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Objectives Since waste from swine industrial livestock operations (ILOs) produces air pollutants associated with negative health outcomes among nearby residents, we assessed the impact of odorant emissions on sleep duration and awakenings. Design A repeated-measures design. Setting Sixteen residential communities in eastern North Carolina hosting swine ILOs. Participants Eighty participants residing in eastern North Carolina from 2003 to 2005. Intervention (if any) Not applicable. Measurements Study participants completed twice-daily diaries in which they rated the strength of hog odors and indicated whether they were asleep or awake per hour for 2 weeks. Simultaneously, a monitoring trailer placed in a central location in each community measured the atmospheric concentration of hydrogen sulfide (H2S). Subject-conditional fixed-effects regression models were used to estimate associations between 2 markers of swine ILO pollutant exposures (H2S and swine odor) and 2 self-reported sleep outcomes (nightly sleep duration and awakening from sleep). Results Among 80 participants, nightly (across a 12-hour period) swine odor was associated with lower nightly sleep duration (mean difference = −14.3 minutes, 95% confidence interval −25.0 to −3.3 minutes) compared to odor-free nights and detection of nightly hydrogen sulfide was associated with an increased risk of awakening (hazard ratio = 1.23, 95% confidence interval 0.98 to 1.55) compared to nights with no detection of hydrogen sulfide. Conclusions These results suggest that environmental odorants are important considerations for sleep health and highlight the importance of sleep as a potential mediator between environmental air pollution and health outcomes impacted by poor sleep.

Introduction Occupational activities related to industrial hog operation (IHO) worker lung function are not well defined. Therefore, we aimed to identify IHO work activities associated with diminished respiratory function and the effectiveness, if any, of personal protective equipment (PPE) use on IHOs. Methods From 2014 to 2015, 103 IHO workers were enrolled and followed for 16 weeks. At each biweekly visit, work activities and PPE use were self-reported via questionnaire and lung function measurements were collected via spirometry. Generalized linear and linear fixed-effects models were fitted to cross-sectional and longitudinal data. Results Increasing years worked on an IHO were associated with diminished lung function, but baseline and longitudinal work activities were largely inconsistent in direction and magnitude. Unexpectedly, a -0.3 L (95% confidence interval: -0.6, -0.04) difference in forced expiratory volume in the first second (FEV1 ) was estimated when workers wore PPE consistently (≥80% of the time at work) versus those weeks they did not. In post-hoc analyses, we found that coveralls and facemasks were worn less consistently when workers experienced worse barn conditions and had more contact with pigs, but coveralls were worn more consistently as cleaning activities increased. Conclusions Similar to past studies, baseline estimates were likely obscured by healthy worker effect bias, but showed decrements in worker lung function as years of work increased. A challenge to disentangling the effect of work activities on lung function was the discovery that IHO workers used PPE differently according to the work task. These data suggest that interventions may be targeted toward improving barn conditions so that workers can consistently utilize IHO-provided PPE.

Antimicrobial use (AMU) in animal agriculture contributes to antimicrobial resistance (AMR) in humans, which imposes significant health and economic costs on society. Economists call these costs negative externalities, societal costs that are not properly reflected in market prices. We review the relevant literature and develop a model to quantify the external costs of AMU in animal agriculture on AMR in humans. Parameters required for this estimate include ( a) the health and economic burden of AMR in humans,( b) the impact of AMU in animal agriculture on AMR in animals, ( c) the fraction of AMR in humans attributable to animal agriculture, and ( d) AMU in animals. We use a well-documented historic case to estimate an externality cost of about US$1,500 per kilogram of fluoroquinolones administered in US broiler chicken production. Enhanced data collection, particularly on the third and fourth parameters, is urgently needed to quantify more fully the externalities of AMU in animal agriculture.

Background: Antibodies against SARS-CoV-2 can be detected by various testing platforms, but a detailed understanding of assay performance is critical.Methods: We developed and validated a simple enzyme-linked immunosorbent assay (ELISA) to detect IgG binding to the receptor-binding domain (RBD) of SARS-CoV-2, which was then applied for surveillance. ELISA results were compared to a set of complimentary serologic assays using a large panel of clinical research samples.Results: The RBD ELISA exhibited robust performance in ROC curve analysis (AUC> 0.99; Se = 89%, Sp = 99.3%). Antibodies were detected in 23/353 (6.5%) healthcare workers, 6/9 RT-PCR-confirmed mild COVID-19 cases, and 0/30 non-COVID-19 cases from an ambulatory site. RBD ELISA showed a positive correlation with neutralizing activity (p = R2 = 0.26).Conclusions: We applied a validated SARS-CoV-2-specific IgG ELISA in multiple contexts and performed orthogonal testing on samples. This study demonstrates the utility of a simple serologic assay for detecting prior SARS-CoV-2 infection, particularly as a tool for efficiently testing large numbers of samples as in population surveillance. Our work also highlights that precise understanding of SARS-CoV-2 infection and immunity at the individual level, particularly with wide availability of vaccination, may be improved by orthogonal testing and/or more complex assays such as multiplex bead assays.

Serological tests play an important role in the fight against Coronavirus Disease 2019 (COVID-19), including monitoring the dynamic immune response after vaccination, identifying past infection and determining community infection rate. Conventional methods for serological testing, such as enzyme-linked immunosorbent assays and chemiluminescence immunoassays, provide reliable and sensitive antibody detection but require sophisticated laboratory infrastructure and/or lengthy assay time. Conversely, lateral flow immunoassays are suitable for rapid point-of-care tests but have limited sensitivity. Here, we describe the development of a rapid and sensitive magnetofluidic immuno-PCR platform that can address the current gap in point-of-care serological testing for COVID-19. Our magnetofluidic immuno-PCR platform automates a magnetic bead-based, single-binding, and one-wash immuno-PCR assay in a palm-sized magnetofluidic device and delivers results in ∼30 min. In the device, a programmable magnetic arm attracts and transports magnetically-captured antibodies through assay reagents pre-loaded in a companion plastic cartridge, and a miniaturized thermocycler and a fluorescence detector perform immuno-PCR to detect the antibodies. We evaluated our magnetofluidic immuno-PCR with 108 clinical serum/plasma samples and achieved 93.8% (45/48) sensitivity and 98.3% (59/60) specificity, demonstrating its potential as a rapid and sensitive point-of-care serological test for COVID-19.

Background Norovirus is a leading cause of acute gastroenteritis worldwide. Routine norovirus diagnosis requires stool collection. The goal of this study was to develop and validate a noninvasive method to diagnose norovirus to complement stool diagnostics and to facilitate studies on transmission. Methods A multiplex immunoassay to measure salivary immunoglobulin G (IgG) responses to 5 common norovirus genotypes (GI.1, GII.2, GII.4, GII.6, and GII.17) was developed. The assay was validated using acute and convalescent saliva samples collected from Peruvian children, This study describes the performance of a multiplex immunoassay to measure salivary immunoglobulin G responses to multiple norovirus genotypes. The assay diagnosed recent norovirus infections at the genotype level with 71% sensitivity and 96% specificity compared to stool-based polymerase chain reaction diagnosis.

BackgroundSustained molecular detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in the upper respiratory tract (URT) in mild to moderate coronavirus disease 2019 (COVID-19) is common. We sought to identify host and immune determinants of prolonged SARS-CoV-2 RNA detection.MethodsNinety-five symptomatic outpatients self-collected midturbinate nasal, oropharyngeal (OP), and gingival crevicular fluid (oral fluid) samples at home and in a research clinic a median of 6 times over 1–3 months. Samples were tested for viral RNA, virus culture, and SARS-CoV-2 and other human coronavirus antibodies, and associations were estimated using Cox proportional hazards models.ResultsViral RNA clearance, as measured by SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR), in 507 URT samples occurred a median (interquartile range) 33.5 (17–63.5) days post–symptom onset. Sixteen nasal-OP samples collected 2–11 days post–symptom onset were virus culture positive out of 183 RT-PCR-positive samples tested. All participants but 1 with positive virus culture were negative for concomitant oral fluid anti-SARS-CoV-2 antibodies. The mean time to first antibody detection in oral fluid was 8–13 days post–symptom onset. A longer time to first detection of oral fluid anti-SARS-CoV-2 S antibodies (adjusted hazard ratio [aHR], 0.96; 95% CI, 0.92–0.99; P = .020) and body mass index (BMI) ≥25 kg/m2 (aHR, 0.37; 95% CI, 0.18–0.78; P = .009) were independently associated with a longer time to SARS-CoV-2 viral RNA clearance. Fever as 1 of first 3 COVID-19 symptoms correlated with shorter time to viral RNA clearance (aHR, 2.06; 95% CI, 1.02–4.18; P = .044).ConclusionsWe demonstrate that delayed rise of oral fluid SARS-CoV-2-specific antibodies, elevated BMI, and absence of early fever are independently associated with delayed URT viral RNA clearance.

We evaluated the durability of IgG responses specific to SARS-CoV-2 nucleocapsid (N), receptor binding domain (RBD), and spike (S) antigens in saliva up to 8 months after RT-PCR-confirmed COVID-19 using a multiplex salivary assay. We estimated a half-life of 64 days (d) (95% CI: 49, 80 d) for N, 100 d for RBD (95% CI: 58, 141 d), and 148 d (95% CI: 62, 238 d) for S IgG responses in saliva, consistent with half-life estimates previously reported in blood. Saliva can serve as an alternative to blood to monitor humoral immune responses on a large scale following SARS-CoV-2 infection and vaccination for surveillance and assessment of population immunity.

Background Nepal’s poultry industry has increased with a growing middle class, which has translated to an increase in antimicrobial consumption and thus a rise in antimicrobial resistance (AMR). Describing and understanding antimicrobial use practices among commercial poultry producers in Nepal may help minimize the risks of AMR development in both humans and animals and determine the effectiveness of relevant policies. Methods From July to August 2018, poultry farmers were randomly recruited from Nepal’s Chitwan District to participate in a cross-sectional study. The lead producer in each poultry operation was administered a quantitative structured-survey via a 30-min interview. Participants were asked to provide demographics, production practices, and knowledge about their antimicrobial use practices. Descriptive data analysis was performed to obtain frequencies and compare practices. Results In total, 150 commercial poultry producers of whom raised between 300 and 40,000 birds completed the interviews. Only 33% (n = 49) of producers reported knowing what AMR was, and among them only 50% (n = 25) consulted a veterinarian for treatment options. Antimicrobial administration for growth promotion was still employed by 13% of poultry producers. Similarly, critically important antimicrobial drugs, specifically colistin, were identified at 35% of participating operations. Producers reported low overall understanding and compliance of withdrawal periods (n = 41; 27%), which may result in both AMR development and adverse health reactions among consumers who ingest antimicrobial residues. Although Nepal has publicized antimicrobial use policies and awareness campaigns to instill healthy production practices, most producers (82%) were unaware of them. Conclusion Many Nepalese poultry producers lack overall antimicrobial use and AMR awareness, which is evidenced by low antimicrobial withdrawal period compliance, use of antimicrobials for growth promotion, and the sustained use of critically important antimicrobials. Improved outreach and educational capacities, paired with increased veterinary resources and extensive monitoring in operations and retail meat products, may increase AMR awareness and policy enforcement.

How weather affects tick development and behavior and human Lyme disease remains poorly understood. We evaluated relations of temperature and humidity during critical periods for the tick lifecycle with human Lyme disease. We used electronic health records from 479,344 primary care patients in 38 Pennsylvania counties in 2006-2014. Lyme disease cases (n = 9657) were frequency-matched (5:1) by year, age, and sex. Using daily weather data at ~4 km2 resolution, we created cumulative metrics hypothesized to promote (warm and humid) or inhibit (hot and dry) tick development or host-seeking during nymph development (March 1-May 31), nymph activity (May 1-July 30), and prior year larva activity (Aug 1-Sept 30). We estimated odds ratios (ORs) of Lyme disease by quartiles of each weather variable, adjusting for demographic, clinical, and other weather variables. Exposure-response patterns were observed for higher cumulative same-year temperature, humidity, and hot and dry days (nymph-relevant), and prior year hot and dry days (larva-relevant), with same-year hot and dry days showing the strongest association (4th vs. 1st quartile OR = 0.40; 95% confidence interval [CI] = 0.36, 0.43). Changing temperature and humidity could increase or decrease human Lyme disease risk.

INTRODUCTION Respiratory disease among industrial hog operation (IHO) workers is well documented; however, it remains unclear whether specific work activities are more harmful and if personal protective equipment (PPE), as used by workers, can reduce adverse health outcomes. METHODS IHO workers (n = 103) completed baseline and up to eight bi-weekly study visits. Workers reported typical (baseline) and transient (bi-weekly) work activities, PPE use, and physical health symptoms. Baseline and longitudinal associations were assessed using generalized logistic and fixed-effects logistic regression models, respectively. RESULTS At baseline, reports of ever versus never drawing pig blood, applying pesticides, and increasing years worked at any IHO were positively associated with reports of eye, nose, and/or throat irritation. Over time, transient exposures, associated with dustiness in barns, cleaning of barns, and pig contact were associated with increased odds of sneezing, headache, and eye or nose irritation, particularly in the highest categories of exposure. When PPE was used, workers had lower odds of symptoms interfering with sleep (odds ratio [OR]: 0.1; 95% confidence interval [CI]: 0.01-0.8), and eye or nose irritation (OR: 0.1; 95% CI: 0.02-0.9). Similarly, when they washed their hands eight times or more per shift (median frequency) versus less frequently, the odds of any respiratory symptom were reduced (OR: 0.3; 95% CI: 0.1-0.8). CONCLUSIONS In this healthy volunteer worker population, increasingly unfavorable IHO activities were associated with self-reported eye, nose, throat, and respiratory health symptoms. Strong protective associations were seen between PPE use and handwashing and the odds of symptoms, warranting further investigation.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of an ongoing pandemic that has infected over 36 million and killed over 1 million people. Informed implementation of government public health policies depends on accurate data on SARS-CoV-2 immunity at a population scale. We hypothesized that detection of SARS-CoV-2 salivary antibodies could serve as a noninvasive alternative to serological testing for monitoring of SARS-CoV-2 infection and seropositivity at a population scale., Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of an ongoing pandemic that has infected over 36 million and killed over 1 million people. Informed implementation of government public health policies depends on accurate data on SARS-CoV-2 immunity at a population scale. We hypothesized that detection of SARS-CoV-2 salivary antibodies could serve as a noninvasive alternative to serological testing for monitoring of SARS-CoV-2 infection and seropositivity at a population scale. We developed a multiplex SARS-CoV-2 antibody immunoassay based on Luminex technology that comprised 12 CoV antigens, mostly derived from SARS-CoV-2 nucleocapsid (N) and spike (S). Saliva and sera collected from confirmed coronavirus disease 2019 (COVID-19) cases and from the pre-COVID-19 era were tested for IgG, IgA, and IgM to the antigen panel. Matched saliva and serum IgG responses (n = 28) were significantly correlated. The salivary anti-N IgG response resulted in the highest sensitivity (100%), exhibiting a positive response in 24/24 reverse transcription-PCR (RT-PCR)-confirmed COVID-19 cases sampled at >14 days post-symptom onset (DPSO), whereas the salivary anti-receptor binding domain (RBD) IgG response yielded 100% specificity. Temporal kinetics of IgG in saliva were consistent with those observed in blood and indicated that most individuals seroconvert at around 10 DPSO. Algorithms employing a combination of the IgG responses to N and S antigens result in high diagnostic accuracy (100%) by as early as 10 DPSO. These results support the use of saliva-based antibody testing as a noninvasive and scalable alternative to blood-based antibody testing.

Avian influenza (AI) is a global health obstacle of critical concern as novel viruses are capable of initiating a pandemic. Recent spillover events of AI into human populations have occurred at human-poultry food system interfaces. As Nepal's poultry sector transitions to more intensified commercial production systems, it is important to examine the epidemiology of AI and the knowledge, attitudes and practices (KAP) of poultry sector workers. We conducted a cross-sectional KAP study utilizing a structured survey to interview 150 commercial poultry farmers in Chitwan District, Nepal. All commercial poultry farmers had knowledge of AI previous to the study and the majority farmers were able to identify farm-farm and poultry-human transmission mechanisms of AI. Farmers had more knowledge surrounding poultry AI symptoms as compared to human AI symptoms. Most farmers believe that AI is serious, contagious and a threat to everyone, yet only half believe it can be prevented. Individual-level personal protective equipment (PPE) uptake, such as facemask, glove and boot usage, on the enrolled farms was low and farm-level biosecurity practices varied greatly. Nine commercial poultry farms (6%) self-reported having an HPAI outbreak and 60 farms (40%) self-reported having an LPAI outbreak in the past 5 years. Layer farms had higher odds (OR: 5.4, 95% CI: 2.3–12.8) of self-reported LPAI as compared broiler farms. Poultry sector farmers face multiple obstacles when attempting to report AI to government authorities such as the fear of flock culling and the perceived lack of monetary compensation for culling. Our study provides updated KAP surrounding AI of farmers and self-reported AI farm-level epidemiology in Nepal's highest density commercial poultry production district. Commercial poultry farmers are fairly knowledgeable on AI, but do not take further protective practice efforts to implement their knowledge and prevent AI. Due to the potential role that human-poultry interfaces may play in AI emergence, it is critical to collaborate with the commercial poultry industry when planning and conducting AI pandemic preparedness mechanisms., Highlights • Farmers had more knowledge surrounding poultry avian influenza symptoms as compared to human avian influenza symptoms. • Farmer personal protective equipment (PPE) uptake, such as facemask, glove and boot usage, was low. • 6% of poultry farms self-reported having an HPAI outbreak and 40% self-reported having an LPAI outbreak in the past 5 years. • Layer farms had higher odds of self-reported LPAI as compared broiler farms. • Poultry farmers fear potential flock culling and lack of monetary compensation for culling when reporting avian influenza.

IntroductionAs occupational activities related to acute industrial hog operation (IHO) worker lung function are not well defined, we aimed to identify IHO work activities associated with diminished respiratory function and the effectiveness, if any, of personal protective equipment (PPE) on IHOs.MethodsFrom 2014-2015, 103 IHO workers were enrolled and followed for 16 weeks. At each bi-weekly visit, lung function measurements were collected via spirometry and work activities and PPE use were self-reported via questionnaire. Generalized linear and linear fixed-effects models were fitted to cross-sectional and longitudinal data.ResultsAt baseline, increasing years worked on an IHO were associated with diminished lung function, but other activities were less consistent in direction and magnitude. In longitudinal models, only reports of working in feeding/finisher barns, showed a consistent association. However, a −0.3 L (95% confidence interval: −0.6, −0.04) difference in FEV1 was estimated when workers wore PPE consistently versus those weeks they did not. In post-hoc analyses, we found that coveralls and facemasks were worn less consistently when workers experienced worse barn conditions and had more contact with pigs, but coveralls were worn more consistently as cleaning activities increased.ConclusionsSimilar to past studies, baseline estimates were likely obscured by healthy worker bias. Also making it challenging to disentangle the effect of work activities on lung function was the discovery that IHO workers used PPE differently according to work task. These data suggest that interventions may be targeted toward improving barn conditions so that workers can consistently utilize IHO-provided PPE.KEY MESSAGESWhat is already known about this subject?Working on industrial hog operations may be deleterious to long- and short-term respiratory health due to airborne bacteria, endotoxin, hazardous gases, dust, and dander in barns. In efficacy studies PPE has been shown to be protective, but studies have shown that PPE utilization among hog workers has historically been sub-optimal.What are the new findings?As barn conditions worsened and contact with pigs increased, workers in this cohort reported wearing coveralls and face masks less often; however, they reported increased PPE use as they conducted more cleaning activities at work. During weeks when workers wore PPE their lung function declined, a possible cause being the improper use of the equipment leading to a false sense of protection or re-exposure to hazardous contaminants.How might this impact on policy or clinical practice in the foreseeable future?Given COVID-19, the H1N1 “swine flu” pandemic, our knowledge of antimicrobial resistant pathogens, and increasing awareness about how food systems are linked to the spread of emerging infectious diseases, occupational health intervention research and workplace policies may focus on creating barn environments that are more conducive to PPE use which could help protect workers and consequently the community.

Background: Longer time between symptom onset and treatment of Lyme disease has been associated with poor outcomes. Reducing time-to-treatment requires knowledge of risks for treatment delays. We conducted a population-based study to evaluate factors associated with delayed treatment of Lyme disease and the relation between delayed treatment and post-treatment Lyme disease syndrome (PTLDS).Methods: We mailed questionnaires to 5,314 individuals with a Lyme disease diagnosis or blood test followed by an antibiotic order in the medical record of a Pennsylvania health system from 2015 to 2017. Analyses were confined to 778 respondents who reported that they were treated for Lyme disease within the past 5 years and reported a rash and/or a positive blood test for Lyme disease. Time-to-treatment was calculated as the sum of two windows before and after seeking care for Lyme disease symptoms: time to first medical contact and time under care. We used logistic regression to evaluate factors associated with delayed time-to-treatment in each time window (>14 days vs. ≤14 days) and the association between total time-to-treatment (>30 days vs. ≤30 days) and PTLDS. We used inverse probability weighting to calculate estimates for the study's source population (5,314 individuals sent questionnaires).Results: In the source population, 25% had time to first contact >14 days, 21% had time under care >14 days, and 31% had a total time-to-treatment >30 days. Being uninsured and attributing initial symptoms to something other than Lyme disease were positively associated with delayed time to first medical contact, while seeking care at an urgent care or emergency setting (vs. primary care) was negatively associated. Diagnoses between November and April, and the absence of rash were positively associated with delays. Individuals whose treatment was delayed, defined as time-to treatment >30 days had 2.26 (95% confidence interval: 1.25, 4.05) times the odds of PTLDS as those who were treated within 30 days of symptom onset.Conclusions: In a population-based study in Pennsylvania, one-third of Lyme disease patients reported delayed treatment, which was associated with PTLDS. To improve Lyme disease outcomes, prevention efforts should aim to reduce the time before and after seeking care.

Correlate(s) of immunity have yet to be defined for shigellosis. As previous disease protects against subsequent infection in a serotype-specific manner, investigating immune response profiles pre- and postinfection provides an opportunity to identify immune markers potentially associated with the development of protective immunity and/or with a reduced risk of developing shigellosis postchallenge. This study is the first to report such an extensive characterization of the immune response after challenge with S. sonnei 53G. Results demonstrate an association of progression to shigellosis with robust intestinal inflammatory and mucosal gut-homing responses. An important finding in this study was the association of elevated Shigella LPS-specific serum IgA and memory B cell IgA responses at baseline with reduced risk of disease. The increased baseline IgA responses may contribute to the lack of dose response observed in the study and suggests that IgA responses should be further investigated as potential correlates of immunity., Shigella is a major cause of moderate to severe diarrhea largely affecting children (

BackgroundRespiratory disease among industrial hog operation (IHO) workers is well documented; however, it remains unclear whether specific work activities are more harmful and if personal protective equipment (PPE), as used by workers, can reduce adverse health outcomes.ObjectivesTo assess the relationship between self-reported IHO work activities and PPE use with mucus membrane and respiratory health symptoms in an occupational cohort.MethodsIHO workers (n=103) completed baseline and up to eight bi-weekly (i.e., every two weeks) study visits. Workers reported typical (baseline) and transient (bi-weekly) work activities, PPE use, and physical health symptoms. Baseline and longitudinal associations between work activities and health outcomes were assessed using generalized logistic and fixed-effects logistic regression models, respectively.ResultsAt baseline, reports of ever versus never drawing pig blood, applying pesticides, and increasing years worked at any IHO were positively associated with reports of eye, nose, and/or throat irritation. Over time, transient exposures, including those associated with dustiness in barns, cleaning of barns, and pig contact were associated with increased odds of symptoms including sneezing, headache, and eye or nose irritation, particularly in the highest categories of exposure. When PPE was used, workers had decreased odds of symptoms interfering with sleep (odds ratio (OR): 0.1; 95% confidence interval (CI): 0.01, 0.8), sneezing (OR: 0.1; 95% CI: 0.01, 1.0), and eye or nose irritation (OR: 0.1; 95% CI: 0.02, 0.9). Similarly, when they washed their hands ≥8 times per shift (the median) versus less frequently, workers had decreased odds of any respiratory symptom (OR: 0.3; 95% CI: 0.1, 0.8).DiscussionIn this healthy volunteer IHO worker population, increasingly unfavorable work activities were associated with self-reported mucus membrane and respiratory health outcomes. Strong protective associations were seen between PPE use and handwashing and the odds of symptoms, warranting further investigation in intervention studies.

Saliva contains pathogen-specific antibodies that can provide quantitative information on the type and temporality of infection. As such, saliva as a biospecimen can be used to noninvasively assess seroconversion to infectious pathogens in the clinical setting as well as for epidemiological surveillance, improving understanding of the epidemiology and natural history of infectious diseases. While saliva is not ideal for analysis of all infectious diseases, it remains a valuable means for data collection across populations varying in age, geographic location, and health status. Developments in the field could allow for rapid testing of exposure to infectious agents through point-of-care assays in areas where blood-based assays or laboratory analysis would be impractical. Here we review the advantages and disadvantages of using salivary assays to assess infectious disease exposure and infection in different settings and explore future directions.

Occupational exposure to swine has been associated with increased Staphylococcus aureus carriage, including antimicrobial-resistant strains, and increased risk of infections. To characterize animal and environmental routes of worker exposure, we optimized methods to identify S. aureus on operations that raise swine in confinement with antibiotics (industrial hog operation: IHO) versus on pasture without antibiotics (antibiotic-free hog operation: AFHO). We associated findings from tested swine and environmental samples with those from personal inhalable air samplers on worker surrogates at one IHO and three AFHOs in North Carolina using a new One Health approach. We determined swine S. aureus carriage status by collecting swab samples from multiple anatomical sites, and we determined environmental positivity for airborne bioaerosols with inhalable and impinger samplers and a single-stage impactor (ambient air) cross-sectionally. All samples were analyzed for S. aureus, and isolates were tested for antimicrobial susceptibility, absence of scn (livestock marker), and spa type. Seventeen of twenty (85%) swine sampled at the one IHO carried S. aureus at >1 anatomical sites compared to none of 30 (0%) swine sampled at the three AFHOs. All S. aureus isolates recovered from IHO swine and air samples were scn negative and spa type t337; almost all isolates (62/63) were multidrug resistant. S. aureus was recovered from eight of 14 (67%) ambient air and two (100%) worker surrogate personal air samples at the one IHO, whereas no S. aureus isolates were recovered from 19 ambient and six personal air samples at the three AFHOs. Personal worker surrogate inhalable sample findings were consistent with both swine and ambient air data, indicating the potential for workplace exposure. IHO swine and the one IHO environment could be a source of potential pathogen exposure to workers, as supported by the detection of multidrug-resistant S. aureus (MDRSA) with livestock-associated spa type t337 among swine, worker surrogate personal air samplers and environmental air samples at the one IHO but none of the three AFHOs sampled in this study. Concurrent sampling of swine, personal swine worker surrogate air, and ambient airborne dust demonstrated that IHO workers may be exposed through both direct (animal contact) and indirect (airborne) routes of transmission. Investigation of the effectiveness of contact and respiratory protections is warranted to prevent IHO worker exposure to multidrug-resistant livestock-associated S. aureus and other pathogens.

Autoimmune retinopathy (AIR) is a rare immune-mediated retinopathy associated with circulating antiretinal antibodies (ARAs). Other prominent features of AIR include visual field deficits and photoreceptor dysfunction in the setting of progressive unexplained vision loss. The role of inflammation is poorly understood in AIR. Since cytokines play a central role in the initiation and development of inflammation, we evaluated the presence of proinflammatory cytokines and chemokines in AIR patient sera. We demonstrate that IL-6 and CXCL9 are both elevated in AIR patient sera. Moreover, the presence and concentration of these 2 molecules appear to correlate with AIR patient disease severity. This cytokine profile, IL-6 and CXCL9, has been described to participate in a variety of autoimmune and inflammatory diseases. Our study provides support for an activated inflammatory process in AIR and identifies possible mechanisms that can drive autoimmunity in this disease.

Background Hepatitis E virus (HEV) infection causes significant morbidity and mortality worldwide, particularly among pregnant women. In clinical settings blood-based testing protocols are commonly used to diagnose HEV infection, but in community settings such invasive sampling can hinder study participation and limit discovery of the ecology and natural history of HEV infection. Oral fluid is a non-invasive biospecimen that can harbor pathogen-specific antibodies and has the potential to replace blood-based testing protocols. Objectives To develop an immunoassay to assess past and recent HEV infection that uses oral fluid instead of serum or plasma. Methods The assay was validated using paired oral fluid and serum samples collected from 141 patients who presented either with (n = 76) or without (n = 65) symptoms of acute viral hepatitis at a clinical diagnostics center in Dhaka, Bangladesh. The sensitivity and specificity of the oral fluid-based immunoassay for HEV IgG (past HEV infection) and HEV IgA (recent HEV infection) antibodies was calculated in reference to Wantai's (Beijing Wantai) serum-based HEV enzyme-linked immunosorbent assay (ELISA) kits for IgG and IgM antibodies, respectively. Results The sensitivity and specificity of the oral fluid-based immunoassay for HEV-IgG antibodies were 98.7% and 98.4%, respectively. The sensitivity and specificity of the oral fluid-based immunoassay for HEV IgA were 89.5% and 98.3%, respectively. Conclusions The high concordance of our non-invasive oral fluid-based immunoassays (HEV IgG and HEV IgA) with commercial high-performance serum HEV ELISA kits (IgG and IgM) means that population-based surveillance of past and recent HEV infection could be expanded to improve understanding of its ecology and natural history.

Background:Antibiotic use in industrial hog operations (IHOs) can support the emergence of antibiotic-resistant (ABR) Staphylococcus aureus. The extent of ABR S. aureus exposure in IHO workers and ...

Background Arsenic exposure through drinking water is an established lung carcinogen. Evidence on non-malignant lung outcomes is less conclusive and suggests arsenic is associated with lower lung function. Studies examining low-moderate arsenic ( Methods The Strong Heart Study is a prospective study of American Indian adults. This analysis used urinary arsenic measurements at baseline (1989–1991) and spirometry at Visit 2 (1993–1995) from 2132 participants to evaluate associations of arsenic exposure with airflow obstruction, restrictive pattern, self-reported respiratory disease, and symptoms. Results Airflow obstruction was present in 21.5% and restrictive pattern was present in 14.4%. The odds ratio (95% confidence interval) for obstruction and restrictive patterns, based on the fixed ratio definition, comparing the 75th to 25th percentile of arsenic, was 1.17 (0.99, 1.38) and 1.27 (1.01, 1.60), respectively, after adjustments, and 1.28 (1.02, 1.60) and 1.33 (0.90, 1.50), respectively, based on the lower limit of normal definition. Arsenic was associated with lower percent predicted FEV1 and FVC, self-reported emphysema and stopping for breath. Conclusion Low-moderate arsenic exposure was positively associated with restrictive pattern, airflow obstruction, lower lung function, self-reported emphysema and stopping for breath, independent of smoking and other lung disease risk factors. Findings suggest that low-moderate arsenic exposure may contribute to restrictive lung disease.

Direct-to-consumer food marketing is a growing niche in the United States food supply chain. Food animal producers who use direct marketing may employ different production models and standard practices from producers selling animal products to the conventional food system. Direct-to-consumer food supply chains (generally and specifically regarding food animal products) are relatively unexplored in food safety and health research. We conducted a cross-sectional, market-basket analysis of the Maryland direct-to-consumer poultry supply chain to assess food safety. We analyzed 40 direct-to-consumer commercial poultry meat products (one product per farm) forEscherichia coli, Staphylococcus aureusandSalmonella spp.using culture-based methods. Isolates underwent antimicrobial susceptibility testing.E. coliandS. aureuswere recovered from 9/40 (23%) and 12/40 (30%) of poultry meat samples, respectively. Of interest for comparing direct-market and mainstream supply chains for food safety risks, noSalmonellaisolates were recovered from any direct-market sampled poultry products and no multidrug resistance was observed inE. coliandS. aureusisolates. Microbial outcomes were compared to a survey of poultry production and processing practices within the same study population.ImportanceThis study demonstrates substantially lower rates of antimicrobial-resistant (AMR) microbial pathogens in the market-basket products from Maryland direct-market broiler poultry supply chain compared to rates of AMR in the conventional supply chain for similar retail meat products from NARMS. We further describe the landscape of the statewide supply chain for direct-market poultry, focusing on characteristics related to risk management strategies applied to microbial food safety. These findings are of public health significance for both the research and policy communities; these data provide an initial evidence base for more targeted research evaluating potential risk factors for microbial food safety in the direct-to-consumer supply chain. These data will also assist the Maryland Department of Agriculture and other state-level agencies with oversight of food safety issues to guide policy efforts for direct-market poultry production and sales.

The epidemiology of methicillin-resistant Staphylococcus aureus has changed considerably over the last 3 decades, including the recognition of lineages associated with the community and with livestock exposure, in addition to nosocomial strains. A recent study by R., The epidemiology of methicillin-resistant Staphylococcus aureus has changed considerably over the last 3 decades, including the recognition of lineages associated with the community and with livestock exposure, in addition to nosocomial strains. A recent study by R. N. Sieber, R. L. Skov, J. Nielsen, J. Schulz, et al. (mBio 9:e02142-18, https://doi.org/10.1128/mBio.02142-18) demonstrates the importance of multisectoral cooperation at the intersection of occupational health, genomics, veterinary medicine practitioners, and farmers in order for us to better understand the epidemiology of antibiotic-resistant organisms.

Background: Industrial hog operation (IHO) workers may persistently carry antibiotic-resistant, livestock-associated Staphylococcus aureus in their nasal cavities. It is unclear whether IHO work activities can alter IHO workers’ and their household members’ exposure to these bacteria. Objective: Our objective was to investigate the relationship of IHO work activities with persistence of antibiotic-resistant, livestock-associated S. aureus nasal carriage among IHO workers and their household members. Methods: At biweekly intervals over 4 months, IHO workers and their household members completed questionnaires and provided nasal swabs that were assessed for S. aureus, multidrug-resistant S. aureus (MDRSA), and livestock-associated markers (tetracycline resistance, scn absence, spa type). We examined the association between transient and habitual IHO work activities and S. aureus nasal carriage outcomes. Results: One hundred one IHO workers and 79 household members completed 1,456 study visits. Face mask use (each 25% increase) was associated with reduced odds of nasal carriage of MDRSA (odds ratio [OR]: 0.65 [95% confidence interval (CI): 0.46, 0.92], tetracycline-resistant S. aureus [OR = 0.74 (95% CI: 0.56, 0.97)], and S. aureus clonal complex (CC) 398/CC9 [OR = 0.77 (95% CI: 0.60, 0.99)]. IHO workers who ever (vs. never) gave pigs injections had higher odds of these outcomes. Among household members, living with an IHO worker who consistently (≥80% of the time) versus sometimes or never used a face mask was associated with reduced odds of carrying scn-negative S. aureus, tetracycline-resistant S. aureus, and S. aureus CC398/CC9 (OR range: 0.12–0.20, all p

Introduction Waste from swine industrial livestock operations (ILOs) produces air pollutants that have been associated with negative health outcomes among nearby residents. Methods Using a repeated-measures design, we assessed the impact of odor emissions on sleep duration and awakenings, important components and determinants of health and quality-of-life. Study participants from 16 residential communities in eastern North Carolina hosting swine ILOs, from 2003 to 2005, completed twice-daily diaries in which they rated the strength of hog odors and indicated whether they were asleep or awake per hour for two weeks. Simultaneously, a monitoring trailer placed in a central location in each community measured the atmospheric concentration of hydrogen sulfide (H2S). Subject-conditional fixed-effects regression models were used to estimate associations between two markers of swine ILO pollutant exposures (H2S and swine odor) and two self-reported sleep outcomes (nightly sleep duration and awakening from sleep). Results Among 80 participants, nightly (across a 12-hour period) swine odor was associated with lower-nightly sleep duration (mean difference = -14.3 minutes, 95% confidence interval -25.0 to -3.3 minutes) compared to odor-free nights and detection of nightly hydrogen sulfide was associated with a 23% increased hazard of awakening (Hazard ratio = 1.23, 95% confidence interval 0.98 to 1.55) compared to nights with no detection of hydrogen sulfide. Conclusion These results suggest that emissions reductions and odor abatement are important public health goals in designing policy and technology solutions to the problems of livestock production and waste management. Support (if any) This work was funded, in part, by the Intramural Program at the NIH, National Institute of Environmental Health Sciences (Z1AES103325-01).

Infection with the hepatitis E virus (HEV) is very common worldwide. The epidemiology, viral genotypes, and transmission routes differ between low-resource countries and economically developed countries. These differences have resulted in the design of diverse prevention and treatment strategies to combat HEV.The population seroprevalence of HEV immunoglobulin G varies between 5 and 50%. However, the diagnosis of acute hepatitis from HEV has not been common in the United States or Western Europe. Chronic progressive HEV infections have been reported among patients who are immunocompromised. Successful treatment of patients with chronic hepatitis from HEV infection with antiviral agents, such as ribavirin or interferon-α, has been reported. Extrahepatic manifestations of HEV infection are common. Large epidemics of hundreds or thousands of cases continue to be reported among populations in Asia and Africa. A subunit peptide HEV vaccine has been found to be highly efficacious in a large clinical trial. However, the vaccine has not been evaluated in populations of pregnant women or other risk groups and is only available in China.Although HEV infections are increasingly recognized as a global public health problem, there are few methods for prevention and treatment that are widely available.

Objective For many individuals with Lyme disease, prompt treatment leads to rapid resolution of infection. However, severe complications can occur if treatment is delayed. Our objective was to identify themes around belated diagnosis or treatment of Lyme disease using the General Model of Total Patient Delay (GMTPD). Design We conducted a qualitative interview study using indepth telephone interviews. Setting Participants were patients from a large, integrated health system in the state of Pennsylvania, USA. Participants There were 26 participants. Participants had to have a diagnosis of Lyme disease between 2014 and 2017 and a positive IgG western blot. We used a stratified purposeful sampling design to identify patients with and without late Lyme disease manifestations. To ensure variation in care experiences, we oversampled patients diagnosed outside of primary care. Outcome measures We asked participants about their experience from first Lyme disease symptoms to treatment. We applied an iterative coding process to identify key themes and then synthesised codes into higher order codes representing the GMTPD stages: appraisal delay (symptom to recognition of illness); illness delay (inferring illness to deciding to seek help); behavioural delay (deciding to seek help to the act of seeking help); scheduling delay (seeking help to attending an appointment); and treatment delay (attending appointment to treatment). Results Appraisal delay themes included symptom misattribution, intermittent symptoms and misperceptions about the necessity of a bull’s-eye rash. Health insurance status was a driver of illness and behavioural delays. Scheduling delay was not noted by participants, in part, because 10 of the 26 patients went to urgent care or emergency department settings. Misdiagnoses were more common in these settings, contributing to treatment delay. Conclusion Our study identified potentially modifiable risk factors for belated treatment. Targeting these risk factors may minimise time to treatment and reduce the occurrence of preventable complications.

Over 50 million hogs are raised annually in the United States for consumption, mostly on industrial hog operations (IHOs). Workers at IHOs are exposed to airborne particulates, zoonotic pathogens, and other workplace hazards, but lack of access to IHOs can hinder exposure assessment in epidemiologic studies. Here, we demonstrate the utility of pig-specific Bacteroidales (Pig-2-Bac) as a biomarker of exposure to pigs and pig waste and to help identify sources of Staphylococcus aureus carriage among IHO workers.

Hepatitis E virus (HEV) is a global pathogen responsible for approximately 20 million infections every year in developing countries, yet remains under-recognized. In this population-based cohort study, 1,025 randomly selected participants were enrolled from Matlab, Bangladesh (2004–2005). All participants were tested for HEV antibodies and total immunoglobulin (Ig), using an in-house enzyme immunoassay developed by Walter Reed Army Institute of Research (WRAIR). In 2014, we retested the banked sera of 1,009 of those participants using the Wantai anti-HEV IgG enzyme-linked immunosorbent assay (ELISA). The WRAIR assay estimated the overall population seroprevalence as 26.6% (95% confidence interval [CI]: 24.0, 29.5), whereas the Wantai assay produced significantly higher estimated seroprevalence, 46.7% (95% CI: 43.5–49.8) (P < 0.001). However, the two tests give nearly identical findings in those 5 years and under (N = 94) with a 98% agreement between the tests. Retesting populations with modern assays is necessary to establish better population-level estimates of disease burden.

Background Hepatitis E causes a significant burden of disease in developing countries and has recently been increasingly recognized in developed countries. Comparing population anti-hepatitis E virus (HEV) seroprevalence across populations has been difficult. Objectives The aim of this study was to compare the anti-HEV IgG seroprevalence in both adults and children in three hyper-endemic areas (Nepal, Bangladesh and southwest France) using a sensitive, commercial anti-HEV IgG assay. Study Design Serum or plasma from adults and children in Nepal (n=498), Bangladesh ( n = 1,009) and Southwest France ( n = 1031) were tested for anti-HEV IgG using the Wantai assay. Results After age-standardization, anti-HEV IgG seroprevalence was 47.1%, 49.8% and 34.0% in Nepal, Bangladesh and southwest France, respectively. There was no difference in seroprevalence by gender in any of the countries. A paucity of infections in children 1–10 years-old was consistently observed (less than 15%) at all 3 locations. Conclusions Surprisingly similar high rates of anti-HEV antibodies were detected using a common, sensitive assay. Despite differences in the epidemiology and circulating genotype of HEV in Nepal, Bangladesh and southwest France, this study found more similarities in population seroprevalence than expected.

Hepatitis E virus (HEV) is an emerging cause of viral hepatitis among immunocompromised individuals in developed countries. Yet the diagnosis of HEV infection in the United States remains challenging, because of the variable sensitivity and specificity of currently available tests, and the lack of a US Food and Drug Administration-approved test. We report a case of multiple discordant HEV serology results in a pediatric liver transplant recipient with idiopathic hepatitis, and review the challenges to diagnosis of HEV infection in the United States.

Objectives This study aimed to evaluate the persistence of nasal carriage of Staphylococcus aureus, methicillin-resistant S. aureus and multidrug-resistant S. aureus over 14 days of follow-up among industrial hog operation workers in North Carolina. Methods Workers anticipating at least 24 h away from work were enrolled June–August 2012. Participants self-collected a nasal swab and completed a study journal on the evening of day 1, and each morning and evening on days 2–7 and 14 of the study. S. aureus isolated from nasal swabs were assessed for antibiotic susceptibility, spa type and absence of the scn gene. Livestock association was defined by absence of scn. Results Twenty-two workers provided 327 samples. S. aureus carriage end points did not change with time away from work (mean 49 h; range >0–96 h). Ten workers were persistent and six were intermittent carriers of livestock-associated S. aureus. Six workers were persistent and three intermittent carriers of livestock-associated multidrug-resistant S. aureus. One worker persistently carried livestock-associated methicillin-resistant S. aureus. Six workers were non-carriers of livestock-associated S. aureus. Eighty-two per cent of livestock-associated S. aureus demonstrated resistance to tetracycline. A majority of livestock-associated S. aureus isolates (n=169) were CC398 (68%) while 31% were CC9. No CC398 and one CC9 isolate was detected among scn-positive isolates. Conclusions Nasal carriage of livestock-associated S. aureus, multidrug-resistant S. aureus and methicillin-resistant S. aureus can persist among industrial hog operation workers over a 14-day period, which included up to 96 h away from work.

Rationale: Exposure to inorganic arsenic, through drinking naturally-contaminated water, is an established cause of lung cancer. Evidence on the impact of arsenic exposure on lung function, however, is less conclusive. The evidence available, mostly from populations exposed to water arsenic levels >100 μg/L, suggests that arsenic exposure is associated with lower lung function. Prospective studies and studies examining low-to-moderate levels of water arsenic exposure (

Swine production work is a risk factor for nasal carriage of livestock-associated (LA-) Staphylococcus aureus and also for skin and soft tissue infection (SSTI). However, whether LA-S. aureus nasal carriage is associated with increased risk of SSTI remains unclear. We aimed to examine S. aureus nasal carriage and recent (≤3 months prior to enrollment) SSTI symptoms among industrial hog operation (IHO) workers and their household contacts. IHO workers and their household contacts provided a nasal swab and responded to a questionnaire assessing self-reported personal and occupational exposures and recent SSTI symptoms. Nasal swabs were analyzed for S. aureus, including methicillin-resistant S. aureus (MRSA), multidrug-resistant-S. aureus (MDRSA), absence of scn (livestock association), and spa type. S. aureus with at least one indicator of LA was observed among 19% of 103 IHO workers and 6% of 80 household members. Prevalence of recent SSTI was 6% among IHO workers and 11% among 54 minor household members (0/26 adult household members reported SSTI). Among IHO workers, nasal carriers of MDRSA and scn-negative S. aureus were 8.8 (95% CI: 1.8, 43.9) and 5.1 (95% CI: 1.2, 22.2) times as likely to report recent SSTI as non-carriers, respectively. In one household, both an IHO worker and child reported recent SSTI and carried the same S. aureus spa type (t4976) intranasally. Prevalence of scn-negative S. aureus (PR: 5.0, 95% CI: 1.2, 21.4) was elevated among IHO workers who reported never versus always wearing a face mask at work. Although few SSTI were reported, this study of IHO workers and their household contacts is the first to characterize a relation between nasal carriage of antibiotic-resistant LA-S. aureus and SSTI. The direction and temporality of this relation and IHO workers' use of face masks to prevent nasal carriage of these bacteria warrant further investigation.

Many communities impacted by environmental injustice, including the disproportionate burden of unhealthy land uses and environmental hazards and lack of access to health-promoting infrastructure, can trace these disparities to inequities in planning, zoning, and community development. These inequities and infrastructure disparities occur in many places because of the way that governance structures, particularly municipal police powers, are applied differentially and how in some cases these legal structures drive segregation and the production of riskscapes. In this article, we will describe how municipal police powers have led to zoning and planning inequities particularly around the use of planning designations (specifically extra-territorial jurisdiction (ETJ) and joint planning agreements) in the state of North Carolina. These planning designations can create patterns of environmental inequality whereby some communities may have infrastructure disparities including a lack of basic amenities (e...

Urban planning has focused on built environment issues in cities such as urban sprawl, availability of green space, and infrastructure for physical activity. However, in small southern towns, there are built environment issues which currently either are understudied or completely neglected by researchers. In this article, we describe the built environment issues that burden unserved and underserved communities of color in North Carolina. We use a case study of Mebane, NC to describe how neighborhoods of color in this small town have been impacted by environmental injustice through the denial of basic amenities, particularly sewer and water services, and overburdened by unhealthy land uses through inequities in the use of extraterritorial jurisdiction and annexation statutes. These planning inequities create public health risks for residents and nearby populations.

Background: Principal investigators (PIs) of communitybased projects are predominantly university faculty who partner with community-based organizations (CBOs) to find a place to conduct research in communities that will cooperate with their research objectives. University-managed research models (UMRMs) are not always beneficial for CBOs because the university usually manages the study, collects and owns the data, and leverages control at each stage of research, without priority to resolution of problems impacting the quality of life of participating communities. Objectives: We present the principles of community-owned and -managed research (COMR), as a new community-driven research model developed by the West End Revitalization Association (WERA), a CBO in Mebane, North Carolina. Methods: We describe WERA’s development of COMR, compare the power hierarchies of COMR with traditional UMRMs, distinguish COMR partnerships from UMRM partnerships, discuss disbursement of funds, and control/ ownership of data. As the PI of research activities, WERA drafted Memoranda of Agreement (MOAs) for all partners, including academic researchers, implemented quality assurance and control procedures, submitted community research protocols for institutional review, and retained data ownership for action, activism, and problem solving. COMR methods encouraged corrective action of environmental justice (EJ) problems in affected communities, including provision of public, regulated drinking water and sewer services. Conclusions: COMR promotes CBOs with demonstrated organizational capacity to PI and project manager. The COMR model goes beyond UMRMs and CBPR because it emphasized the credibility and capacity of CBOs to develop, own, manage, foster, and sustain viable research agendas to address ongoing environmental hazards and related threats to health and quality of life.

Background. Autochthonous hepatitis E virus (HEV) infection has been reported in over 200 solid organ transplant (SOT) recipients since 2006, yet little is known about the burden of HEV among SOT recipients in North America. We performed a retrospective, cross-sectional study to investigate the prevalence and risk factors associated with HEV infection among SOT recipients at our institution. Methods. Children and adults (n = 311) who received allografts between 1988 and 2012 at the Johns Hopkins Hospital were assessed for evidence of HEV infection by testing posttransplantation serum samples for HEV antibody by enzyme immunoassay and HEV RNA by reverse transcription quantitative polymerase chain reaction. Individuals with evidence of posttransplant HEV infection (presence of anti-HEV immunoglobulin [Ig]M antibody, anti-HEV IgG seroconversion, or HEV RNA) were compared with individuals without evidence of infection and assessed for risk factors associated with infection. Results. Twelve individuals (4%) developed posttransplant HEV infection. Posttransplant HEV infection was associated with an increased risk for graft rejection (odds ratio, 14.2; P = .03). No individuals developed chronic infection. Conclusions. Solid organ transplant recipients in the United States are at risk for posttransplant HEV infection. Further studies are needed to characterize environmental risk factors and the risk of HEV infection after SOT in North America.

Background Arsenic has immunomodulatory properties and may have the potential to alter susceptibility to infection in humans. Objectives We aimed to assess the relation of arsenic exposure during pregnancy with immune function and hepatitis E virus (HEV) infection, defined as seroconversion during pregnancy and postpartum. Methods We assessed IgG seroconversion to HEV between 1st and 3rd trimester (TM) and 3 months postpartum (PP) among 1100 pregnancies in a multiple micronutrient supplementation trial in rural Bangladesh. Forty women seroconverted to HEV and were matched with 40 non-seroconverting women (controls) by age, parity and intervention. We assessed urinary inorganic arsenic plus methylated species (∑As) (µg/L) at 1st and 3rd TM and plasma cytokines (pg/mL) at 1st and 3rd TM and 3 months PP. Results HEV seroconverters’ urinary ∑As was elevated throughout pregnancy. Non-seroconverters’ urinary ∑As was similar to HEV seroconverters at 1st TM but declined at 3rd TM. The adjusted odds ratio (95% confidence interval) of HEV seroconversion was 2.17 (1.07, 4.39) per interquartile range (IQR) increase in average-pregnancy urinary ∑As. Increased urinary ∑As was associated with increased concentrations of IL-2 during the 1st and 3rd TM and 3 months PP among HEV seroconverters but not non-seroconverters. Conclusions The relation of urinary arsenic during pregnancy with incident HEV seroconversion and with IL-2 levels among HEV-seroconverting pregnant women suggests arsenic exposure during pregnancy may enhance susceptibility to HEV infection.

Swine farming has gone through many changes in the last few decades, resulting in operations with a high animal density known as confined animal feeding operations (CAFOs). These operations produce a large quantity of fecal waste whose environmental impacts are not well understood. The purpose of this study was to investigate microbial water quality in surface waters proximal to swine CAFOs including microbial source tracking of fecal microbes specific to swine. For one year, surface water samples at up- and downstream sites proximal to swine CAFO lagoon waste land application sites were tested for fecal indicator bacteria (fecal coliforms, Escherichia coli and Enterococcus) and candidate swine-specific microbial source-tracking (MST) markers (Bacteroidales Pig-1-Bac, Pig-2-Bac, and Pig-Bac-2, and methanogen P23-2). Testing of 187 samples showed high fecal indicator bacteria concentrations at both up- and downstream sites. Overall, 40%, 23%, and 61% of samples exceeded state and federal recreational water quality guidelines for fecal coliforms, E. coli, and Enterococcus, respectively. Pig-1-Bac and Pig-2-Bac showed the highest specificity to swine fecal wastes and were 2.47 (95% confidence interval [CI] = 1.03, 5.94) and 2.30 times (95% CI = 0.90, 5.88) as prevalent proximal down- than proximal upstream of swine CAFOs, respectively. Pig-1-Bac and Pig-2-Bac were also 2.87 (95% CI = 1.21, 6.80) and 3.36 (95% CI = 1.34, 8.41) times as prevalent when 48 hour antecedent rainfall was greater than versus less than the mean, respectively. Results suggest diffuse and overall poor sanitary quality of surface waters where swine CAFO density is high. Pig-1-Bac and Pig-2-Bac are useful for tracking off-site conveyance of swine fecal wastes into surface waters proximal to and downstream of swine CAFOs and during rain events.

Nasal carriage of Staphylococcus aureus is commonly evaluated via culture-based methods. We found that parallel use of two media, Baird-Parker and CHROMagar™ Staph aureus, increased detection of S. aureus from a healthy population by 29 %. We suggest use of both media for optimal identification of S. aureus from healthy cohorts.

Objectives: Administration of antibiotics to food animals may select for drug-resistant pathogens of clinical significance, such as methicillin-resistant Staphylococcus aureus (MRSA). In the United States, studies have examined prevalence of MRSA carriage among individuals exposed to livestock, but prevalence of multidrug-resistant S. aureus (MDRSA) carriage and the association with livestock raised with versus without antibiotic selective pressure remains unclear. We aimed to examine prevalence, antibiotic susceptibility, and molecular characteristics of S. aureus among industrial livestock operation (ILO) and antibiotic-free livestock operation (AFLO) workers and household members in North Carolina. Methods: Participants in this cross-sectional study were interviewed and provided a nasal swab for S. aureus analysis. Resulting S. aureus isolates were assessed for antibiotic susceptibility, multi-locus sequence type, and absence of the scn gene (a marker of livestock association). Results: Among 99 ILO and 105 AFLO participants, S. aureus nasal carriage prevalence was 41% and 40%, respectively. Among ILO and AFLO S. aureus carriers, MRSA was detected in 7% (3/41) and 7% (3/42), respectively. Thirty seven percent of 41 ILO versus 19% of 42 AFLO S. aureus-positive participants carried MDRSA. S. aureus clonal complex (CC) 398 was observed only among workers and predominated among ILO (13/34) compared with AFLO (1/35) S. aureus-positive workers. Only ILO workers carried scn-negative MRSA CC398 (2/34) and scn-negative MDRSA CC398 (6/34), and all of these isolates were tetracycline resistant. Conclusions: Despite similar S. aureus and MRSA prevalence among ILO and AFLO-exposed individuals, livestock-associated MRSA and MDRSA (tetracycline-resistant, CC398, scn-negative) were only present among ILO-exposed individuals. These findings support growing concern about antibiotics use and confinement in livestock production, raising questions about the potential for occupational exposure to an opportunistic and drug-resistant pathogen, which in other settings including hospitals and the community is of broad public health importance.

Background: The West End Revitalization Association (WERA), a community-based organization (CBO) in Mebane, North Carolina, was awarded a Collaborative Problem-Solving (CPS) grant from the U.S. Environmental Protection Agency’s Office of Environmental Justice (EPA OEJ). Objectives: The purpose of this paper is to highlight WERA’s efforts to bring stakeholders in three low-income AfricanAmerican communities where environmental hazards created public health risks together for collaboration rather than litigation. Methods: WERA’s board and staff organized nine working groups with specific areas of expertise that would facilitate research, identify lack of basic amenities, and encourage funding for corrective action and participation in progress reporting workshops. WERA used consensus building, dispute resolution, and resource mobilization as part of the CPS model to address noncompliance with environmental laws, including the Clean Air Act, Clean Water Act, Safe Drinking Water Act, Toxic Substances Control Act, and Solid Waste Disposal Act. Results: WERA’s CPS “Right to Basic Amenities” project produced a framework for (1) grassroots management and ownership of a collaborative problem-solving process; (2) bringing stakeholders together with diverse and conflicting viewpoints; (3) implementation of an innovative communityowned and managed (COMR) research model; and (4) leveraging millions of dollars to fund installation of first-time municipal water/sewer services, street paving, and relocation of the 119-bypass to advance environmental health solutions. Conclusion: The structure and successes of WERA’s Right to Basic Amenities project have been discussed at demonstration and training sessions to help others replicate the model in comparable low-income communities of color in North Carolina and across the United States.