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Anhydrous ammonia is transported via ship, rail, and road everyday in the United States as a refrigerated liquid at ambient pressure. As a result, unintential release of a large amount of anhydrous ammonia could result from an accident during transportation. The aim of this paper is to provide a better understanding of the evaporation of anhydrous ammonia from porous media. In our investigation, laboratory‐scale concrete coupons were used as a surrogate for a larger concrete pad that could be present in an event involving an unintentional release of liquid anhydrous ammonia. Concrete coupons sized 5 cm × 5 cm × 1.9 cm were saturated in liquid anhydrous ammonia, and measurements of the subsequent evaporation from the coupons were made in an environmental chamber. The ambient air temperature within the chamber varied from 5 to 45°C, and the relative humidity varied from 5% to 75%. Mass‐difference calculation and Berthelot's reaction were used to determine the average evaporation rate from a concrete coupon across all trials, which was found to be 6.5 ± 1.9 mg/s. To validate these evaporation rates, the remaining ammonia in the concrete coupon was measured for each trial. We found that the time‐integrated calculated evaporation rates correlated well with the total mass of ammonia that was lost from the coupons. In addition, it was found that ambient air temperature and relative humidity had little influence on anhydrous ammonia evaporation from the concrete coupons. [ABSTRACT FROM AUTHOR]

Context: Sexual health discussions between healthcare providers and adolescent and young adult patients are an important strategy for addressing and improving sexual health. However, healthcare providers often do not engage in comprehensive sexual health discussions with young patients during routine clinical visits. Methods: We propose the use of a conceptual model, the Unified Theory of Behavior (UTB), as a tool that can aid healthcare providers in facilitating more comprehensive sexual health conversations with young patients. Results: We present clinical scenarios on how healthcare providers can use the UTB with existing sexual health assessments during routine, clinical visits with their patients. Conclusions: Using the UTB may be one effective tool to aid healthcare providers in initiating sexual health discussions and facilitating more comprehensive sexual health conversations with adolescent and young adult patients during routine clinical visits and sexual and reproductive health‐focused visits. [ABSTRACT FROM AUTHOR]

The extant literature provides unclear findings on how innovation impacts the profit metrics and market performance of the announcing firm as well as its rivals, particularly in different contexts regarding the relative positions of these firms in the market. Therefore, the primary objective of this study is to investigate the effects of new product introductions by focal firms on the corporate value of their competitors. The analysis is based on a dataset comprising 2,452 new product announcements in the United States spanning the period from 2010 to 2020. The findings reveal that the innovativeness of new products has a positive impact on the abnormal returns of large rival firms but a negative impact on the abnormal returns of small rival firms. Further examination of moderation effects indicates that the positive effect of product innovativeness on the abnormal returns of large rival firms is strengthened when these firms possess advantages regarding media presence and market positioning. Conversely, the negative effect of product innovativeness on the abnormal returns of small rival firms is mitigated when these firms have advantages in terms of brand reputation and media influence. These findings suggest that the market expansion and market penetration hypotheses hold true only under specific firm conditions. Furthermore, the results indicate that when a rival firm holds a dominant market position and receives significant positive electronic word-of-mouth signaling customer satisfaction with its products, focal firms tend to respond by increasing their innovation efforts to create distance between themselves and the leading rival firms. [ABSTRACT FROM AUTHOR]

Researchers have grown increasingly interested in studying the effects of purpose and in cultivating purpose among lay people. However, little is known about how people discuss purpose in their daily lives; understanding this would be useful to mental health professionals and purpose-fostering programs trying to help people cultivate purpose. Using key words and phrases generated through natural language processing, we identified 2,000 Tweets referencing purpose and used them to conduct three thematic analyses. Findings suggest that people regard the pursuit of purpose as a socially desirable aim, that they find the search for purpose to be anxiety-provoking, and that they believe purposes can be cultivated even if they are not necessarily sure how to go about doing so. This study highlights a novel and potentially useful method for studying lay conceptions of positive psychological constructs, and it outlines implications of our findings for the study and support of purpose. [ABSTRACT FROM AUTHOR]

Background Measles elimination (interruption of endemic measles virus transmission) in the United States was declared in 2000; however, the number of cases and outbreaks have increased in recent years. We characterized the epidemiology of measles outbreaks and measles transmission patterns after elimination to identify potential gaps in the US measles control program. Methods We analyzed national measles notification data from 1 January 2001 to 31 December 2019. We defined measles infection clusters as single cases (isolated cases not linked to additional cases), 2-case clusters, or outbreaks with ≥3 linked cases. We calculated the effective reproduction number (R) to assess changes in transmissibility and reviewed molecular epidemiology data. Results During 2001–2019, a total of 3873 measles cases, including 747 international importations, were reported in the United States; 29% of importations were associated with outbreaks. Among 871 clusters, 69% were single cases and 72% had no spread. Larger and longer clusters were reported since 2013, including 7 outbreaks with >50 cases lasting >2 months, 5 of which occurred in known underimmunized, close-knit communities. No measles lineage circulated in a single transmission chain for >12 months. Higher estimates of R were noted in recent years, although R remained below the epidemic threshold of 1. Conclusions Current epidemiology continues to support the interruption of endemic measles virus transmission in the United States. However, larger and longer outbreaks in recent postelimination years and emerging trends of increased transmission in underimmunized communities emphasize the need for targeted approaches to close existing immunity gaps and maintain measles elimination. [ABSTRACT FROM AUTHOR]

PURPOSE Racial and ethnic minorities remain underrepresented in research and clinical trials. Better understanding of the components of effective minority recruitment into research studies is critical to understanding and reducing health disparities. Research on recruitment strategies for cancer-specific research—including colorectal cancer (CRC)—among African American men is particularly limited. We present an instrumental exploratory case study examining successful and unsuccessful strategies for recruiting African American men into focus groups centered on identifying barriers to and facilitators of CRC screening completion. METHODS The parent qualitative study was designed to explore the social determinants of CRC screening uptake among African American men 45-75 years of age. Recruitment procedures made use of community-based participatory research strategies combined with built community relationships, including the use of trusted community members, culturally tailored marketing materials, and incentives. RESULTS Community involvement and culturally tailored marketing materials facilitated recruitment. Barriers to recruitment included limited access to public spaces, transportation difficulties, and medical mistrust leading to reluctance to participate. CONCLUSION The use of strategies such as prioritizing community relationship building, partnering with community leaders and gatekeepers, and using culturally tailored marketing materials can successfully overcome barriers to the recruitment of African American men into medical research studies. To improve participation and recruitment rates among racial and ethnic minorities in cancer-focused research studies, future researchers and clinical trial investigators should aim to broaden recruitment, strengthen community ties, offer incentives, and use multifaceted approaches to address specific deterrents such as medical mistrust and economic barriers. [ABSTRACT FROM AUTHOR]

Deep brain stimulation (DBS) is cleared for treatment of obsessive-compulsive disorder (OCD) but is an investigational treatment for major depressive disorder (MDD). The aim of this study is to compare the characteristics of patients who received DBS as part of standard care for OCD versus those who received it a part of a research protocol for MDD. The inpatient sample (N = 110) was drawn from the 2012–2014 Nationwide Inpatient Sample (NIS), and included adults with a primary discharge diagnosis of MDD (N = 50) or OCD (N = 60) and primary procedure of DBS. The study compared various patient demographics, clinical, hospital and insurance variables between the 2 groups. DBS recipients with OCD were younger compared to those with MDD. DBS recipients with MDD tended to be from high-income families compared to those with OCD. DBS patients with MDD were in the South region, while DBS patients with OCD were in the Midwest and South regions of the United States (US). The study did not detect a significant difference in the length of stay and total charges among DBS recipients with OCD versus MDD. DBS patients with MDD are typically older with more financial resources compared to those with OCD. DBS is federally cleared for OCD, but not for MDD, demonstrating the need for further investigation to establish DBS as a federally cleared treatment for difficult to treat MDD if well-powered randomized trials further support its use. [ABSTRACT FROM AUTHOR]

At 9%, and 2% when diagnosed at advanced stage, the 5-year relative survival rate for pancreatic ductal adenocarcinoma (pdac) is the lowest of any cancer. The currently approved treatment options for metastatic pdac in the United States are folfirinox [irinotecan-fluorouracil (5fu)-leucovorin (lv)-oxaliplatin], gemcitabine-nab-paclitaxel, and liposomal irinotecan plus 5fu-lv. Liposomal irinotecan is a novel formulation of irinotecan encapsulated within a lipid bilayer, which favours local metabolic activation. The napoli-1 trial demonstrated the efficacy of liposomal irinotecan in combination with 5fu and lv for the treatment of advanced pdac after progression on gemcitabine-based chemotherapy. The 1-year survival in those patients was 25%; however, none had had irinotecan-refractory disease before treatment with liposomal irinotecan. Furthermore, the U.S. National Comprehensive Cancer Network guidelines recommend liposomal irinotecan plus 5fu-lv in patients who have received prior fluoropyrimidine-based therapy if no prior irinotecan therapy has been given. Here, we report a male patient with stage iv cancer of pancreas or bile duct (site unconfirmed) who experienced a prolonged (51 weeks) response to liposomal irinotecan plus 5fu-lv despite prior disease progression on irinotecan. Several factors have previously been associated with long-term survival in patients receiving liposomal irinotecan therapy: no prior irinotecan-based chemotherapy, high Karnofsky performance status score, age 65 years or less, serum carbohydrate antigen 19-9 less than 59 U/mL, neutrophil-to-lymphocyte ratio 5 or less, and absence of liver metastasis. The patient in the present report had none of those characteristics indicative of long-term survival, except his age at diagnosis--47 years. [ABSTRACT FROM AUTHOR]

Prior studies have supported the effectiveness of the use of Lay Health Workers (LHWs) as an intervention model for managing chronic health conditions, yet few have documented the mechanisms that underlie the effectiveness of the interventions. This study provides a first look into how LHWs delivered a family-based intervention and the challenges encountered. We utilize observation data from LHW-led educational sessions delivered as part of a randomized controlled trial (RCT) designed to test a LHW outreach family-based intervention to promote smoking cessation among Vietnamese American smokers. The RCT included experimental (smoking cessation) and control (healthy living) arms. Vietnamese LHWs were trained to provide health information in Vietnamese to groups of family dyads (smoker and family member). Bilingual, bicultural research team members conducted unobtrusive observations in a subset of LHW educational sessions and described the setting, process and activities in structured fieldnotes. Two team members coded each fieldnote following a grounded theory approach. We utilized Atlas.ti qualitative software to organize coding and facilitate combined analysis. Findings offer a detailed look at the 'black box' of how LHWs work with their participants to deliver health messages. LHWs utilized multiple relational strategies, including preparing an environment that enables relationship building, using recognized teaching methods to engage learners and co-learners as well as using humor and employing culturally specific strategies such as hierarchical forms of address to create trust. Future research will assess the effectiveness of LHW techniques, thus enhancing the potential of LHW interventions to promote health among underserved populations. [ABSTRACT FROM AUTHOR]

During January 1-October 1, 2019, a total of 1,249 measles cases and 22 measles outbreaks were reported in the United States. This represents the most U.S. cases reported in a single year since 1992 (1), and the second highest number of reported outbreaks annually since measles was declared eliminated* in the United States in 2000 (2). Measles is an acute febrile rash illness with an attack rate of approximately 90% in susceptible household contacts (3). Domestic outbreaks can occur when travelers contract measles outside the United States and subsequently transmit infection to unvaccinated persons they expose in the United States. Among the 1,249 measles cases reported in 2019, 1,163 (93%) were associated with the 22 outbreaks, 1,107 (89%) were in patients who were unvaccinated or had an unknown vaccination status, and 119 (10%) measles patients were hospitalized. Closely related outbreaks in New York City (NYC) and New York State (NYS; excluding NYC), with ongoing transmission for nearly 1 year in large and close-knit Orthodox Jewish communities, accounted for 934 (75%) cases during 2019 and threatened the elimination status of measles in the United States. Robust responses in NYC and NYS were effective in controlling transmission before the 1-year mark; however, continued vigilance for additional cases within these communities is essential to determine whether elimination has been sustained. Collaboration between public health authorities and undervaccinated communities is important for preventing outbreaks and limiting transmission. The combination of maintenance of high national vaccination coverage with measles, mumps, and rubella vaccine (MMR) and rapid implementation of measles control measures remains the cornerstone for preventing widespread measles transmission (4). [ABSTRACT FROM AUTHOR]

A case studywas conducted to explore the experiences of Chinese nurseswhen completing a graduate nursing degree taught in English (as a second language) in the United States over a 1-year period. The study explored language, academic, and social challenges perceived by the students, strategies used to overcome challenges, and academic support services designed to help students succeed in their studies. Survey data were collected at three different points in time, and three interviews were conducted with each participant. The study identified participants’ difficulty with academic writing, mixed experiences with speaking, moderate-to-high levels of strategy use, and appreciation of the support services offered. The study offered implications for improvements in pedagogies and programming for international students. [ABSTRACT FROM AUTHOR]

While learners’ engagement has been recognized as important for second language (L2) learning in task-based language teaching (TBLT), how engagement is manifest in learners’ L2 use during task performance and how tasks can be designed to facilitate better engagement have not received enough attention in the L2 research. This study investigates the relationship between learners’ expressed preferences for two communicative L2 tasks and their engagement in L2 use during task performance. Twenty-one learners of English as a second language (ESL) performed two distinct tasks and participated in an interview after finishing them. This article compares behavioral, cognitive, and social measures of learners’ engagement in L2 use while performing the task they preferred more and the task they preferred less as well as their expressed reasons for these preferences. The findings revealed a higher level of cognitive engagement in L2 use (i.e. greater negotiation of meaning and form) during the performance of the task they preferred more. The findings also revealed that the topic as well as opportunities to create ideas and address a genuine communicative need were the most important factors in determining learners’ expressed task preferences. Implications for task design include allowing learners to create content for the tasks they perform and choosing topics that are familiar, personally relevant, and emotionally engaging to learners. [ABSTRACT FROM AUTHOR]

Background The WHO framework for non-communicable disease (NCD) describes risks and outcomes comprising the majority of the global burden of disease. These factors are complex and interact at biological, behavioural, environmental and policy levels presenting challenges for population monitoring and intervention evaluation. This paper explores the utility of machine learning methods applied to population-level web search activity behaviour as a proxy for chronic disease risk factors. Methods Web activity output for each element of the WHO's Causes of NCD framework was used as a basis for identifying relevant web search activity from 2004 to 2013 for the USA. Multiple linear regression models with regularisation were used to generate predictive algorithms, mapping web search activity to Centers for Disease Control and Prevention (CDC) measured risk factor/disease prevalence. Predictions for subsequent target years not included in the model derivation were tested against CDC data from population surveys using Pearson correlation and Spearman's r. Results For 2011 and 2012, predicted prevalence was very strongly correlated with measured risk data ranging from fruits and vegetables consumed (r=0.81; 95% CI 0.68 to 0.89) to alcohol consumption (r=0.96; 95% CI 0.93 to 0.98). Mean difference between predicted and measured differences by State ranged from 0.03 to 2.16. Spearman's r for state-wise predicted versus measured prevalence varied from 0.82 to 0.93. Conclusions The high predictive validity of web search activity for NCD risk has potential to provide real-time information on population risk during policy implementation and other population-level NCD prevention efforts. [ABSTRACT FROM AUTHOR]

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Agricultural pesticide use in Viet Nam has more than tripled since 1990. However, pesticide legislation and regulations have not been developed in response to this large increase in usage, as a result of which pesticides pose a serious threat to human health and the environment. This paper identifies the need to improve pesticide regulations in Viet Nam through a comparative analysis of pesticide regulations in Viet Nam and the United States of America, where the rate of acute poisoning among agricultural workers is much lower than in Viet Nam and where information pertaining to pesticide regulations is made accessible to the public. The analysis identified several measures that would help to improve Viet Nam's pesticide regulations. These include enhancing pesticide legislation, clarifying the specific roles and active involvement of both the environmental and health sectors; performing a comprehensive risk-benefit evaluation of pesticide registration and management practices; improving regulations on pesticide suspension and cancellation, transport, storage and disposal; developing import and export policies and enhancing pesticide-related occupational safety programmes. [ABSTRACT FROM AUTHOR]

Generic antiepileptic drugs achieve blood concentrations similar to those of innovator drugs in healthy volunteers, but their comparative effectiveness has not been well evaluated. Thus, we assessed the efficacy, tolerability, and safety of innovator versus generic antiepileptic drugs. We searched the MEDLINE database, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science for studies that evaluated innovator and generic antiepileptic drugs in patients with epilepsy and reported data on prespecified outcomes. We extracted data on study design, interventions, quality criteria, study population, baseline characteristics, and outcomes. Compared with initiation of innovator antiepileptic drugs, initiation of generic antiepileptic drugs did not significantly alter seizure occurrence (relative risk [ RR] 0.87, 95% confidence interval [ CI] 0.64-1.18; strength of evidence: low) or frequency (standardized mean difference 0.03, 95% CI −0.08-0.14; strength of evidence: low), withdrawals due to lack of efficacy ( RR 1.02, 95% CI 0.41-2.54; strength of evidence: low) or adverse events ( RR 0.79, 95% CI 0.28-2.20; strength of evidence: low), pharmacokinetic concentrations (maximum, minimum, or area under the curve [strength of evidence: low]), or a myriad of adverse events (strength of evidence: low or insufficient) in clinical trials. In qualitatively evaluated observational studies, switching between forms of antiepileptic drug (innovator to generic, generic to generic) may increase the risk of hospitalization (strength of evidence: low), hospital stay duration (strength of evidence: low), and a composite end point of medical service utilization (strength of evidence: insufficient) but may not increase outpatient service utilization (strength of evidence: low). Data are limited predominantly to carbamazepine, phenytoin, and valproic acid. Clinical trials are limited by small sample size, short-term nature, and lack of specification of A-rated generic products (generics that the United States Food and Drug Administration has deemed bioequivalent to the innovator drug). Observational trials lack full accounting for confounders and have inherent limitations. With a low strength of evidence, it appears that initiating an innovator or generic antiepileptic drug will provide similar efficacy, tolerability, and safety but that switching from one form to the other may be associated with more hospitalizations and longer hospital stays. [ABSTRACT FROM AUTHOR]

The article analyzes the U.S. Centers for Disease Control data from the National Notifiable Diseases Surveillance System (NNDSS) for the period January 2001-February 2011 in order to characterize imported measles cases reported in the first two months of 2011 in U.S. travelers aged 6-23 months. Results indicate a total of 13 cases were reported in U.S. residents for January-February 2011 and 159 for the period 2001-2010. The Advisory Committee for Immunization Practices advises U.S. children who travel abroad should be vaccinated at an earlier age.

The article discusses a report on the outbreak of mumps in New York and New Jersey from June 2009 and January 2010, published in the 2010 issue of "Morbidity and Mortality Weekly Report." As of January 29, 2010, 1,521 cases of mumps have been reported, primarily involving the Jewish community. Most patients are aged six and older, with a median age of 15 years. Eighty eight percent of patients with mumps were found to have received at least a dose of mumps vaccine. According to the report, the mumps outbreak can occur among people who were vaccinated. It also emphasized that several factors influence mumps outbreak and control in the U.S.

The article presents a study that investigates the complexity of languages used in the Supreme Courts of different states in the U.S. It presents the correlation between linguistic complexity and geography. Moreover, it features the different methods used in courts to achieve plainness in legal language.

The decennial census is one of the most venerable components of American democracy and a paragon of population enumeration for the whole world. However, as an integral part of the American political tradition, it has shared the very peculiar nature of the American polity. It then deliberately counted Blacks as fractional persons--the Three-Fifths Compromise--and now, it involuntarily undercounts the Black population disproportionately. This undercount, in addition to decreasing the fair shares of political representation and federal funds entitled to African Americans, has resulted in various biased statistics on them. [ABSTRACT FROM AUTHOR]

Presents a study that examined gender differences in sexually harassing and coercive behaviors among college students in the U.S. Background on the link between alcohol use or expectancies and sexual aggression; Effects of developmental, individual and situational factors on sexual harassing and coercive behavior; Correlations between adult sexual victimization and sexual coercion.

Examines the undercount of the Afro-American population. Description of so-called biased statistics on blacks; Undercount rate of the black and non-black populations; 1990 census differential undercount estimated by demographic analysis; Impacts of the black undercount; Crude death rates of black and white males; Recommendations to address black population undercounts.

• Three parent groups completed a semi-structured interview and validated survey tool. • Hispanic/Latinx parental groups had higher COVID-19 vaccine hesitancy. • Hypothetical parental willingness to vaccinate children was similar across groups. • Reasons for hesitancy fell most under Confidence, followed by Complacency. • Targeted COVID-19 vaccine education to different populations should be considered. COVID-19 vaccinations are now recommended in the United States (U.S.) for children ≥ 6 months old. However, pediatric vaccination rates remain low, particularly in the Hispanic/Latinx population. Using the 4C vaccine hesitancy framework (calculation, complacency, confidence, convenience), we examined parental attitudes in the emergency department (ED) towards COVID-19 vaccination, identified dimensions of parental vaccine hesitancy, and assessed parental willingness to have their child receive the COVID-19 vaccine. As part of a larger multi-methods study examining influenza vaccine hesitancy, we conducted interviews that included questions about COVID-19 vaccine authorization for children. We used directed content analysis to extract qualitative themes from 3 groups of parents in the ED: Hispanic/Latinx Spanish speaking (HS), Hispanic/Latinx English speaking (HE), non-Hispanic/non-Latinx White English speaking (WE). Themes were triangulated with the Parent Attitudes about Childhood Vaccines (PACV) survey, where higher scores indicate increased vaccine hesitancy. Factors influencing vaccine hesitancy were mapped to the 4C framework from 58 sets of interviews and PACVs. HE and HS parents, compared to WE parents, had less knowledge about COVID-19 and its vaccine, and more beliefs in COVID-19 vaccine myths. However, both HS and HE parent groups were more inclined to endorse COVID-19 vaccine effectiveness as a reason to have their children vaccinated. HS parents felt that COVID-19 increased their fear of illnesses in general and were worried about confusing COVID-19 with other infections. Median PACV scores of HS (Mdn = 20) and HE (Mdn = 20) parent groups were higher than of WE parents (Mdn = 10), but parental willingness to have their child receive COVID-19 vaccination was similar across groups. Higher COVID-19 vaccine hesitancy among HS and HE parents compared to WE parents may be attributed to insufficient knowledge about COVID-19, its vaccine, along with COVID-19 vaccine myths. Efforts to provide targeted vaccine education to different populations is warranted. [ABSTRACT FROM AUTHOR]

Local anesthesia (LA) for open inguinal hernia repair (OIHR) is not widely used in the United States. An LA program for OIHR was initiated at the Dallas Veteran Affairs Medical Center in 2015. We hypothesize that outcomes under LA for OIHR are similar to general anesthesia with adequate patient satisfaction. A total of 1422 groin hernias were performed by a single surgeon using a standardized technique at the Dallas Veteran Affairs Medical Center (2015-2019). Only unilateral, primary, elective, OIHRs were included (n = 1092). LA was used in 26.0% (n = 285) and compared with patients undergoing general anesthesia. Univariate analysis was performed by the Student t -test for continuous variables and χ2 test (or the Fisher exact test) for categorical variables. OIHR performed with LA increased from 15.5% in 2015 to 76.6% in 2019. Patients undergoing LA were older and had significantly more comorbidities. Holding time to operating room (OR), OR to start of the operation, skin-to-skin time, and end of the operation to out of the OR were all reduced with LA (all P values <0.05). Inguinodynia, recurrence, and overall complications were similar. Patients undergoing LA indicated that they were comfortable (93.0%), rated their worst pain as 2.03 ± 2.2 (of 10), and would undergo LA if they had to do it again (94.0%). LA was associated with decreased OR times and had good patient satisfaction. Overall complication rates were similar despite a higher burden of comorbid conditions in patients undergoing LA. [ABSTRACT FROM AUTHOR]

Background: By 2005, vaccination had reduced the annual incidence of mumps in the United States by more than 99%, with few outbreaks reported. However, in 2006, a large outbreak occurred among highly vaccinated populations in the United States, and similar outbreaks have been reported worldwide. The outbreak described in this report occurred among U.S. Orthodox Jewish communities during 2009 and 2010. Methods: Cases of salivary-gland swelling and other symptoms clinically compatible with mumps were investigated, and demographic, clinical, laboratory, and vaccination data were evaluated. Results: From June 28, 2009, through June 27, 2010, a total of 3502 outbreak-related cases of mumps were reported in New York City, two upstate New York counties, and one New Jersey county. Of the 1648 cases for which clinical specimens were available, 50% were laboratory-confirmed. Orthodox Jewish persons accounted for 97% of case patients. Adolescents 13 to 17 years of age (27% of all patients) and males (78% of patients in that age group) were disproportionately affected. Among case patients 13 to 17 years of age with documented vaccination status, 89% had previously received two doses of a mumps-containing vaccine, and 8% had received one dose. Transmission was focused within Jewish schools for boys, where students spend many hours daily in intense, face-to-face interaction. Orchitis was the most common complication (120 cases, 7% of male patients ≥12 years of age), with rates significantly higher among unvaccinated persons than among persons who had received two doses of vaccine. Conclusions: The epidemiologic features of this outbreak suggest that intense exposures, particularly among boys in schools, facilitated transmission and overcame vaccine-induced protection in these patients. High rates of two-dose coverage reduced the severity of the disease and the transmission to persons in settings of less intense exposure. [ABSTRACT FROM PUBLISHER]