ethnicity, education, and study center. We estimated aORs for any CLD and CLD subtypes (i.e., transverse, longitudinal, and preaxial). Potential confounding by co-pollutant was assessed by adjusting for one additional air pollutant. Using the single pollutant model, we further investigated effect measure modification by body mass index, cigarette smoking, and folic acid use. Sensitivity analyses were conducted restricting to those with a residence closer to an air monitor.
Results: We observed near-null aORs for CLDs per interquartile range (IQR) increase in PM10, PM2.5, and O3. However, weekly averages of the daily average NO2 and SO2, and daily max NO2, SO2, and CO concentrations were associated with increased odds of CLDs. The crude ORs ranged from 1.03 to 1.12 per IQR increase in these air pollution concentrations, and consistently elevated aORs were observed for CO. Stronger associations were observed for SO2 and O3 in subtype analysis (preaxial). In co-pollutant adjusted models, associations with CO remained elevated (aORs: 1.02-1.30); but aORs for SO2 and NO2 became near-null. The aORs for CO remained elevated among mothers who lived within 20 km of an air monitor. The aORs varied by maternal BMI, smoking status, and folic acid use.
Conclusion: We observed modest associations between CLDs and air pollution exposures during pregnancy, including CO, SO2, and NO2, though replication through further epidemiologic research is warranted.

Maughan BC, Becker EA. Drug-related mortality after discharge from treatment: A record-linkage study of substance abuse clients in Texas, 2006-2012. Drug Alcohol Depend. 2019 Aug 30;204:107473. Epub 2019 Aug 30. doi: 10.1016/j.drugalcdep.2019.05.011
Patients have higher mortality immediately after substance abuse treatment discharge, but there are few data on post-discharge mortality differences across treatment modalities.
Methods: A retrospective cohort study examined individuals discharged from substance abuse treatment during 2006-2012 and probabilistically matched treatment records to death records. Logistic regression examined associations between drug-related death (DRD) and demographics; route, frequency, and classes of drugs abused; and treatment. Primary outcome was DRD during post-discharge days 0-28; secondary outcomes examined DRD during days 29-90 and 91-365.
Results: We examined 178,749 patients discharged from 254,814 treatment episodes. There were 97 DRD during days 0-28 (4.1/1000 person-years), 115 DRD during days 29-90 (2.6/1000 person-years; IRR 0.6 [95% CI 0.5-0.8]), and 293 DRD during days 91-365 (1.9/1000 person-years; IRR 0.5 [0.4-0.6]). Higher 28-day DRD was associated with abuse of opioids (aOR 2.5 [1.4-4.4]), depressants (aOR 2.0 [1.2-3.4]), or alcohol (aOR 1.7 [1.1-2.6]); and opioid injection (aOR 2.2 [1.3-3.7]). Lower DRD was associated with treatment completion (aOR 0.6 [0.4-0.9]), female sex (aOR 0.6 [0.4-0.8]), and employment (aOR 0.5 [0.3-0.9]). Among all patients, DRD rates were higher following residential (IRR 2.6, [1.6-4.2]) and detoxification (IRR 2.9, [1.7-4.9]) treatment compared to outpatient. Patients with prior opioid abuse had higher 28-day DRD after outpatient (6.7/1000 person-years; IRR 4.1 [1.8-9.1]), residential (13.6/1000 person-years; IRR 4.2 [2.2-8.2]), and detoxification (8.8/1000 person-years; IRR 3.2 [1.2, 8.5]) compared to those without.
Conclusions: Drug-related mortality is highest during days 0-28 after discharge, especially following residential and detoxification treatment. Opioid abuse is strongly associated with early post-discharge mortality.

Johnson KE, Sales A, Rew L, Haussler Garing J, Crosnoe R. Using polytomous latent class analysis to compare patterns of substance use and co-occurring health-risk behaviors between students in alternative and mainstream high schools. J Adolesc. 2019 Aug;75:151-162. Epub 2019 Aug 6. doi: 10.1016/j.adolescence.2019.07.010
Alternative high school (AHS) students, an understudied and underserved population, experience educational, social, and health disparities relative to students in mainstream high schools. Disparities in single types of substance use are particularly high, yet no known studies have compared patterns of substance use or relationships between these patterns and other health-risk behaviors between AHS and mainstream high schools.
Methods: Using data from the Texas Alternative School Health Survey (n = 515; mean age 17.1 years, 49% male, 59% Hispanic, 23% White, 15% Black) and the Texas Youth Risk Behavior Survey (n = 2,113; mean age 16 years, 47% male, 64% Hispanic, 22% White, 7% Black), we used latent class analyses to compare patterns of substance use in AHSs and mainstream high schools. We used latent class regression to examine relationships between patterns of substance use and involvement in other health-risk behaviors in each school setting.
Results: Students in AHSs and mainstream high schools had similar patterns of substance use, and youth in higher risk categories engaged in higher levels of other health-risk behaviors. A substantially greater proportion of AHS students, however, fell into the moderate and high use categories, in support of continuing disparities for AHS students.
Conclusions: Additional support is needed in AHSs to address the prevalence of high-risk patterns of substance use and associated health-risk behaviors. For example, ongoing public health surveillance is needed in AHSs, just as is done in mainstream high schools, to monitor trends in substance use and impact of policies and interventions.

Pace ND, Siega-Riz AM, Olshan AF, et al. Survival of infants with spina bifida and the role of maternal prepregnancy body mass index. Birth Defects Res. 2019 Oct 1;111(16):1205-1216. Epub 2019 Jul 19. doi: 10.1002/bdr2.1552
To investigate first-year survival of infants born with spina bifida, and examine the association of maternal prepregnancy body mass index (BMI) with infant mortality.
Methods: This is a retrospective cohort study of 1,533 liveborn infants with nonsyndromic spina bifida with estimated dates of delivery from 1998 to 2011 whose mothers were eligible for the National Birth Defects Prevention Study (NBDPS). NBDPS data were linked to death records to conduct survival analyses. Kaplan-Meier survival functions estimated mortality risk over the first year of life. Cox proportional hazards models estimated hazard ratios (HRs) for maternal prepregnancy BMI categorized as underweight (<18.5), normal (18.5-24.9), overweight (25-29.9), and obese (≥30).
Results: Infant mortality risk among infants with spina bifida was (4.4% [3.52, 5.60%]). Infants with multiple co-occurring defects, very preterm delivery, multiple gestation, high-level spina bifida lesions, or non-Hispanic Black mothers had an elevated risk of infant mortality. Maternal prepregnancy underweight and obesity were associated with higher infant mortality (15.7% [7.20, 32.30%] and 5.82% [3.60, 9.35%], respectively). Adjusted HR estimates showed underweight and obese mothers had greater hazard of infant mortality compared to normal weight mothers (HR: 4.5 [1.08, 16.72] and 2.6 [1.36, 8.02], respectively).
Conclusion: The overall risk of infant mortality for infants born with spina bifida was lower than most previously reported estimates. Infants born with spina bifida to mothers who were underweight or obese prepregnancy were at higher risk of infant mortality. This study provides additional evidence of the importance of healthy maternal weight prior to pregnancy.

Benjamin RH, Yu X, Navarro Sanchez ML, et al. Co-occurring defect analysis: A platform for analyzing birth defect co-occurrence in registries. Birth Defects Res. 2019 Nov 1;111(18):1356-1364. Epub 2019 Jul 16. doi: 10.1002/bdr2.1549
Few studies have systematically evaluated birth defect co-occurrence patterns, perhaps, in part, due to the lack of software designed to implement large-scale, complex analytic methods.
Methods: We created an R-based platform, "co-occurring defect analysis" (CODA), designed to implement analyses of birth defect co-occurrence patterns in birth defect registries. CODA uses an established algorithm for calculating the observed-to-expected ratio of a given birth defect combination, accounting for the known tendency of birth defects to co-occur nonspecifically. To demonstrate CODA's feasibility, we evaluated the computational time needed to assess 2- to 5-way combinations of major birth defects in the Texas Birth Defects Registry (TBDR) (1999-2014). We report on two examples of pairwise patterns, defects co-occurring with trisomy 21 or with non-syndromic spina bifida, to demonstrate proof-of-concept.
Results: We evaluated combinations of 175 major birth defects among 206,784 infants in the TBDR. CODA performed efficiently in the data set, analyzing 1.5 million 5-way combinations in 18 hr. As anticipated, we identified large observed-to-expected ratios for the birth defects that co-occur with trisomy 21 or spina bifida.
Conclusions: CODA is available for application to birth defect data sets and can be used to better understand co-occurrence patterns. Co-occurrence patterns elucidated by using CODA may be helpful for identifying new birth defect associations and may provide etiological insights regarding potentially shared pathogenic mechanisms. CODA may also have wider applications, such as assessing patterns of additional types of co-occurrence patterns in other large data sets (e.g., medical records).

Sapp SGH, Alhabshan RN, Bishop HS, et al. Ocular trematodiasis caused by the avian eye fluke Philophthalmus in southern Texas. Open Forum Infect Dis. 2019 Jun 13;6(7):ofz265. doi: 10.1093/ofid/ofz265
A trematode identified as a Philophthalmus sp was extracted from the bulbar conjunctiva of a patient in southern Texas with short-distance travel to Mexico. This parasite is very rarely reported from humans, and species identification is challenging. Aspects of diagnosis, zoonotic transmission, and unresolved questions about Philophthalmus spp are discussed.

Yu X, Nassar N, Mastroiacovo P, et al. Hypospadias prevalence and trends in international birth defect surveillance systems, 1980-2010. Eur Urol. 2019 Oct;76(4):482-490. Epub 2019 Jul 9. doi: 10.1016/j.eururo.2019.06.027
Hypospadias is a common male birth defect that has shown widespread variation in reported prevalence estimates. Many countries have reported increasing trends over recent decades.
Objective: To analyze the prevalence and trends of hypospadias for 27 international programs over a 31-yr period.
Design, setting, and participants: The study population included live births, stillbirths, and elective terminations of pregnancy diagnosed with hypospadias during 1980-2010 from 27 surveillance programs around the world.
Outcome measurements and statistical analysis: We used joinpoint regression to analyze changes over time in international total prevalence of hypospadias across programs, prevalence for each specific program, and prevalence across different degrees of severity of hypospadias.
Results and limitations: The international total prevalence of hypospadias for all years was 20.9 (95% confidence interval: 19.2-22.6) per 10000 births. The prevalence for each program ranged from 2.1 to 39.1 per 10000 births. The international total prevalence increased 1.6 times during the study period, by 0.25 cases per 10000 births per year (p<0.05). When analyzed separately, there were increasing trends for first-, second-, and third-degree hypospadias during the early 1990s to mid-2000s. The majority of programs (61.9%) had a significantly increasing trend during many of the years evaluated. Limitations include known differences in data collection methods across programs.
Conclusions: Although there have been changes in clinical practice and registry ascertainment over time in some countries, the consistency in the observed increasing trends across many programs and by degrees of severity suggests that the total prevalence of hypospadias may be increasing in many countries. This observation is contrary to some previous reports that suggested that the total prevalence of hypospadias was no longer increasing in recent decades.
Patient summary: We report on the prevalence and trends of hypospadias among 27 birth defect surveillance systems, which indicate that the prevalence of hypospadias continues to increase internationally.

Benjamin RH, Ethen MK, Canfield MA, et al. Association of interpregnancy change in body mass index and spina bifida. 2019 Nov 1;111(18):1389-1398. Birth Defects Res. Epub 2019 Jul 10. doi: 10.1002/bdr2.1547
Epidemiologic studies have consistently identified an association between spina bifida and maternal body mass index (BMI). Whether this reflects a causal relationship is unknown. If this association does reflect a causal relationship, the risk of spina bifida should change with changes in maternal BMI. We evaluated the association between spina bifida and maternal change in BMI, assessed using interpregnancy change in BMI (IPC-BMI).
Methods: We used data from the Texas Birth Defects Registry and statewide vital records for 248 spina bifida cases and 2,562 controls (2006-2012) to conduct a case-control study. We used logistic regression to estimate the association between IPC-BMI and spina bifida, with adjustment for potential confounders.
Results: When assessed as a continuous variable, IPC-BMI was associated with spina bifida, with a 5% increase in the odds of spina bifida per unit (approximately 6 pounds) increase in BMI (adjusted odds ratios [aOR] = 1.05, 95% CI: 1.02, 1.09). When assessed as a categorical variable, with weight stable women as the referent, the odds of spina bifida were lower in women with any BMI decrease (aOR = 0.73, 95% CI: 0.50, 1.08) and higher in women with an increase of ≥1 BMI units (aOR = 1.17, 95% CI: 0.85, 1.62).
Conclusions: Our findings provide suggestive, although not conclusive, evidence that maternal prepregnancy change in BMI, assessed using IPC-BMI, is associated with spina bifida in the later pregnancy. Additional studies aimed at confirming this association and further strengthening the evidence for a causal relationship between spina bifida and maternal BMI are needed.

Le MT, Shumate CJ, Hoyt AT, Wilkinson AV, Canfield MA. The prevalence of birth defects among non-Hispanic Asian/Pacific Islanders and American Indians/Alaska Natives in Texas, 1999-2015. Birth Defects Res. 2019 Nov 1;111(18):1380-1388. Epub 2019 Jul 1. doi: 10.1002/bdr2.1543
There is considerable variability in the prevalence of birth defects among racial/ethnic groups. This study estimated birth defect prevalence among the less studied non-Hispanic (NH) Asian/Pacific Islander (PI) and American Indian/Alaska Native (AI/AN) populations in Texas relative to NH Whites.
Methods: Data were obtained from the Texas Birth Defect Registry from 1999 to 2015 for deliveries to Texas-resident women who were NH White, NH Asian/PI, or AI/AN. This covers a live birth population of 2.6 million. Prevalence ratios and 95% confidence intervals (95% CIs) were calculated for NH Asian/PIs and AI/ANs (relative to NH Whites) for 44 birth defects using Poisson regression adjusting for maternal age.
Results: After adjustment there were 33 statistically significant prevalence ratios (aPRs). Among NH Asian/PIs, 23 defects had a lower aPR (0.38-0.86) and three defects had a higher aPR (1.19-2.50). AI/ANs had one defect with a significantly lower aPR (0.64) and six with a higher aPR (1.36-4.63).
Conclusions: Non-Hispanic Asian/PIs generally have a lower prevalence ratio for many birth defects while AI/ANs have a higher prevalence ratio compared to NH Whites. These findings update the limited literature on this topic and warrant additional research to identify the true associations across a range of birth defects among these understudied racial/ethnic groups.

Stoops CA, Qualls WA, Nguyen TT, Richards SL. A review of studies evaluating insecticide barrier treatments for mosquito control from 1944 to 2018. Environ Health Insights. 2019 Jun 26;13:1178630219859004. doi: 10.1177/1178630219859004
Background and purpose:
Barrier insecticide treatments have a long history in mosquito control programs but have been used more frequently in the United States in recent years for control of invasive "backyard" species (eg, Aedes albopictus) and increases in incidence of vector-borne diseases (eg, Zika).
Methods: We reviewed the published literature for studies investigating barrier treatments for mosquito control during the last 74 years (1944-2018). We searched databases such as PubMed, Web of Science, and Google Scholar to retrieve worldwide literature on barrier treatments.
Results: Forty-four studies that evaluated 20 active ingredients (AIs) and 21 formulated products against multiple mosquito species are included. Insecticides investigated for efficacy included organochlorines (dichlorodiphenyltrichloroethane [DDT], β-hexachlorocyclohexane [BHC]), organophosphates (malathion), and pyrethroids (bifenthrin, deltamethrin, permethrin, lambda-cyhalothrin) as AIs. Study design varied with multiple methods used to evaluate effectiveness of barrier treatments. Barrier treatments were effective at lowering mosquito populations although there was variation between studies and for different mosquito species. Factors other than AI, such as exposure to rainfall and application equipment used, also influenced control efficacy.
Conclusions: Many of the basic questions on the effectiveness of barrier insecticide applications have been answered, but several important details still must be investigated to improve precision and impact on vector-borne pathogen transmission. Recommendations are made to assist future evaluations of barrier treatments for mosquito control and to limit the potential development of insecticide resistance.

Matas JL, Agana DFG, Germanos GJ, et al. Exploring classification of birth defects severity in national hospital discharge databases compared to an active surveillance program. Birth Defects Res. 2019 Nov 1;111(18):1343-1355. Epub 2019 Jun 20. doi: 10.1002/bdr2.1539 
To explore the extent to which the severity of birth defects could be differentiated using severity of illness (SOI) and risk of mortality (ROM) measures available in national discharge databases.
Methods: Data from the 2012-14 National Inpatient Sample (NIS) was used to identify hospitalizations with one or more major birth defects reported annually to the National Birth Defects Prevention Network using the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) diagnosis codes. Each hospitalization also contained a 4-level SOI and 4-level ROM classification measure. For each birth defect and for each individual birth defect-related ICD-9-CM code, we calculated mean and median SOI and ROM, the proportion of hospitalizations in each level of SOI and ROM, the inpatient mortality rate, and level of agreement between various existing or derived severity proxies in the NIS and the Texas Birth Defects Registry (TBDR).
Results: Mean SOI ranged from 1.5 (cleft lip alone) to 3.7 (single ventricle), and mean ROM ranged from 1.1 (cleft lip alone) to 3.9 (anencephaly). As a group, critical congenital heart defects had the highest average number of co-occurring defects, mean SOI, and ROM, whereas orofacial and genitourinary defects had the lowest SOI and ROM. We found strong levels of agreement between TBDR severity classifications and NIS severity classifications defined using Level 3 or 4 SOI or ROM Level 3 or 4.
Conclusions: This preliminary investigation demonstrated how severity indices of birth defects could be differentiated and compared to a severity algorithm of an existing surveillance program.

Schnall AH, Hanchey A, Nakata N, et al. Disaster-related shelter surveillance during the Hurricane Harvey response - Texas 2017. Disaster Med Public Health Prep. 2020;14(1):49-55. Epub 2019 Jun 21. doi: 10.1017/dmp.2019.25
Hurricane Harvey left a path of destruction in its wake, resulting in over 100 deaths and damaging critical infrastructure. During a disaster, public health surveillance is necessary to track emerging illnesses and injuries, identify at-risk populations, and assess the effectiveness of response efforts. The Centers for Disease Control and Prevention (CDC) and American Red Cross collaborate on shelter surveillance to monitor the health of the sheltered population and help guide response efforts.
Methods: We analyzed data collected from 24 Red Cross shelters between August 25, 2017, and September 14, 2017. We described the aggregate morbidity data collected during Harvey compared with previous hurricanes (Gustav, Ike, and Sandy).
Results: Over one-third (38%) of reasons for visit were for health care maintenance; 33% for acute illnesses, which includes respiratory conditions, gastrointestinal symptoms, and pain; 19% for exacerbation of chronic disease; 7% for mental health; and 4% for injury. The Red Cross treated 41% of clients within the shelters; however, reporting of disposition was often missed. These results are comparable to previous hurricanes.
Conclusion: The capacity of Red Cross shelter staff to address the acute health needs of shelter residents is a critical resource for local public health agencies overwhelmed by the disaster. However, there remains room for improvement because reporting remained inconsistent.

Haidar A, Ranjit N, Archer N, Hoelscher DM. Parental and peer social support is associated with healthier physical activity behaviors in adolescents: a cross-sectional analysis of Texas School Physical Activity and Nutrition (TX SPAN) data. BMC Public Health. 2019 May 27;19(1):640. doi: 10.1186/s12889-019-7001-0
Parental and peer support can influence children's physical activity; however, these associations have not been fully examined in a multi-ethnic population across early and late adolescence. The objective of this study was to examine associations between perceived parental/peer social support, perceived parental disapproval for not exercising, and physical activity/screen time behaviors among a multi-ethnic sample of adolescents.
Methods: The Texas School Physical Activity and Nutrition (TX SPAN) survey is a cross-sectional statewide probability-based survey, used to assess obesity-related behaviors such as diet and physical activity. The SPAN 2009-2011 study measured 8th and 11th grade students using a self-report questionnaire with established psychometric properties, along with objectively measured height and weight. Associations were examined using multiple logistic and linear regression.
Results: For every 1-point increase in parental physical activity support, adolescents had 1.14 higher odds of engaging in five or more days of moderate physical activity per week (p < 0.001), and 1.12 higher odds of engaging in three or more days of vigorous physical activity per week (p < 0.001). For every 1-point increase in peer physical activity support, adolescents had 1.17 higher odds of engaging in five or more days of moderate physical activity per week (p < 0.001), and 1.15 higher odds of engaging in three or more days of vigorous physical activity per week (p < 0.001).
Conclusions: Parental and peer social support is associated with positive physical activity behaviors in adolescents. Strategies to focus on parent and peer support should be integral to intervention programs designed to increase physical activity in adolescents in middle and high schools.

Lopez A, Benjamin RH, Raut JR, et al. Mode of delivery and mortality among neonates with gastroschisis: A population-based cohort in Texas. Paediatr Perinat Epidemiol. 2019 May;33(3):204-212. Epub 2019 May 14. doi: 10.1111/ppe.12554
Mode of delivery is hypothesised to influence clinical outcomes among neonates with gastroschisis. Results from previous studies of neonatal mortality have been mixed; however, most studies have been small, clinical cohorts and have not adjusted for potential confounders.
Objectives: To evaluate whether caesarean delivery is associated with mortality among neonates with gastroschisis.
Methods: We studied liveborn, nonsyndromic neonates with gastroschisis delivered during 1999-2014 using data from the Texas Birth Defect Registry. Using multivariable Cox proportional hazards regression, we separately assessed the relationship between caesarean and death during two different time periods, prior to 29 days (<29 days) and prior to 365 days (<365 days) after delivery, adjusting for potential confounders. We also updated a recent meta-analysis on this relationship, combining our estimates with those from the literature.
Results: Among 2925 neonates with gastroschisis, 63% were delivered by caesarean. No associations were observed between caesarean delivery and death <29 days (adjusted hazard ratio [aHR] 1.00, 95% confidence interval [CI] 0.63, 1.61) or <365 days after delivery (aHR 0.99, 95% CI 0.70, 1.41). The results were similar among those with additional malformations and among those without additional malformations. When we combined our estimate with prior estimates from the literature, results were similar (combined risk ratio [RR] 1.00, 95% CI 0.84, 1.19).
Conclusions: Although caesarean rates among neonates with gastroschisis were high, our results suggest that mode of delivery is not associated with mortality among these individuals. However, data on morbidity outcomes (eg intestinal damage, infection) were not available in this study.

Hyde JR, Sears SC, Buendia JR, Odem SL, Vaaler ML, Mgbere OO. HIV comorbidities: Pay attention to hypertension amid changing guidelines - an analysis of Texas Medical Monitoring Project Data. Am J Hypertens. 2019 May 9. pii: hpz078. doi: 10.1093/ajh/hpz078
Hypertension is a significant risk factor for cardiovascular disease, a leading cause of death among people living with HIV (PLWH). Studies suggest that hypertension prevalence among PLWH is high, yet none assess how the 2017 redefinition of hypertension as ≥130/80 rather than the previous standard of ≥140/90 mmHg will impact prevalence among PLWH. The present study addresses this gap.
Methods: We examined medical record abstractions of 957 PLWH in Texas from the 2013-2014 Medical Monitoring Project survey. Hypertensive participants were identified by charted diagnosis, antihypertensive medication use, or blood pressure readings ≥140/90 and ≥130/80 mmHg. Associations with sociodemographic and clinical variables were assessed using Rao-Scott chi-square tests, and odds of having hypertension were calculated using multivariable logistic regression models while adjusting for several demographic and HIV-related variables.
Results: The 2017 redefinition of hypertension increased prevalence in the sample by 44.3%, from 47.6% to 68.7%. Age group, body mass index, sex, and race remained significantly associated with hypertension (all p<0.01).While prevalence was near equal between males and females at ≥140/90 mmHg (47.4 and 48.5%, respectively), males were 2.36 times more likely to have hypertension than females (95% CI: 1.55-3.60) at ≥130/80 mmHg. Prevalence remained comparable between white (73.3%) and black participants (72.9%).
Conclusions: This study shows that hypertension prevalence is remarkably high among PLWH and is further increased by updated guidelines. Barriers to hypertension control in the HIV care setting should be identified and addressed to facilitate continued improvement in quality and length of life for PLWH.

Pezzi C, Lee D, Kennedy L, et al. Blood lead levels among resettled refugee children in select US states, 2010-2014. Pediatrics. 2019;143(5):e20182591. doi: 10.1542/peds.2018-2591
Elevated blood lead levels (EBLLs; ≥5 µg/dL) are more prevalent among refugee children resettled in the United States than the general US population and contribute to permanent health and neurodevelopmental problems. The Centers for Disease Control and Prevention recommends screening of refugee children aged 6 months to 16 years on arrival in the United States and retesting those aged 6 months to 6 years between 3- and 6-months postarrival.
Methods: We analyzed EBLL prevalence among refugee children aged 6 months to 16 years who received a domestic refugee medical examination between January 1, 2010 and September 30, 2014. We assessed EBLL prevalence by predeparture examination country and, among children rescreened 3 to 6 months after initial testing, we assessed EBLL changes during follow-up screening.
Results: Twelve sites provided data on 27 284 children representing nearly 25% of refugee children resettling during the time period of this analysis. The EBLL prevalence during initial testing was 19.3%. EBLL was associated with younger age, male sex, and overseas examination country. Among 1121 children from 5 sites with available follow-up test results, EBLL prevalence was 22.7%; higher follow-up BLLs were associated with younger age and predeparture examination country.
Conclusions: EBLL decreased over the time period of our analysis in this population of refugee children. Refugee children may be exposed to lead before and after resettlement to the United States. Efforts to identify incoming refugee populations at high risk for EBLL can inform prevention efforts both domestically and overseas.

Yeh CY, Wheeler A, Bethea L, et al. Identifying barriers to implementation of emergency epinephrine bills: The Texas experience. J Allergy Clin Immunol Pract. 2019;7(8):2875-2877.e2. doi:10.1016/j.jaip.2019.04.032. Epub 2019 May 3. doi.org/10.1016/j.jaip.2019.04.032
Despite the passage of a law allowing use of undesignated stock epinephrine in public schools, a surprisingly small number of school districts in Texas have implemented the policy. We identified the common barriers widespread adoption.

Gray MS, Judd SE, Sloane R, Snyder DC, Miller PE, Demark-Wahnefried W. Rural-urban differences in health behaviors and outcomes among older, overweight, long-term cancer survivors in the RENEW randomized control trial. Cancer Causes Control. 2019 Apr;30(4):301-309. Epub 2019 Feb 19. doi: 10.1007/s10552-019-01141-x
Rural cancer survivors (RCS) have poorer health outcomes and face multiple challenges-older age, and limited transportation, education, income, and healthcare access. Yet, RCS are understudied. The Reach-out to ENhancE Wellness(RENEW) trial, a home-based, diet and exercise intervention among 641 breast, prostate, and colorectal cancer survivors addressed many of these challenges.
Methods: We examined whether rural and urban participants differed in their response to the RENEW intervention (e.g., physical functioning, quality-of-life, intakes of fruits and vegetables (F&V) and saturated fat, body mass index(BMI), physical activity, and adverse events).
Results: Rural versus urban survivors report significantly more favorable mean (SE) changes in physical functioning [- 0.66 (1.47) v - 1.71 (1.00)], physical health [+ 0.14 (0.71) v - 0.74 (0.50)], and fewer adverse events [1.58 (0.08) v 1.64 (0.06)]. Rural versus urban survivors reported smaller increases in F&Vs [+ 1.47 (0.23) v + 1.56(0.16); p = 0.018], and lower percentages achieved goal behavior for endurance exercise and intakes of F&Vs and saturated fat.
Conclusions: The RENEW intervention reduced declines in physical health and functioning among RCS to a significantly greater extent than for urban cancer survivors. All survivors significantly improved intakes of F&V and saturated fat, and endurance exercise; however, lower percentages of rural versus urban survivors met goal suggesting that more intensive interventions may be needed for RCS.

Hoyt AT, Shumate CJ, Canfield MA, Le M, Ramadhani T, Scheuerle AE. Selected acculturation factors and birth defects in the National Birth Defects Prevention Study, 1997-2011. Birth Defects Res. 2019 Jun 1;111(10):598-612. Epub 2019 Apr 25. doi: 10.1002/bdr2.1494
Acculturation has been examined with respect to various pregnancy adverse outcomes, including birth defects. Given the mixed and limited findings on the association between nativity and birth defects, we sought to further explore parental nativity and years lived in the U.S. across a range of defects.
Methods: Data from the National Birth Defects Prevention Study were used for this analysis. Infants with one of 46 major isolated birth defects (30 noncardiac/16 cardiac conditions) and infants without birth defects (controls) born during 1997-2011 were included. We examined parental nativity (foreign-born mothers, fathers, and both parents combined compared to a referent of both U.S.-born parents) and the number of years lived in the U.S. (≤5/6+ years). Descriptive statistics and logistic regression analyses were performed to estimate crude/adjusted odds ratios and 95% confidence intervals.
Results: Compared to U.S.-born mothers, foreign-born mothers tended to be older (25+ years), of Hispanic or Other race/ethnicity and were less likely to have reported drinking, smoking, illicit drug use, or having taken folic acid. In the adjusted analysis, seven findings among both parents reporting a foreign-birth were significant, including an increased association with spina bifida, anotia/microtia, and diaphragmatic hernia (aORs range: 1.3-1.7), and a reduced association with craniosynostosis and gastroschisis (aORs = 0.7). A generally protective effect was observed among foreign-born subjects living in the U.S. ≤5 years.
Conclusions: We found that nativity was associated with some selected isolated defects, although the direction of effect varied by phenotype and by a number of years residing in the U.S.

Canfield MA, Langlois PH, Rutenberg GW, et al. The association between newborn screening analytes and childhood autism in a Texas Medicaid population, 2010-2012. Am J Med Genet B Neuropsychiatr Genet. 2019 Jul;180(5):291-304. Epub 2019 Apr 24. doi: 10.1002/ajmg.b.32728
Autism (or autism spectrum disorder [ASD]) is an often disabling childhood neurologic condition of mostly unknown cause. It is commonly diagnosed at 3 or 4 years of age. We explored whether there was an association of any analytes measured by newborn screening tests with a later diagnosis of ASD. A database was compiled of 3-5 year-old patients with any ASD diagnosis in the Texas Medicaid system in 2010-2012. Two controls (without any ASD diagnosis) were matched to each case by infant sex and birth year/month. All study subjects were linked to their 2007-2009 birth and newborn screening laboratory records, including values for 36 analytes or analyte ratios. We examined the association of analytes/ratios with a later diagnosis of ASD. Among 3,258 cases and 6,838 controls, seven analytes (e.g., 17-hydroxyprogesterone, acylcarnitines) were associated with a later ASD diagnosis. In this exploratory study, an ASD diagnosis was associated with 7 of 36 newborn screening analytes/ratios. These findings should be replicated in other population-based datasets.

Hoang TT, Lei Y, Mitchell LE, et al. Maternal genetic markers for risk of celiac disease and their potential association with neural tube defects in offspring. Mol Genet Genomic Med. 2019 Jun;7(6):e688. Epub 2019 Apr 9. doi: 10.1002/mgg3.688
We examined the association between the maternal genotype for celiac disease-associated variants and risk of neural tube defects (NTDs).
Methods: We conducted a case-control study, using data from the National Birth Defects Prevention Study. We evaluated 667 cases (women with an offspring with NTD) and 743 controls (women with an offspring without a birth defect). We classified women as having low, intermediate, or high risk of celiac disease based on human leukocyte antigen (HLA) variants. We used logistic regression to assess the relationship between HLA celiac risk group (low, intermediate, high) and risk of NTDs. Fifteen non-HLA variants (identified from genome-wide association studies of celiac disease) were individually evaluated and modeled additively.
Results: There was no association between HLA celiac risk group and NTDs (intermediate vs. low risk: aOR, 1.0; 95% CI, 0.8-1.3; high vs. low risk: aOR, 0.8; 95% CI, 0.5-1.3). Of the fifteen non-HLA variants, we observed five significant associations after accounting for multiple comparisons. Three negative associations were observed with rs10903122, rs13314993, rs13151961 (aOR range: 0.69-0.81), and two positive associations were observed with rs13003464 and rs11221332 (aOR range: 1.27-1.73).
Conclusion: If confirmed, our results suggest that the maternal variants related to celiac disease may be involved in the risk of NTDs.

Benjamin RH, Littlejohn S, Canfield MA, Ethen MK, Hua F, Mitchell LE. Interpregnancy change in body mass index and infant outcomes in Texas: a population-based study. BMC Pregnancy Childbirth. 2019 Apr 5;19(1):119. doi: 10.1186/s12884-019-2265-z
Maternal prepregnancy body mass index (BMI) is associated with several infant outcomes, but it is unclear whether these associations reflect causal relationships. We conducted a study of interpregnancy change in BMI (IPC-BMI) to improve understanding of the associations between BMI and large for gestational age (LGA), small for gestational age (SGA), and preterm birth (PTB).
Methods: Birth certificate data from 2481 linked sibling pairs (Texas, 2005-2012) were used to estimate IPC-BMI and evaluate its association with LGA, SGA, and PTB in the younger sibling of the pair. Multivariable logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) using data from the full sample and within strata defined by prepregnancy BMI for the older sibling.
Results: On average, women gained 1.1 BMI units between pregnancies. In the full sample, interpregnancy BMI decreases were associated with reduced odds of LGA and increased odds of SGA and PTB (IPC-BMI < -1 versus 0 to < 1: LGA aOR 0.7, 95% CI 0.4, 1.1; SGA aOR 1.6, 95% CI 1.0, 2.7; PTB aOR 1.9, 95% CI 1.3, 2.8). In stratified analyses, similar associations were observed in some, but not all, strata. Findings for interpregnancy BMI increases were less consistent, with little evidence for associations between these outcomes and the most extreme IPC-BMI increases.
Conclusions: There is growing evidence that interpregnancy BMI decreases are associated with LGA, SGA, and PTB. However, taken as a whole, the literature provides insufficient evidence to establish causal links between maternal BMI and these outcomes.

Sheth KR, Kovar E, White JT, et al. Hypospadias risk is increased with maternal residential exposure to hormonally active hazardous air pollutants. Birth Defects Res. 2019 Apr 15;111(7):345-352. Epub 2019 Jan 29. doi: 10.1002/bdr2.1461
With the increasing birth prevalence of hypospadias, there is growing concern for pollutant exposure interfering with normal penile development. We assess the association between hypospadias and hormonally active hazardous air pollutants (HAHAPs) through a nationwide database of hazardous air pollutants and the Texas Birth Defects Registry (TBDR).
Methods: Using the TBDR, we identified 8,981 nonsyndromic isolated hypospadias cases from 1999 to 2008. Birth certificate controls were matched for birth year at a 10:1 ratio to cases. Estimated HAHAP concentrations from the 2005 U.S. EPA National-Scale Air Toxics Assessment were used to assign exposure based on maternal residence at birth. Exposure levels were categorized as quintiles based on the distribution in controls. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (CI) for each increasing exposure category of selected HAHAPs.
Results: Of the 10 HAHAPs studied, seven were significantly associated with hypospadias risk. The HAHAP that was most strongly associated with hypospadias was phenol, which was associated with risk in all groups except the high exposure group. Cumulative HAHAP exposure demonstrated a modest increase in hypospadias risk (OR 1.15, 95% CI: 1.07-1.24, p < 0.001) in the medium and medium-high quintiles.
Conclusions: While maternal exposure to some HAHAPs was significantly associated with the risk of hypospadias in male offspring, the effects were modest, and no dose-response effects were observed. Future work should employ biomarkers of exposure to better delineate the relationship.

Spector LG, Brown MB, Wantman E, et al. Association of In Vitro Fertilization With Childhood Cancer in the United States. JAMA Pediatr. 2019 Jun 1;173(6):e190392. Epub 2019 Apr 1. doi: 10.1001/jamapediatrics.2019.0392
In vitro fertilization (IVF) is associated with birth defects and imprinting disorders. Because these conditions are associated with an increased risk of childhood cancer, many of which originate in utero, descriptions of cancers among children conceived via IVF are imperative.
Objective: To compare the incidence of childhood cancers among children conceived in vitro with those conceived naturally.
Design, setting, and participants: A retrospective, population-based cohort study linking cycles reported to the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System from January 1, 2004, to December 31, 2012, that resulted in live births from September 1, 2004, to December 31, 2013, to the birth and cancer registries of 14 states, comprising 66% of United States births and 75% of IVF-conceived births, with follow-up from September 1, 2004, to December 31, 2014. The study included 275,686 children conceived via IVF and a cohort of 2,266,847 children, in which 10 births were randomly selected for each IVF birth. Statistical analysis was performed from April 1, 2017, to October 1, 2018.
Exposure: In vitro fertilization.
Main outcomes and measures: Cancer diagnosed in the first decade of life.
Results: A total of 321 cancers were detected among the children conceived via IVF (49.1% girls and 50.9% boys; mean [SD] age, 4.6 [2.5] years for singleton births and 5.9 [2.4] years for multiple births), and a total of 2042 cancers were detected among the children not conceived via IVF (49.2% girls and 50.8% boys; mean [SD] age, 6.1 [2.6] years for singleton births and 4.7 [2.6] years for multiple births). The overall cancer rate (per 1 000 000 person-years) was 251.9 for the IVF group and 192.7 for the non-IVF group (hazard ratio, 1.17; 95% CI, 1.00-1.36). The rate of hepatic tumors was higher among the IVF group than the non-IVF group (hepatic tumor rate: 18.1 vs 5.7; hazard ratio, 2.46; 95% CI, 1.29-4.70); the rates of other cancers did not differ between the 2 groups. There were no associations with specific IVF treatment modalities or indication for IVF.
Conclusions and relevance: This study found a small association of IVF with overall cancers of early childhood, but it did observe an increased rate of embryonal cancers, particularly hepatic tumors, that could not be attributed to IVF rather than to underlying infertility. Continued follow-up for cancer occurrence among children conceived via IVF is warranted.

Sears S, Buendia JR, Odem S, et al. Metabolic syndrome among people living with HIV receiving medical care in southern United States: prevalence and risk factors. AIDS Behav. 2019 Nov;23(11):2916-2925. Epub 2019 Mar 30. doi: 10.1007/s10461-019-02487-8
Using representative data among 1861 in care people living with HIV (PLWH) in four southern states (Texas, Mississippi, Florida, and Georgia) from the 2013-2014 Medical Monitoring Project (MMP) survey, we estimated the prevalence and odds of metabolic syndrome (MetS) among various demographic and HIV related risk factors. Overall MetS prevalence was 34%, with our participants being mostly black (55%), male (72%), ≥ 50 years old (46%), and overweight or obese (60%) with undetectable viral loads (≤ 200 copies/ml, 69%), and were currently taking antiretroviral medication (98%). Compared to those who were ≥ 60 years, 18-39 year olds had a 79% (95% CI 0.13-0.33) lower odds of having MetS. Women were 2.24 times more likely to have MetS than men (95% CI 1.69-2.97). Age and sex were significant predictors of MetS. Since MetS is a combination of chronic disease risk factors, regular screening for MetS risk factors among aging PLWH is crucial.

Ryan MA, Olshan AF, Canfield MA, et al. Sociodemographic, health behavioral, and clinical risk factors for anotia/microtia in a population-based case-control study. Int J Pediatr Otorhinolaryngol. 2019 Jul;122:18-26. Epub 2019 Mar 23. doi: 10.1016/j.ijporl.2019.03.026
Anotia and microtia are congenital malformations of the external ear with few known risk factors. We conducted a comprehensive assessment of a wide range of potential risk factors using data from the National Birth Defects Prevention Study (NBDPS), a population-based case-control study of non-chromosomal structural birth defects in the United States.
Methods: Mothers of 699 infants with anotia or microtia (cases) and 11,797 non-malformed infants (controls) delivered between 1997 and 2011 were interviewed to obtain information about sociodemographic, health behavioral, and clinical characteristics. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated with logistic regression.
Results: Infants with anotia/microtia were more likely to be male (aOR, 1.29; 95% CI, 1.10-1.50) and from a multifetal pregnancy (aOR, 1.68; 95% CI, 1.16-2.42). Cases were also more likely to have parents of Hispanic ethnicity (maternal aOR, 3.19; 95% CI, 2.61-3.91; paternal aOR, 2.11; 95% CI, 1.54-2.88), and parents born outside the United States (maternal aOR, 1.29; 95% CI, 1.06-1.57; paternal aOR, 1.92; 95% CI, 1.53-2.41). Maternal health conditions associated with increased odds of anotia/microtia included obesity (aOR, 1.31; 95% CI, 1.06-1.61) and pre-pregnancy diabetes (type I aOR, 9.89; 95% CI, 5.46-17.92; type II aOR, 4.70; 95% CI, 2.56-8.63). Reduced odds were observed for black mothers (aOR, 0.57; 95% CI, 0.38-0.85) and mothers reporting daily intake of folic acid-containing supplements (aOR, 0.59; 95% CI, 0.46-0.76).
Conclusion: We identified several risk factors for anotia/microtia, some which have been previously reported (e.g., diabetes) and others which we investigate for perhaps the first time (e.g., binge drinking) that warrant further investigation. Our findings point to some potentially modifiable risk factors and provide further leads toward understanding the etiology of anotia/microtia.

Kirby RS1, Mai CT2, Wingate MS3, et al. Prevalence of selected birth defects by maternal nativity status, United States, 1999-2007. Birth Defects Res. 2019 Jul 1;111(11):630-639. Epub 2019 Mar 28. doi.org/10.1002/bdr2.1489
We investigated differences in prevalence of major birth defects by maternal nativity within racial/ethnic groups for 27 major birth defects.
Methods: Data from 11 population-based birth defects surveillance systems in the United States including almost 13 million live births (approximately a third of U.S. births) during 1999-2007 were pooled. We calculated prevalence estimates for each birth defect for five racial/ethnic groups. Using Poisson regression, crude and adjusted prevalence ratios (aPRs) were also calculated using births to US-born mothers as the referent group in each racial/ethnic group.
Results: Approximately 20% of case mothers and 26% of all mothers were foreign-born. Elevated aPRs for infants with foreign-born mothers were found for spina bifida and trisomy 13, 18, and 21, while lower prevalence patterns were found for pyloric stenosis, gastroschisis, and hypospadias.
Conclusions: This study demonstrates that birth defects prevalence varies by nativity within race/ethnic groups, with elevated prevalence ratios for some specific conditions and lower prevalence for others. More detailed analyses focusing on a broader range of maternal behaviors and characteristics are required to fully understand the implications of our findings.

Abara WE, Trujillo L, Broz D, et al. Age-related differences in past or present HCV infection among people who inject drugs - national HIV behavioral surveillance, eight U.S Cities, 2015. J Infect Dis. 2019 Jul 2;220(3):377-385. Epub 27 March 2019. doi: 10.1093/infdis/jiz142
Historically, older people who inject drugs (PWID) have had the highest hepatitis C burden, however, young PWID account for recent increases in HCV infection. We assessed factors associated with past or present HCV infection (HCV antibody-positive) among young (≤35 years) and older PWID (>35 years).
Methods: Using Poisson regression, we calculated adjusted prevalence ratios (aPR) to examine socio-demographic and past 12-month injection risk behaviors associated with HCV infection.
Results: Of 4,094 PWID, 55.2% were HCV antibody-positive (anti-HCV). Among young PWID, anti-HCV prevalence was 42.1% and associated with ≤high school diploma/GED (aPR=1.17, 95%CI=1.03-1.32), receptive syringe sharing (aPR=1.37, 95%CI=1.21-1.56), sharing injection equipment (aPR=1.16, 95%CI=1.01-1.35), arrest history (aPR=1.14, 95%CI=1.02-1.29), and injecting speedball (aPR=1.37, 95%CI=1.16-1.61). Among older PWID, anti-HCV prevalence was 62.2% and associated with ≤high school diploma/GED (aPR= 1.08, 95%CI=1.02-1.15), sharing injection equipment (aPR=1.08, 95% CI=1.02-1.15), high injection frequency (aPR=1.16, 95%CI=1.01-1.34), and injecting speedball (aPR=1.09, 95%CI=1.01-1.16).
Conclusions: Anti-HCV positivity prevalence is high and associated with risky injection practices. Almost half of young PWID were anti-HCV positive. Improving access to direct-acting antiviral treatment, syringe service programs, and medication-assisted therapy are critical to reducing HCV transmission risk and infection burden, particularly among young PWID who are more likely to be newly infected.

White JT, Kovar E, Chambers TM, et al. Hypospadias risk from maternal residential exposure to heavy metal hazardous air pollutants. Int J Environ Res Public Health. 2019;16(6):930. Epub 2019 Mar 15. doi: 10.3390/ijerph16060930
Investigate whether residential prenatal exposure to heavy metal hazardous air pollutants (HMHAPs) is associated with an increased risk of hypospadias.
Methods: Data on non-syndromic hypospadias cases (n = 8981) and control patients delivered in Texas were obtained from the Texas Birth Defects Registry and matched 1:10 by birth year. Average exposure concentrations of HMHAPs were obtained from the 2005 U.S. Environmental Protection Agency National-Scale Air Toxics Assessment and categorized into quintiles. Odds ratios and 95% confidence intervals were estimated. STROBE reporting guidelines were followed.
Results: We observed associations between hypospadias and prenatal HMHAP exposure. Manganese demonstrated significant increased risk of hypospadias at the medium, medium-high and high exposure quintiles; lead in the medium-high and high exposure quintiles. Cadmium, mercury and nickel demonstrated a significant inverted "U-shaped" association for exposures with significant associations in the medium and medium-high quintiles but not in the medium-low and high quintiles. Arsenic and chromium demonstrated a significant bivalent association for risk of hypospadias in a lower quintile as well as a higher quintile with non-significant intermediate quintiles.
Conclusions: Using data from one of the world's largest active surveillance birth defects registries, we identified significant associations between hypospadias and HMHAP exposures. These results should be used in counseling for maternal demographic risk factors as well as avoidance of heavy metals and their sources.

Lindsey NP, Porse CC, Potts E, et al. Postnatally acquired Zika virus disease among children, United States, 2016-2017. Clin Infect Dis. 2020;70(2):227-231. Epub 2019 Mar 11.  doi: 10.1093/cid/ciz195
The clinical findings among children with postnatally acquired Zika virus disease are not well characterized. We describe and compare clinical signs and symptoms for children aged <18 years.
Methods: Zika virus disease cases were included if they met the national surveillance case definition, had illness onset in 2016 or 2017, resided in a participating state, and were reported to CDC. Pediatric cases were aged <18 years; congenital and perinatal infections were excluded. Pediatric cases were matched to adult cases (18‒49 years). Clinical information was compared between younger and older pediatric cases and between children and adults.
Results; A total of 141 pediatric Zika virus disease cases were identified; none experienced neurologic disease. Overall, 28 (20%) were treated in an emergency department, 1 (<1%) was hospitalized; none died. Of the four primary clinical signs and symptoms associated with Zika virus disease, 133 (94%) children had rash, 104 (74%) fever, 67 (48%) arthralgia, and 51 (36%) conjunctivitis. Fever, arthralgia, and myalgia were more common in older children (12‒17 years) than younger children (1‒11 years). Arthralgia, arthritis, edema, and myalgia were more common in adults compared to children.
Conclusions: This report supports previous findings that Zika virus disease is generally mild in children. The most common symptoms are similar to other childhood infections, and clinical findings and outcomes are similar to those in adults. Healthcare providers should consider a diagnosis of Zika virus infection in children with fever, rash, arthralgia, or conjunctivitis, who reside in or have traveled to an area where Zika virus transmission is occurring.

Kapoor R, Kancherla V, Cao Y, et al. Prevalence and descriptive epidemiology of infantile hypertrophic pyloric stenosis in the United States: A multistate, population-based retrospective study, 1999-2010. Birth Defects Res. 2019 Feb 1; 111(3):159-169. Epub 2018 Dec 13. doi: 10.1002/bdr2.1439 
Antecedents for infantile hypertrophic pyloric stenosis (IHPS) vary across studies; therefore, we conducted a multistate, population-based retrospective study of the prevalence and descriptive epidemiology of IHPS in the United States (US).
Methods: Data for IHPS cases (n = 29,554) delivered from 1999-2010 and enumerated from 11 US population-based birth defect surveillance programs, along with data for live births (n = 14,707,418) delivered within the same birth period and jurisdictions, were analyzed using Poisson regression to estimate IHPS prevalence per 10,000 live births. Additional data on deliveries from 1999-2005 from seven of these programs were analyzed using multivariable logistic regression to estimate adjusted prevalence ratios (aPR)s and 95% confidence intervals (CI)s for selected infant and parental characteristics.
Results: Overall, IHPS prevalence from 1999-2010 was 20.09 (95% CI = 19.87, 20.32) per 10,000 live births, with statistically significant increases from 2003-2006 and decreases from 2007-2010. Compared to their respective referents, aPRs were higher in magnitude for males, preterm births, and multiple births, but lower for birth weights <2,500 g. The aPRs for all cases increased with decreasing parental age, maternal education, and maternal parity, but decreased for parental race/ethnicity other than non-Hispanic White. Estimates restricted to isolated cases or stratified by infant sex were similar to those for all cases.
Conclusions: This study covers one of the largest samples and longest temporal period examined for IHPS in the US. Similar to findings reported in Europe, estimates suggest that IHPS prevalence has decreased recently in the US. Additional analyses supported associations with several infant and parental characteristics.

Benjamin RH, Mitchell LE, Canfield MA, et al. Fish consumption prior to pregnancy and pregnancy outcomes in the National Birth Defects Prevention Study, 1997-2011. Public Health Nutr. 2019 Feb;22(2):336-343. Epub 2018 Oct 17. doi: 10.1017/S1368980018002641
To evaluate the relationships between maternal fish consumption and pregnancy outcomes in a large, population-based sample of women in the USA.
Design: We collected average fish consumption prior to pregnancy using a modified version of the semi-quantitative Willett FFQ. We estimated adjusted OR (aOR) and 95 % CI for associations between different levels of fish consumption and preterm birth (&lt;37 weeks), early preterm birth (&lt;32 and &lt;35 weeks) and small-for-gestational-age infants (SGA; &lt;10th percentile).
Setting: The National Birth Defects Prevention Study (NBDPS).
Subjects: Control mother-infant pairs with estimated delivery dates between 1997 and 2011 (n 10 919).
Results: No significant associations were observed between fish consumption and preterm birth or early preterm birth (aOR = 0·7-1·0 and 0·7-0·9, respectively). The odds of having an SGA infant were elevated (aOR = 2·1; 95 % CI 1·2, 3·4) among women with daily fish consumption compared with women consuming fish less than once per month. No associations were observed between other levels of fish consumption and SGA (aOR = 0·8-1·0).
Conclusions: High intake of fish was associated with twofold higher odds of having an SGA infant, while moderate fish consumption prior to pregnancy was not associated with preterm or SGA. Our study, like many other studies in this area, lacked information regarding preparation methods and the specific types of fish consumed. Future studies should incorporate information on nutrient and contaminant contents, preparation methods and biomarkers to assess these relationships.

Endres BT1, Begum K1, Sun H2, et al. Epidemic Clostridioides difficile ribotype 027 lineages: comparisons of Texas versus worldwide strains. Open Forum Infect Dis. 2019 Feb 9;6(2):ofz013. doi: 10.1093/ofid/ofz013
The epidemic Clostridioides difficile ribotype 027 strain resulted from the dissemination of 2 separate fluoroquinolone-resistant lineages: FQR1 and FQR2. Both lineages were reported to originate in North America; however, confirmatory large-scale investigations of C difficile ribotype 027 epidemiology using whole genome sequencing has not been undertaken in the United States.
Methods: Whole genome sequencing and single-nucleotide polymorphism (SNP) analysis was performed on 76 clinical ribotype 027 isolates obtained from hospitalized patients in Texas with C difficile infection and compared with 32 previously sequenced worldwide strains. Maximum-likelihood phylogeny based on a set of core genome SNPs was used to construct phylogenetic trees investigating strain macro- and microevolution. Bayesian phylogenetic and phylogeographic analyses were used to incorporate temporal and geographic variables with the SNP strain analysis.
Results: Whole genome sequence analysis identified 2841 SNPs including 900 nonsynonymous mutations, 1404 synonymous substitutions, and 537 intergenic changes. Phylogenetic analysis separated the strains into 2 prominent groups, which grossly differed by 28 SNPs: the FQR1 and FQR2 lineages. Five isolates were identified as pre-epidemic strains. Phylogeny demonstrated unique clustering and resistance genes in Texas strains indicating that spatiotemporal bias has defined the microevolution of ribotype 027 genetics.
Conclusions: Clostridioides difficile ribotype 027 lineages emerged earlier than previously reported, coinciding with increased use of fluoroquinolones. Both FQR1 and FQR2 ribotype 027 epidemic lineages are present in Texas, but they have evolved geographically to represent region-specific public health threats.

Hoang TT, Lei Y, Mitchell LE, et al. Maternal lactase polymorphism (rs4988235) is associated with neural tube defects in offspring in the National Birth Defects Prevention Study. J Nutr. 2019 Feb 1;149(2):295-303. Epub 2019 Jan 24. doi: 10.1093/jn/nxy246
The risk of neural tube defect (NTD)-affected pregnancies is reduced with adequate folic acid intake during early pregnancy. However, NTDs have been observed among offspring of women with adequate folic acid intake. Some of these women are possibly not absorbing enough folic acid. Because lactase deficiency can lead to poor nutrient absorption, we hypothesized that lactase-deficient women will be at increased risk of having offspring with NTDs.
Objective: We examined the association between maternal rs4988235 (a lactase deficiency genetic marker) and NTDs in offspring.
Methods: We conducted a case-control study using data from the National Birth Defects Prevention Study, United States, 1997-2009, restricting to non-Hispanic white (NHW) and Hispanic women. Cases were women with an offspring with an NTD (n = 378 NHW, 207 Hispanic), and controls were women with an offspring without a birth defect (n = 461 NHW, 165 Hispanic). Analyses were conducted separately by race/ethnicity, using logistic regression. Women with the CC genotype were categorized as being lactase deficient. To assess potential effect modification, analyses were stratified by lactose intake, folic acid supplementation, dietary folate, and diet quality.
Results: Among NHW women, the odds of being lactase deficient were greater among cases compared with controls (OR: 1.37; 95% CI: 1.02, 1.82). Among Hispanic women, the odds of being lactase deficient were significantly lower among cases compared with controls (OR: 0.50, 95% CI: 0.33, 0.77). The association differed when stratified by lactose intake in NHW women (higher odds among women who consumed ≥12 g lactose/1000 kcal) and by dietary folate in Hispanic women (opposite direction of associations). The association did not differ when stratified by folic acid supplementation or diet quality.
Conclusions: Our findings suggest that maternal lactase deficiency is associated with NTDs in offspring. However, we observed opposite directions of effect by race/ethnicity that could not be definitively explained.

Shewale JB, Ganduglia Cazaban CM, Waller DK, Mitchell LE, Langlois PH, Agopian AJ. Microcephaly inpatient hospitalization and potential Zika outbreak in Texas: A cost and predicted economic burden analysis. Travel Med Infect Dis. 2019 Jul-Aug;30:67-72. Epub 2019 Jan 9. doi: 10.1016/j.tmaid.2019.01.001
Estimate inpatient hospitalization costs for patients with microcephaly, and predict cost increases due to a potential Zika virus outbreak.
Methods: We identified Texas-wide inpatient hospitalization discharge records (2008-2015), for newborns and non-newborns with microcephaly. We estimated the cost of each hospitalization by applying cost-to-charge ratios on the actual hospitalization charge. For comparison, newborn visits for patients without microcephaly were also identified, and hospital costs were compared between patients with and without microcephaly. We estimated costs for microcephaly during the first year of life following a Zika outbreak (possible 1-50% increase in birth prevalence) in Texas.
Results: There were 8005 microcephaly hospitalizations ($203,899,042; total cost). The median admission cost for newborns with microcephaly (N = 1393) was higher compared to those without microcephaly ($6751 vs $725, p < 0.001). Microcephaly hospitalizations of newborns had a lower median cost compared to non-newborns ($6751 vs $9754, p < 0.001). Based on these observed hospitalization costs, we estimated that a potential Zika virus outbreak in Texas could result in an additional $1-6 million per year for hospitalizations.
Conclusion: Hospitalizations of patients with microcephaly are associated with high costs. An increase in microcephaly prevalence due to a Zika outbreak in Texas could have a considerable impact on health care costs.

Haidar A, Ranjit N, Saxton D, Hoelscher DM. Perceived parental and peer social support is associated with healthier diets in adolescents. J Nutr Educ Behav. 2019 Jan;51(1):23-31. doi: 10.1016/j.jneb.2018.10.003
Investigate associations between perceived parental/peer support for a healthy diet and adolescent dietary behaviors using data from the 2009-2011 School Physical Activity and Nutrition (SPAN) survey.
Design: A secondary analysis of SPAN, a cross-sectional statewide study using a validated self-administered questionnaire, assessed obesity-related behaviors.
Setting: Probability-based sample of Texas 8th- and 11th-grade students.
Participants: A total of 6,716 8th- and 11th-grade students.
Main outcome measures: Obtained by self-report and included sugary beverage consumption, fruit and vegetable intake, and SPAN healthy eating score.
Analysis: Multiple logistic regression and linear regression were used to determine associations, controlling for demographic variables.
Results: For every 1-point increase in parental support (range, 0-12), adolescents had 1.19 times higher odds of consuming ≥1 fruits or vegetables/d (P < .001) and 1.1 times lower odds of consuming ≥2 sugary beverages/d (P < .05), and had a SPAN healthy eating score (range, -100 to 100) that was 1.6 points higher (P < .001). For every 1-point increase in peer support, adolescents had 1.14 times higher odds of consuming ≥1 fruits and vegetables/d (P < .001) and a higher SPAN healthy eating score (P < .05).
Conclusions and implications: Parental/peer support was associated with healthier dietary behaviors. Future research could conduct pre-post intervention studies to determine whether an increase in parental/peer support is associated with positive changes in healthier eating.

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Last updated May 18, 2022