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DSHS Authors: 2018 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 in the last five years. For more information about these articles or for a full-text copy, please contact the Medical and Research Library by e-mail at library@dshs.texas.gov by calling (512) 776-7559.

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mrl-diamond2018 Articles (in date order with most recent first)

Ramsey J, Mayes B. Outcomes of community-based prenatal education programs for pregnant women in rural Texas. Fam Community Health. 2018 Jul/Sep;41(3):E1-E4. doi: 10.1097/FCH.0000000000000191.
A prenatal, evidenced-based education program was implemented in 7 rural counties and provided by trained staff at the Texas Department of State Health Services. This was implemented to address health disparities, in regard to birth outcomes, in rural minorities of Southeast Texas. The participants were given a preassessment (N = 382) and a postassessment (N = 326) of relevant health knowledge and a follow-up assessment (N = 149) to document the outcomes of their birth as well as health practices they were employing as new parents. The assessment results were analyzed to determine the effectiveness of the programs on improving health outcomes and knowledge.

Lin S, Lin Z, Ou Y, Soim A, Shrestha S, Langlois P, et al. Maternal ambient heat exposure during early pregnancy in summer and spring and congenital heart defects - A large US population-based, case-control study. Environ Int. 2018 Jun 7;118:211-221. doi: 10.1016/j.envint.2018.04.043. [Epub ahead of print]
BACKGROUND/OBJECTIVE: Few studies have assessed the effect of ambient heat during the fetal development period on congenital heart defects (CHDs), especially in transitional seasons. We examined and compared the associations between extreme heat and CHD phenotypes in summer and spring, assessed their geographical differences, and compared different heat indicators.
METHODS: We identified 5848 CHD cases and 5742 controls (without major structural defects) from the National Birth Defects Prevention Study, a US multicenter, population-based case-control study. Extreme heat events (EHEs) were defined by using the 95th (EHE95) or 90th (EHE90) percentile of daily maximum temperature and its frequency and duration during postconceptional weeks 3-8. We used a two-stage Bayesian hierarchical model to examine both regional and study-wide associations. Exposure odds ratios (ORs) were calculated using multivariate logistic regression analyses, while controlling for potential confounding factors.
RESULTS: Overall, we observed no significant relationships between maternal EHE exposure and CHDs in most regions during summer. However, we found that 3-11 days of EHE90 during summer and spring was significantly associated with ventricular septal defects (VSDs) study-wide (ORs ranged: 2.17-3.24). EHE95 in spring was significantly associated with conotruncal defects and VSDs in the South (ORs: 1.23-1.78). Most EHE indicators in spring were significantly associated with increased septal defects (both VSDs and atrial septal defects (ASDs)) in the Northeast.
CONCLUSION: While generally null results were found, long duration of unseasonable heat was associated with the increased risks for VSDs and ASDs, mainly in South and Northeast of the US. Further research to confirm our findings is needed.

Uejio C, Morano L, Jung J, Kintziger K, Jagger M, Chalmers J, et al. Occupational heat exposure among municipal workers. Int Arch Occup Environ Health. 2018 Jun 5. doi: 10.1007/s00420-018-1318-3. [Epub ahead of print]
PURPOSE: Outdoor workers face elevated and prolonged heat exposures and have limited access to air-conditioned spaces. This study's overarching research aim is to increase knowledge of municipal worker heat exposure and adaptation practices. The study's sub-objectives are: (1) quantifying exposure misclassification from estimating personal heat exposure from the official weather station; (2) surveying worker's knowledge and practices to adapt to extreme heat; and (3) relating heat exposure and adaptation practices to self-reported thermal comfort.
METHODS: Participants wore a personal heat exposure sensor over 7 days from June 1st to July 3rd, 2015 in Tallahassee, Florida US. Next, participants confirmed the days that they wore the sensor and reported their daily thermal comfort and heat adaptations. Finally, participants completed an extreme heat knowledge, attitudes, and practices survey.
RESULTS: Some participants (37%) experienced hotter and more humid conditions (heat index > 2) than the weather station. The most common heat adaptations were staying hydrated (85%), wearing a hat (46%), and seeking shade (40%). During work hours, higher temperatures increased the odds (odds ratio: 1.21, 95% confidence interval: 1.03-1.41, p = 0.016) of a participant feeling too hot. Shifting work duty indoors made workers to feel more comfortable (odds ratio: 0.28, 95% confidence interval: 0.11-0.70, p = 0.005).
CONCLUSION: In hot and humid climates, everyday heat exposures continuously challenge the health of outdoor workers.

Lee D, Montour J, Fulton A, Benoit S, Nelson N, Liu Y. Overseas Hepatitis B Vaccinations Among Newly Arrived Cubans in Texas-2010-2015. J Immigr Minor Health. 2018 Jun;20(3):755-758. doi: 10.1007/s10903-017-0649-6.
We assessed hepatitis B virus (HBV) serologic results among newly arrived Cubans with vaccination documentation. We matched the post-arrival health assessment HBV serologic results of Cubans who arrived during 2010-2015 in Texas with their overseas hepatitis B (HepB) vaccination records in the CDC's Electronic Disease Notification database and calculated the proportion of those immune due to HepB vaccinations. Among 2123 who had overseas HepB vaccination and serologic results, 1072 (50.5%) had three valid documented doses of HepB. Of these 1072, 441 (41.1%) were immune due to HepB vaccination, 24 (2.2%), immune due to natural infection, 599 (55.9%), susceptible to HBV, and 8 (0.7%), HBV infected. Stratified by age, 21 (87.5%) of 24 children <5 years of age showed protection, and the antibody to HepB surface antigen (anti-HBs) decreased as age increased. Our findings concurred with previous observations that anti-HBs serologic results wane over time. Many newly arrived Cubans with complete HepB vaccination records on the U.S. Department of State overseas vaccination forms might be immune despite <10 mIU/mL anti-HBs response levels.

Borner K, Mitchell T, Gray J, Davis A, Pont S, Sweeney B, et al. Factor structure of a Spanish translation of an obesity-specific parent-report measure of health-related quality of life. J Pediatr Psychol. 2018 May 15. doi: 10.1093/jpepsy/jsy030. [Epub ahead of print]
OBJECTIVE: Latino youth are disproportionately affected by pediatric obesity and consequently experience impaired health-related quality of life (HRQOL). Although many caregivers of Latino youth do not speak English fluently, no validated Spanish translations of obesity-specific HRQOL measures exist for this population. Therefore, non-English-speaking Latino parents have typically been excluded from analyses related to HRQOL. This study assesses the factor structure of a Spanish translation of a parent-report measure of obesity-specific HRQOL, Sizing Them Up, in a treatment-seeking sample of children with obesity.
METHODS: Structural equation modeling was used to assess the factor structure of the 6-subscale, 22-item Sizing Them Up measure in 154 parents of treatment-seeking Latino youth (5-18 years of age). Analyses exploring internal consistency and convergent validity were also conducted.
RESULTS: Acceptable measurement fit was achieved for the six-factor solution. However, the higher-order model assessing Total HRQOL did not reach acceptable levels, as results found that the Positive Social Attributes (PSA) subscale was not representative of Total HRQOL; internal consistency and convergent validity results also supported this finding.
CONCLUSIONS: The current study provides support for the utility of a modified version of Sizing Them Up, excluding the PSA Scale, as a parent-report measure of obesity-specific HRQOL in treatment-seeking Latino youth with obesity.

Chen R, Mukhopadhyay S, Merits A, Bolling B, Nasar F, Coffey L, et al. ICTV virus taxonomy profile: Togaviridae. J Gen Virol. 2018 May 10. doi: 10.1099/jgv.0.001072. [Epub ahead of print]
The Togaviridae is a family of small, enveloped viruses with single-stranded, positive-sense RNA genomes of 10-12 kb. Within the family, the genus Alphavirus includes a large number of diverse species, while the genus Rubivirus includes the single species Rubella virus. Most alphaviruses are mosquito-borne and are pathogenic in their vertebrate hosts. Many are important human and veterinary pathogens (e.g. chikungunya virus and eastern equine encephalitis virus). Rubella virus is transmitted by respiratory routes among humans. 

Baeva S, Saxton D, Ruggiero K, Kormondy M, Hollier L, Hellerstedt J, et al. Identifying maternal deaths in Texas using an enhanced method, 2012. Obstet Gynecol. 2018 May;131(5):762-769. doi: 10.1097/AOG.0000000000002565.
OBJECTIVE: To more accurately estimate the 2012 maternal mortality ratio for Texas using an enhanced method for identifying maternal deaths.
METHODS: This population-based descriptive study used both data matching and record review to verify pregnancy or delivery within 42 days for 147 deaths with obstetric cause-of-death codes, and used data matching alone to identify additional maternal deaths within the same timeframe. Crude maternal mortality ratios were calculated for confirmed maternal deaths overall, by race and ethnicity, and by age. These maternal mortality ratios were compared with maternal mortality ratios computed using obstetric cause-of-death codes alone (standard method).
RESULTS: Fifty-six maternal deaths were confirmed to have occurred during pregnancy or within 42 days postpartum. Using our enhanced method, the 2012 maternal mortality ratio for Texas was 14.6 maternal deaths per 100,000 live births, less than half that obtained using the standard method (n=147). Approximately half (50.3%) of obstetric-coded deaths showed no evidence of pregnancy within 42 days, and a large majority of these incorrectly indicated pregnancy at the time of death. Insufficient information was available to determine pregnancy for 15 obstetric-coded deaths, which were excluded from the 2012 maternal mortality ratio estimate; however, had these deaths been included, the resulting maternal mortality ratio would still be significantly lower than that reported using the standard method.
CONCLUSION: Relying solely on obstetric codes for identifying maternal deaths appears to be insufficient and can lead to inaccurate maternal mortality ratios. A method enhanced with data matching and record review yields more accurate ratios. Results likely have national implications, because miscoding of obstetric deaths with the standard method may affect the accuracy of other states' maternal mortality ratios.

Bosh K, Coyle J, Hansen V, Kim E, Speers S, Rowlinson E, et al. HIV and viral hepatitis coinfection analysis using surveillance data from 15 US states and two cities. Epidemiol Infect. 2018 Apr 11:1-11. doi: 10.1017/S0950268818000766. [Epub ahead of print]
Coinfection with human immunodeficiency virus (HIV) and viral hepatitis is associated with high morbidity and mortality in the absence of clinical management, making identification of these cases crucial. We examined characteristics of HIV and viral hepatitis coinfections by using surveillance data from 15 US states and two cities. Each jurisdiction used an automated deterministic matching method to link surveillance data for persons with reported acute and chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections, to persons reported with HIV infection. Of the 504 398 persons living with diagnosed HIV infection at the end of 2014, 2.0% were coinfected with HBV and 6.7% were coinfected with HCV. Of the 269 884 persons ever reported with HBV, 5.2% were reported with HIV. Of the 1 093 050 persons ever reported with HCV, 4.3% were reported with HIV. A greater proportion of persons coinfected with HIV and HBV were males and blacks/African Americans, compared with those with HIV monoinfection. Persons who inject drugs represented a greater proportion of those coinfected with HIV and HCV, compared with those with HIV monoinfection. Matching HIV and viral hepatitis surveillance data highlights epidemiological characteristics of persons coinfected and can be used to routinely monitor health status and guide state and national public health interventions.

Forrester M. Megalopyge opercularis caterpillar stings reported to Texas poison centers. Wilderness Environ Med. 2018 Apr 3. doi: 10.1016/j.wem.2018.02.002. [Epub ahead of print] 
INTRODUCTION: The Megalopyge opercularis caterpillar is covered with spines that break off and release venom on contact, resulting in severe pain, erythema, rash, and other adverse effects. In Texas, these caterpillars are abundant and of potential health threat. This study describes M opercularis caterpillar stings reported to Texas poison centers.
METHODS: Cases were M opercularis caterpillar stings reported to Texas poison centers during 2000-2016. The distribution of stings was determined related to exposure circumstances and management.
RESULTS: There were 3484 M opercularis caterpillar stings reported during 2000-2016. The annual number of stings did not consistently change over the 17-year time period. The monthly number of stings was highest in July (12%) and October to November (59%). The patients were female in 53% of cases and aged 20 years or more in 56%. The sting occurred at the patient's own residence in 91% of cases. The patients were managed outside of a healthcare facility in 89% of cases; 93% of the patients were known or expected to have no or at most minor clinical effects. Dermal clinical effects were reported in 90% of cases, the most common being irritation/pain (84%), puncture/wound (45%), erythema/flushed (29%), and edema (15%).
CONCLUSIONS: M opercularis caterpillar stings reported to Texas poison centers were more frequently reported in July and October to November. Most of the patients were adults. The majority of patients were managed outside of healthcare facilities and did not have serious outcomes. Most of the adverse clinical effects were dermal in nature.

Hoyt A, Canfield M, Romitti P, Botto L, Anderka M, Krikov S, et al. Does maternal exposure to secondhand tobacco smoke during pregnancy increase the risk for preterm or small-for-gestational age birth? Matern Child Health J. 2018 Mar 24. doi: 10.1007/s10995-018-2522-1. [Epub ahead of print]
Introduction While associations between active smoking and various adverse birth outcomes (ABOs) have been reported in the literature, less is known about the impact of secondhand smoke (SHS) on many pregnancy outcomes. Methods We examined the relationship between maternal exposure to SHS during pregnancy and preterm (< 37 weeks gestation) and small-for-gestational age (SGA; assessed using sex-, race/ethnic-, and parity-specific growth curves) singleton births using non-smoking controls from the National Birth Defects Prevention Study (1997-2011). Multivariable logistic regression models for household, workplace/school, and combined SHS exposure-controlled for maternal education, race/ethnicity, pre-pregnancy body mass index, and high blood pressure-were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Interaction was assessed for maternal folic acid supplementation, alcohol use, age at delivery, and infant sex. Results Infants of 8855 mothers were examined in the preterm birth analysis with 666 (7.5%) categorized as preterm, 574 moderately preterm (32-36 weeks), and 92 very preterm (< 32 weeks). For the SGA analysis, infants of 8684 mothers were examined with 670 (7.7%) categorized as SGA. The aORs for mothers reporting both household and workplace/school SHS were elevated for preterm (aOR 1.99; 95% CI 1.13-3.50) and moderately preterm birth (32-36 weeks) (aOR 2.17; 95% CI 1.22-3.88). No results for the SGA analysis achieved significance, nor was evidence of interaction evident. Conclusion The findings suggest an association between SHS from multiple exposure sources and preterm birth, but no evidence for association with SGA births. Continued study of SHS and ABOs is needed to best inform public health prevention programs.

Rowlinson E, Goings S, Minnerly S, Surita K, Pogosjans S. Differences in partner services outcomes for men who have sex with men diagnosed with primary and secondary syphilis by HIV serostatus. Sex Transm Dis. 2018 Mar;45(3):152-157. doi: 10.1097/OLQ.0000000000000710
Background: Differences in partner services outcomes in men who have sex with men (MSM) by HIV serostatus have not been explored as a potential driver of differential early syphilis (ES) burden in this population. Methods: We compared partner services outcomes (number of partners named, notified, tested, diagnosed, and treated) between HIV-positive and HIV-negative MSM initiated for ES partner services in Texas from 2013 to 2016 using logistic regression and Wilcoxon-Mann-Whitney tests. Logistic regression was used to assess the relationship between HIV serostatus and having a no-partner-initiated (NPI) partner services interview controlling for demographic characteristics, prior partner services interactions, and geosocial phone application use. Results: A total of 4161 HIV-positive MSM and 5254 HIV-negative MSM were initiated for ES partner services. HIV-positive MSM named fewer partners than did HIV-negative MSM (mean, 1.2 vs. 1.9; P < 0.001) and had lower indices of partners notified, tested, diagnosed, and treated. HIV seropositivity was significantly associated with NPI. However, this association was not significant when limited to MSM with previous partner services interviews (adjusted risk ratio [aRR] 1.06; P = 0.38); in this subset of MSM, using geosocial phone application was negatively associated with having an NPI interview (aRR, 0.90), and having 1 (aRR, 1.33) or more than 1 previous NPI interview (aRR, 1.57) was associated with an NPI interview during the study period. Conclusions: Suboptimal outcomes for syphilis partner service may result in missed opportunities for testing and treatment of sexual contacts, which could allow for propagation of syphilis. Implementation of innovative protocols is needed to ensure that partner services continue to be an effective and acceptable method of syphilis disease intervention in MSM.

Carey FR, Wilkinson AV, Ranjit N, Mandell D, Hoelscher DM. Perceived Weight and bullying victimization in boys and girls. J Sch Health. 2018 Mar;88(3):217-226. doi: 10.1111/josh.12600.
Background: Research suggests that perceived weight poses separate risks from objective weight on adolescents' risks of being bullied. We examined if the prevalence of bullying victimization differed by perceived and objective weight status, and how these associations varied by sex. Methods: Data were analyzed for 6716 8th and 11th graders from the School Physical Activity and Nutrition project, a Texas statewide survey of public school students. Participants reported demographics, bullying victimization, and weight perceptions. Height and weight were measured. Results: In the last 6 months, 10.8% of students reported being bullied. Nearly 70% of normal weight and overweight and 50% of obese adolescents perceived themselves as weighing the right amount. Perceiving oneself as weighing too little or too much was significantly associated with increased bullying victimization (p < .05 for both), whereas objective weight was not. Statistical interactions between perceived weight and sex were significantly associated with victimization (p < .05) among boys only; boys who perceived themselves as weighing too little had higher predicted probabilities of victimization. Conclusions: Perceived weight may play a greater role in bullying victimization than objective weight, especially among boys. Interventions to prevent bullying should consider adolescents' self-perceptions of weight to effectively identify those at greater risk for victimization.

Mba-Jonas A, Culpepper W, Hill T, Cantu V, Loera J, Borders J, et al.  A multistate outbreak of human Salmonella Agona infections associated with consumption of fresh, whole papayas imported from Mexico-United States, 2011. Clin Infect Dis. 2018 Feb 19. doi: 10.1093/cid/cix1094.
Background: Nontyphoidal Salmonella causes ~1 million food-borne infections annually in the United States. We began investigating a multistate outbreak of Salmonella serotype Agona infections in April 2011. Methods: A case was defined as infection with the outbreak strain of Salmonella Agona occurring between 1 January and 25 August 2011. We developed hypotheses through iterative interviews. Product distribution analyses and traceback investigations were conducted. The Food and Drug Administration (FDA) tested papayas from Mexico for Salmonella. Results: We identified 106 case patients from 25 states. Their median age was 21 years (range, 1-91). Thirty-nine of 61 case patients (64%) reported Hispanic/Latino ethnicity; 11 of 65 (17%) travelled to Mexico before illness. Thirty-two of 56 case patients (57%) reported papaya consumption. Distribution analyses revealed that three firms, including Distributor A, distributed papaya to geographic areas that aligned with both the location and timing of illnesses. Traceback of papayas purchased by ill persons in four states identified Distributor A as the common supplier. FDA testing isolated the outbreak strain from a papaya sample collected at distributor A and from another sample collected at the US-Mexico border, destined for distributor A. FDA isolated Salmonella species from 62 of 388 papaya import samples (16%). The investigation led to a recall of fresh, whole papayas from Distributor A and an FDA import alert for all papayas from Mexico. Conclusions: This is the first reported Salmonella outbreak in the United States linked to fresh, whole papayas. The outbreak highlights important issues regarding the safety of imported produce.

Delaney A, Mai C, Smoots A, Cragan J, Ellington S, Langlois P, et al. Population-based surveillance of birth defects potentially related to Zika virus infection - 15 states and U.S. territories, 2016. MMWR Morb Mortal Wkly Rep. 2018 Jan 26;67(3):91-96. doi: 10.15585/mmwr.mm6703a2
Zika virus infection during pregnancy can cause serious birth defects, including microcephaly and brain abnormalities (1). Population-based birth defects surveillance systems are critical to monitor all infants and fetuses with birth defects potentially related to Zika virus infection, regardless of known exposure or laboratory evidence of Zika virus infection during pregnancy. CDC analyzed data from 15 U.S. jurisdictions conducting population-based surveillance for birth defects potentially related to Zika virus infection. Jurisdictions were stratified into the following three groups: those with 1) documented local transmission of Zika virus during 2016; 2) one or more cases of confirmed, symptomatic, travel-associated Zika virus disease reported to CDC per 100,000 residents; and 3) less than one case of confirmed, symptomatic, travel-associated Zika virus disease reported to CDC per 100,000 residents. A total of 2,962 infants and fetuses (3.0 per 1,000 live births; 95% confidence interval [CI] = 2.9-3.2) (2) met the case definition. In areas with local transmission there was a non-statistically significant increase in total birth defects potentially related to Zika virus infection from 2.8 cases per 1,000 live births in the first half of 2016 to 3.0 cases in the second half (p = 0.10). However, when neural tube defects and other early brain malformations (NTDs)§ were excluded, the prevalence of birth defects strongly linked to congenital Zika virus infection increased significantly, from 2.0 cases per 1,000 live births in the first half of 2016 to 2.4 cases in the second half, an increase of 29 more cases than expected (p = 0.009). These findings underscore the importance of surveillance for birth defects potentially related to Zika virus infection and the need for continued monitoring in areas at risk for Zika.

Loza O, Alvarez CR, Peralta-Torres D. Healthcare and social services providers who serve sexual and gender minorities in a U.S.-Mexico border city. J Immigr Minor Health. 2018 Jan 15. doi: 10.1007/s10903-018-0688-7.
Sexual and gender minorities, including lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals, experience barriers to healthcare as a result of stigma, discrimination, and poor cultural competence by healthcare and social services providers (HCSSP). The purpose of the study is to increase access to care and services for the LGBTQ community in a U.S.-Mexico border city by identifying LGBTQ-friendly HCSSP. A survey, developed based on concerns voiced in a predominantly Hispanic LGBTQ community, was administered to HCSSP and used to create a referral list, "The Purple Pages of El Paso" (PPoEP). Overall, 77 HCSSP have responded and 43 are included in the most recent version of the PPoEP. This model for developing a referral list of providers can be adapted in areas where LGBTQ communities face similar barriers to care and services. To be effective in reducing barriers to care, PPoEP must be updatable and sustainable.

Forrester MB. Pediatric exposures to Bombina toads reported to poison centers. Pediatr Emerg Care 2018;34:25-26.
OBJECTIVES: Fire-bellied toads (genus Bombina) secrete toxins from their skin that may cause problems to humans, particularly if they get in the eye. This study aimed to describe pediatric exposures to fire-bellied toads reported to a large poison center system. METHODS: Cases were fire-bellied toad exposures among patients aged 13 years or younger reported to Texas poison centers during 2000-2014. The distribution by various demographic and clinical factors was determined. RESULTS: Of 20 total exposures, the mean patient age was 5.8 years (range, 2-13 years); 70% of the patients were boys. The exposure route was ocular (70%), dermal (55%), and ingestion (20%). Eighty-five percent of the exposures occurred at the patient's own residence. Sixty percent of the patients were managed onsite, and 40% were already at or en route to a health care facility. The medical outcome was as follows: minor effects (45%), moderate effects (5%), and not followed but judged to have minimal clinical effects (50%). The most common reported symptoms were ocular irritation/pain (65%), dermal irritation/pain (30%), and red eye (20%). Decontamination by dilution/irrigation/wash was reported in 95% of the patients. CONCLUSIONS: Few pediatric exposures to fire-bellied toads were reported. Those that were reported were most likely to involve ocular followed by dermal routes. The exposures tended not to be serious and could be managed outside of a health care facility.

Raut J, Simeone R, Tinker S, Canfield M, Day R, Agopian A. Proportion of orofacial clefts attributable to recognized risk factors. Cleft Palate Craniofac J. 2018 Jan 1. doi: 10.1177/1055665618774019. [Epub ahead of print]
OBJECTIVE: Estimate the population attributable fraction (PAF) for a set of recognized risk factors for orofacial clefts.
DESIGN: We used data from the National Birth Defects Prevention Study. For recognized risk factors for which data were available, we estimated crude population attributable fractions (cPAFs) to account for potential confounding, average-adjusted population attributable fractions (aaPAFs). We assessed 11 modifiable and 3 nonmodifiable parental/maternal risk factors. The aaPAF for individual risk factors and the total aaPAF for the set of risk factors were calculated using a method described by Eide and Geffler.
SETTING: Population-based case-control study in 10 US states.
PARTICIPANTS: Two thousand seven hundred seventy-nine cases with isolated cleft lip with or without cleft palate (CL±P), 1310 cases with isolated cleft palate (CP), and 11 692 controls with estimated dates of delivery between October 1, 1997, and December 31, 2011.
MAIN OUTCOME MEASURES: Crude population attributable fraction and aaPAF.
RESULTS: The proportion of CL±P and CP cases attributable to the full set of examined risk factors was 50% and 43%, respectively. The modifiable factor with the largest aaPAF was smoking during the month before pregnancy or the first month of pregnancy (4.0% for CL±P and 3.4% for CP). Among nonmodifiable factors, the factor with the largest aaPAF for CL±P was male sex (27%) and for CP it was female sex (16%).
CONCLUSIONS: Our results may inform research and prevention efforts. A large proportion of orofacial cleft risk is attributable to nonmodifiable factors; it is important to better understand the mechanisms involved for these factors.

Glowicz J, Crist M, Gould C, Moulton-Meissner H, Noble-Wang J, de Man TJB, Perry KA, Miller Z, Yang WC, Langille S, Ross J, Garcia B, et al. A multistate investigation of health care-associated Burkholderia cepacia complex infections related to liquid docusate sodium contamination, January-October 2016. Am J Infect Control. 2018 Jan 9. pii: S0196-6553(17)31287-7. doi: 10.1016/j.ajic.2017.11.018. [Epub ahead of print]
Background: Outbreaks of health care-associated infections (HAIs) caused by Burkholderia cepacia complex (Bcc) have been associated with medical devices and water-based products. Water is the most common raw ingredient in nonsterile liquid drugs, and the significance of organisms recovered from microbiologic testing during manufacturing is assessed using a risk-based approach. This incident demonstrates that lapses in manufacturing practices and quality control of nonsterile liquid drugs can have serious unintended consequences. Methods: An epidemiologic and laboratory investigation of clusters of Bcc HAIs that occurred among critically ill, hospitalized, adult and pediatric patients was performed between January 1, 2016, and October 31, 2016. Results: One hundred and eight case patients with Bcc infections at a variety of body sites were identified in 12 states. Two distinct strains of Bcc were obtained from patient clinical cultures. These strains were found to be indistinguishable or closely related to 2 strains of Bcc obtained from cultures of water used in the production of liquid docusate, and product that had been released to the market by manufacturer X. Conclusions: This investigation highlights the ability of bacteria present in nonsterile, liquid drugs to cause infections or colonization among susceptible patients. Prompt reporting and thorough investigation of potentially related infections may assist public health officials in identifying and removing contaminated products from the market when lapses in manufacturing occur.

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Last updated January 7, 2019