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The association between thromboembolic events (TE) and COVID-19 infection is not completely understood at the population level in the United States. We examined their association using a large US healthcare database. We analyzed data from the Premier Healthcare Database Special COVID-19 Release and conducted a case-control study. The study population consisted of men and non-pregnant women aged ≥ 18 years with (cases) or without (controls) an inpatient ICD-10-CM diagnosis of TE between 3/1/2020 and 6/30/2021. Using multivariable logistic regression, we assessed the association between TE occurrence and COVID-19 diagnosis, adjusting for demographic factors and comorbidities. Among 227,343 cases, 15.2% had a concurrent or prior COVID-19 diagnosis within 30 days of their index TE. Multivariable regression analysis showed a statistically significant association between a COVID-19 diagnosis and TE among cases when compared to controls (adjusted odds ratio [aOR] 1.75, 95% CI 1.72-1.78). The association was more substantial if a COVID-19 diagnosis occurred 1-30 days prior to index hospitalization (aOR 3.00, 95% CI 2.88-3.13) compared to the same encounter as the index hospitalization. Our findings suggest an increased risk of TE among persons within 30 days of being diagnosed COVID-19, highlighting the need for careful consideration of the thrombotic risk among COVID-19 patients, particularly during the first month following diagnosis.

The US Centers for Disease Control and Prevention (CDC); state, tribal, local, and territorial health departments; other US government departments and agencies; the private sector; and international partners have engaged in a real-time public health response to the coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Vaccination, variants, and vigilance were themes that arose in the second year of pandemic response in the United States. The findings included in this supplement emerged from these themes and represent some of the many collaborative efforts to improve public health knowledge and action to reduce transmission, infection, and disease severity.

Long-term symptoms often associated with COVID-19 (post-COVID conditions or long COVID) are an emerging public health concern that is not well understood. Prevalence of post-COVID conditions has been reported among persons who have had COVID-19 (range = 5%-80%), with differences possibly related to different study populations, case definitions, and data sources (1). Few studies of post-COVID conditions have comparisons with the general population of adults with negative test results for SARS-CoV-2, the virus that causes COVID-19, limiting ability to assess background symptom prevalence (1). CDC used a nonprobability-based Internet panel established by Porter Novelli Public Services* to administer a survey to a nationwide sample of U.S. adults aged ≥18 years to compare the prevalence of long-term symptoms (those lasting >4 weeks since onset) among persons who self-reported ever receiving a positive SARS-CoV-2 test result with the prevalence of similar symptoms among persons who reported always receiving a negative test result. The weighted prevalence of ever testing positive for SARS-CoV-2 was 22.2% (95% confidence interval [CI] = 20.6%-23.8%). Approximately two thirds of respondents who had received a positive test result experienced long-term symptoms often associated with SARS-CoV-2 infection. Compared with respondents who received a negative test result, those who received a positive test result reported a significantly higher prevalence of any long-term symptom (65.9% versus 42.9%), fatigue (22.5% versus 12.0%), change in sense of smell or taste (17.3% versus 1.7%), shortness of breath (15.5% versus 5.2%), cough (14.5% versus 4.9%), headache (13.8% versus 9.9%), and persistence (>4 weeks) of at least one initially occurring symptom (76.2% versus 69.6%). Compared with respondents who received a negative test result, a larger proportion of those who received a positive test result reported believing that receiving a COVID-19 vaccine made their long-term symptoms better (28.7% versus 15.7%). Efforts to address post-COVID conditions should include helping health care professionals recognize the most common post-COVID conditions and optimize care for patients with persisting symptoms, including messaging on potential benefits of COVID-19 vaccination.

Purpose: We explored mechanisms of paternal influence associated with adolescent male condom decision making and behavior within an integrated framework of social neurobiological and behavioral theories of condom use. Method: Self-administered surveys from Latino and Black adolescent males aged 15–19 years ( n = 191) and their fathers were obtained. Dyads were recruited using area sampling methodology. Analyses included multivariable logistic and ordinary least squares regression examining direct and indirect associations of adolescent decision-analytic and paternal influence factors with adolescent condomless sex in the past 3 months. Results: Notions of masculinity, low-risk perception, partner approval of, and self-efficacy for condomless sex were associated with engaging in unprotected sex. Adolescent males reported reduced odds of engaging in condomless sex when indicating greater levels of father–son communication, relationship satisfaction, and paternal monitoring. Conclusion: Father-based interventions grounded in integrated theoretical frameworks of behavioral decision making and neuroscience have the potential to promote condom use among adolescent males.

Community-wide initiatives (CWI) to prevent teen pregnancy were implemented in 10 communities in the USA. The CWI supported the implementation of evidence-based teen pregnancy interventions (EBIs) and implementation of best practices for adolescent reproductive health care. Implementation was supported through mobilizing communities, educating stakeholders, and strategies to promote health equity. We assessed indicators of progress of the CWI for the following five project components (data collected from 2010 to 2015): community mobilization, stakeholder education, working with diverse communities, evidence-based interventions, and increasing access to clinical services and the potential contributions of training and technical assistance. Communities engaged multiple stakeholder groups to contribute to planning, community outreach and education, and partnership development and used multiple dissemination methods to share information on adolescent reproductive health needs and teen pregnancy prevention strategies. The amount of training and technical assistance from state- and community-based organizations was associated with increased numbers of youth receiving EBIs and increased provision of contraceptives. The number of health centers implementing best practices for adolescent reproductive health services increased; conducting sexual health assessments, offering hormonal contraception or IUD, and offering quick start of IUDs were associated with increases in long-acting reversible contraception utilization. These findings demonstrate that scaled prevention efforts can occur with adequate support including training and technical assistance and community awareness and engagement in the process. The findings raise important questions for understanding what factors contribute to successful community-wide implementation of EBIs and health center best practices for contraceptive access and whether these lead to reductions in teen pregnancies in highly impacted communities.

OBJECTIVES To describe coronavirus disease 2019 (COVID-19)–related pediatric hospitalizations during a period of B.1.617.2 (Δ) variant predominance and to determine age-specific factors associated with severe illness. METHODS We abstracted data from medical charts to conduct a cross-sectional study of patients aged RESULTS Of 947 hospitalized patients, 759 (80.1%) had COVID-19, of whom 287 (37.8%) had severe illness. Factors associated with severe illness included coinfection with respiratory syncytial virus (RSV) (PR 3.64) and bacteria (PR 1.88) in infants; RSV coinfection in patients aged 1 to 4 years (PR 1.96); and obesity in patients aged 5 to 11 (PR 2.20) and 12 to 17 years (PR 2.48). Having ≥2 underlying medical conditions was associated with severe illness in patients aged CONCLUSIONS Among patients hospitalized for COVID-19, factors associated with severe illness included RSV coinfection in those aged

Summary Background Since August, 2019, US public health officials have been investigating a national outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). A spectrum of histological patterns consistent with acute to subacute lung injury has been seen in biopsies; however, autopsy findings have not been systematically characterised. We describe the pathological findings in autopsy and biopsy tissues submitted to the US Centers for Disease Control and Prevention (CDC) for the evaluation of suspected EVALI. Methods Between Aug 1, 2019, and Nov 30, 2019, we examined lung biopsy (n=10 individuals) and autopsy (n=13 individuals) tissue samples received by the CDC, submitted by 16 US states, from individuals with: a history of e-cigarette, or vaping, product use; respiratory, gastrointestinal, or constitutional symptoms; and either pulmonary infiltrates or opacities on chest imaging, or sudden death from an undetermined cause. We also reviewed medical records, evaluated histopathology, and performed infectious disease testing when indicated by histopathology and clinical history. Findings 21 cases met surveillance case definitions for EVALI, with a further two cases of clinically suspected EVALI evaluated. All ten lung biopsies showed histological evidence of acute to subacute lung injury, including diffuse alveolar damage or organising pneumonia. These patterns were also seen in nine of 13 (69%) autopsy cases, most frequently diffuse alveolar damage (eight autopsies), but also acute and organising fibrinous pneumonia (one autopsy). Additional pulmonary pathology not necessarily consistent with EVALI was seen in the remaining autopsies, including bronchopneumonia, bronchoaspiration, and chronic interstitial lung disease. Three of the five autopsy cases with no evidence of, or a plausible alternative cause for acute lung injury, had been classified as confirmed or probable EVALI according to surveillance case definitions. Interpretation Acute to subacute lung injury patterns were seen in all ten biopsies and most autopsy lung tissues from individuals with suspected EVALI. Acute to subacute lung injury can have numerous causes; however, if it is identified in an individual with a history of e-cigarette, or vaping, product use, and no alternative cause is apparent, a diagnosis of EVALI should be strongly considered. A review of autopsy tissue pathology in suspected EVALI deaths can also identify alternative diagnoses, which can enhance the specificity of public health surveillance efforts. Funding US Centers for Disease Control and Prevention.

Preventing unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection, among adolescents is a public health priority. This report presents prevalence estimates for condom and contraceptive use among sexually active U.S. high school students from the 2019 Youth Risk Behavior Survey. Behaviors examined included any condom use, primary contraceptive method use, and condom use with a more effective contraceptive method, all reported at last sexual intercourse. Analyses were limited to sexually active students (i.e., those who had sexual intercourse with one or more persons during the 3 months before the survey). Except for any condom use, students reporting only same-sex sexual contact were excluded from analyses. Weighted prevalence estimates were calculated, and bivariate differences in prevalence were examined by demographic characteristics (sex, race/ethnicity, and grade) and other sexual risk behaviors (age of sexual initiation, previous 3-month and lifetime number of sex partners, and substance use before last sexual intercourse). Nationwide, 27.4% of high school students reported being sexually active (n = 3,226). Among sexually active students who reported having had sexual contact with someone of the opposite sex (n = 2,698), most students (89.7%) had used a condom or a primary contraceptive method at last sexual intercourse. Prevalence of any condom use at last sexual intercourse was 54.3%, and condoms were the most prevalent primary contraceptive method (43.9% versus 23.3% for birth control pills; 4.8% for intrauterine device [IUD] or implant; and 3.3% for shot, patch, or ring). Approximately 9% had used condoms with an IUD, implant, shot, patch, ring, or birth control pills. Using no pregnancy prevention method was more common among non-Hispanic black (23.2%) and Hispanic (12.8%) students compared with non-Hispanic white students (6.8%); compared with Hispanic students, using no pregnancy prevention method was more common among non-Hispanic black students. Prevalence of condom use was consistently lower among students with other sexual risk behaviors. Results underscore the need for public health professionals to provide quality sexual and reproductive health education and clinical services for preventing unintended pregnancy and STDs/HIV and decreasing disparities among sexually active youths.

More information is needed to understand the clinical epidemiology of children and young adults hospitalized with diabetes and COVID-19. We describe the demographic and clinical characteristics of patients21 years old hospitalized with COVID-19 and either Type 1 or Type 2 Diabetes Mellitus (T1DM or T2DM) during peak incidence of SARS-CoV-2 infection with the B.1.617.2 (Delta) variant.This is a descriptive sub-analysis of a retrospective chart review of patients aged21 years hospitalized with COVID-19 in six US children's hospitals during July-August 2021. Patients with COVID-19 and either newly diagnosed or known T1DM or T2DM were described using originally collected data and diabetes-related data specifically collected on these patients.Of the 58 patients hospitalized with COVID-19 and diabetes, 34 had T1DM and 24 had T2DM. Of those with T1DM and T2DM, 26% (9/34) and 33% (8/24), respectively, were newly diagnosed. Among those12 years old and eligible for COVID-19 vaccination, 93% were unvaccinated (42/45). Among patients with T1DM, 88% had diabetic ketoacidosis (DKA) and 6% had COVID-19 pneumonia; of those with T2DM, 46% had DKA and 58% had COVID-19 pneumonia. Of those with T1DM or T2DM, 59% and 46%, respectively, required ICU admission.Our findings highlight the importance of considering diabetes in the evaluation of children and young adults presenting with COVID-19; the challenges of managing young patients who present with both COVID-19 and diabetes, particularly T2DM; and the importance of preventive actions like COVID-19 vaccination to prevent severe illness among those eligible with both COVID-19 and diabetes.

Equitable access to high quality adolescent sexual and reproductive health (ASRH) services can help reduce unintended pregnancies, sexually transmitted diseases, and disparities in these outcomes. The Centers for Disease Control and Prevention (CDC), Division of Reproductive Health, has a long history of working to improve access to and quality of ASRH services through applied research and public health practice. This report from CDC summarizes the evolution of these efforts from more than a decade of work-from community-based demonstration projects to an initiative to support wide-scale implementation. We describe a community-wide teen pregnancy prevention program model that includes a component addressing ASRH services (2010-2015), focused efforts related to quality improvement (QI) of and community-clinic linkages to ASRH services (2015-2020), and the development of a QI package that collates implementation strategies and tools to improve ASRH services (2020-2022). We conclude by discussing future directions. In disseminating key strategies and resources from this work, we aim to support broader public health and clinical efforts to strengthen ASRH care in the United States in ways that promote health equity.

This cross-sectional study uses data from the Centers for Disease Control and Prevention’s Coronavirus Self-checker to assess which symptoms are reported with new loss of taste or smell among individuals with and without SARS-CoV-2.

Quality adolescent sexual and reproductive health (ASRH) services play an important role in supporting the overall health and well-being of adolescents. Improving access to this care can help reduce unintended pregnancies, sexually transmitted diseases (STDs), and human immunodeficiency virus (HIV) infection and their associated consequences, as well as promote health equity. The Centers for Disease Control and Prevention funded three grantees to implement a clinic-based ASRH quality improvement initiative complimented by activities to strengthen systems to refer and link youth to ASRH services. The purpose of this study is to describe the initiative and baseline assessment results of ASRH best practice implementation in participating health centers. The assessment found common use of the following practices: STD/HIV screening, education on abstinence and the use of dual protection, and activities to increase accessibility (e.g., offering after-school hours and walk-in and same-day appointments). The following practices were used less frequently: provider training for Long-Acting Reversible Contraception (LARC) insertion and removal, LARC availability, same-day provision of all contraceptive methods, and consistent sharing of information about confidentiality and minors' rights with adolescent clients. This study describes the types of training and technical assistance being implemented at each health center and discusses implications for future programming.

Introduction Teen pregnancy prevention typically focuses on young women, overlooking the unique prevention needs of young men. Identifying factors associated with teen pregnancy for young men is essential to developing relevant and effective programming. Methods We conducted a scoping review of studies with findings on factors associated with pregnancies/birth specific to young men. We searched Scopus, OVID, and PubMed databases for peer-reviewed articles published from 2000 to 2015. We reviewed 1750 articles for inclusion of studies conducted in the United States with a sample size greater than 200 that assessed the effect of factors on teen pregnancy/birth using multivariate, male-specific analyses. Two coders abstracted 48 articles (having established 80% reliability with 10% of the articles). We grouped study variables into factors and used a matrix to summarize findings for each factor. During analysis, 29 articles were excluded for a final sample of 19 articles, each describing a separate study. Results Study settings included households, healthcare organizations, schools, neighborhoods, and correctional facilities. Factors showing associations with teen pregnancy/birth included: experiencing childhood abuse; engaging in serious or repeated delinquent behaviors; substance abuse; having a teen parent; serious family disruption; not living with either parent; and Hispanic ethnicity. No studies assessed knowledge and attitudes about contraceptive methods, or access and use of clinical services; and few assessed relationship factors (n = 4) or gender and power (n = 1). Conclusions Factors related to disadvantaged social contexts were associated with teen pregnancy/birth. Resilience-based research may identify protective factors to support vulnerable families and youth.

Background Clinical severity of coronavirus disease 2019 (COVID-19) may vary over time; trends in clinical severity at admission during the pandemic among hospitalized patients in the United States have been incompletely described, so a historical record of severity over time is lacking. Methods We classified 466677 hospital admissions for COVID-19 from April 2020 to April 2021 into 4 mutually exclusive severity grades based on indicators present on admission (from most to least severe): Grade 4 included intensive care unit (ICU) admission and invasive mechanical ventilation (IMV); grade 3 included non-IMV ICU and/or noninvasive positive pressure ventilation; grade 2 included diagnosis of acute respiratory failure; and grade 1 included none of the above indicators. Trends were stratified by sex, age, race/ethnicity, and comorbid conditions. We also examined severity in states with high vs low Alpha (B.1.1.7) variant burden. Results Severity tended to be lower among women, younger adults, and those with fewer comorbidities compared to their counterparts. The proportion of admissions classified as grade 1 or 2 fluctuated over time, but these less-severe grades comprised a majority (75%–85%) of admissions every month. Grades 3 and 4 consistently made up a minority of admissions (15%–25%), and grade 4 showed consistent decreases in all subgroups, including states with high Alpha variant burden. Conclusions Clinical severity among hospitalized patients with COVID-19 has varied over time but has not consistently or markedly worsened over time. The proportion of admissions classified as grade 4 decreased in all subgroups. There was no consistent evidence of worsening severity in states with higher vs lower Alpha prevalence.

OBJECTIVES To describe the demographics, clinical characteristics, and hospital course among persons METHODS We conducted a retrospective case series of suspected SARS-CoV-2-associated deaths in the United States in persons RESULTS We included 112 SARS-CoV-2-associated deaths from 25 participating jurisdictions. The median age was 17 years (IQR 8.5–19 years). Most decedents were male (71, 63%), 31 (28%) were Black (non-Hispanic) persons, and 52 (46%) were Hispanic persons. Ninety-six decedents (86%) had at least 1 underlying condition; obesity (42%), asthma (29%), and developmental disorders (22%) were most commonly documented. Among 69 hospitalized decedents, common complications included mechanical ventilation (75%) and acute respiratory failure (82%). The sixteen (14%) decedents who met multisystem inflammatory syndrome in children (MIS-C) criteria were similar in age, sex, and race and/or ethnicity to decedents without MIS-C; 11 of 16 (69%) had at least 1 underlying condition. CONCLUSIONS SARS-CoV-2-associated deaths among persons

BACKGROUND We assess the impact of School-Based Health Centers (SBHCs) on National Performance Measures (NPMs) related to health care access and utilization among Medicaid-insured youth in Delaware. METHODS Our retrospective analysis of Delaware's SBHC program data linked with Medicaid claims during 2014-2016 for 13 to 18-year-olds assessed achievement of NPMs and use of mental health services using propensity scores. We estimated crude and adjusted prevalence ratios (APR) for SBHC-enrolled compared with non-enrolled youth. RESULTS Students enrolled in SBHCs had more health care visits (M = 8.7; 95% CI: 7.9-9.5) compared with non-SBHC-enrolled youth (M = 4.5; 95% CI: 4.3-4.7). Compared with non-SBHC, those enrolled in SBHCs were more likely to receive: well-child visits (APR = 1.2; 95% CI: 1.1-1.3); annual risk assessment (APR = 11.0; 95% CI: 6.9-17.5); BMI screening (APR = 5.6; 95% CI: 3.3-9.4); nutrition counseling (APR = 4.1; 95% CI: 2.8-6.0); physical activity counseling (APR = 6.3; 95% CI: 4.2-9.4); STIs and chlamydia screening (APR = 1.9; 95% CI: 1.3-2.8); mental health visits (APR = 2.6; 95% CI: 2.2-3.1). CONCLUSIONS We found that among Medicaid-insured youth, those enrolled in SBHCs vs not enrolled in SBHCs had greater health care utilization as evident from NPMs and mental health services.

Objective To develop a more comprehensive description of multisystem inflammatory syndrome in children (MIS-C), a novel syndrome linked to severe acute respiratory syndrome coronavirus 2, by conducting a systematic analysis of studies from different settings that used various inclusion criteria. Study design MIS-C studies were identified by searching PubMed and Embase as well as preprint repositories and article references to identify studies of MIS-C cases published from April 25, 2020, through June 29, 2020. MIS-C study metadata were assessed and information on case demographics, clinical symptoms, laboratory measurements, treatments, and outcomes were summarized and contrasted between studies. Results Eight studies were identified representing a total of 440 MIS-C cases. Inclusion criteria varied by study: 3 studies selected patients diagnosed with Kawasaki disease, 2 required cardiovascular involvement, and 3 had broader multisystem inclusion criteria. Median age of patients by study ranged from 7.3 to 10 years, and 59% of patients were male. Across all studies, the proportion of patients with positive results for severe acute respiratory syndrome coronavirus 2 reverse transcriptase-polymerase chain reaction tests ranged from 13% to 69% and for serology, from 75% to 100%. Patients with MIS-C had high prevalence of gastrointestinal (87%), dermatologic/mucocutaneous (73%), and cardiovascular (71%) symptoms. Prevalence of cardiovascular, neurologic, and respiratory system involvement significantly differed by study inclusion criteria. All studies reported elevated C-reactive protein, interleukin-6, and fibrinogen levels for at least 75% of patients in each study. Conclusions This systematic review of MIS-C studies assists with understanding this newly identified syndrome and may be useful in developing a refined, universal case definition of MIS-C.

Since February 12, 2020, approximately 6.5 million cases of SARS-CoV-2 infection, the cause of coronavirus disease 2019 (COVID-19), and 190,000 SARS-CoV-2-associated deaths have been reported in the United States (1,2). Symptoms associated with SARS-CoV-2 infection are milder in children compared with adults (3). Persons aged

In April 2020, during the peak of the coronavirus disease 2019 (COVID-19) pandemic in Europe, a cluster of children with hyperinflammatory shock with features similar to Kawasaki disease and toxic shock syndrome was reported in England* (1). The patients' signs and symptoms were temporally associated with COVID-19 but presumed to have developed 2-4 weeks after acute COVID-19; all children had serologic evidence of infection with SARS-CoV-2, the virus that causes COVID-19 (1). The clinical signs and symptoms present in this first cluster included fever, rash, conjunctivitis, peripheral edema, gastrointestinal symptoms, shock, and elevated markers of inflammation and cardiac damage (1). On May 14, 2020, CDC published an online Health Advisory that summarized the manifestations of reported multisystem inflammatory syndrome in children (MIS-C), outlined a case definition,† and asked clinicians to report suspected U.S. cases to local and state health departments. As of July 29, a total of 570 U.S. MIS-C patients who met the case definition had been reported to CDC. A total of 203 (35.6%) of the patients had a clinical course consistent with previously published MIS-C reports, characterized predominantly by shock, cardiac dysfunction, abdominal pain, and markedly elevated inflammatory markers, and almost all had positive SARS-CoV-2 test results. The remaining 367 (64.4%) of MIS-C patients had manifestations that appeared to overlap with acute COVID-19 (2-4), had a less severe clinical course, or had features of Kawasaki disease.§ Median duration of hospitalization was 6 days; 364 patients (63.9%) required care in an intensive care unit (ICU), and 10 patients (1.8%) died. As the COVID-19 pandemic continues to expand in many jurisdictions, clinicians should be aware of the signs and symptoms of MIS-C and report suspected cases to their state or local health departments; analysis of reported cases can enhance understanding of MIS-C and improve characterization of the illness for early detection and treatment.

During January 1, 2020-May 18, 2020, approximately 1.3 million cases of coronavirus disease 2019 (COVID-19) and 83,000 COVID-19-associated deaths were reported in the United States (1). Understanding the demographic and clinical characteristics of decedents could inform medical and public health interventions focused on preventing COVID-19-associated mortality. This report describes decedents with laboratory-confirmed infection with SARS-CoV-2, the virus that causes COVID-19, using data from 1) the standardized CDC case-report form (case-based surveillance) (https://www.cdc.gov/coronavirus/2019-ncov/php/reporting-pui.html) and 2) supplementary data (supplemental surveillance), such as underlying medical conditions and location of death, obtained through collaboration between CDC and 16 public health jurisdictions (15 states and New York City).

Background A multisystem inflammatory syndrome in children (MIS-C) is associated with coronavirus disease 2019. The New York State Department of Health (NYSDOH) established active, statewide surveillance to describe hospitalized patients with the syndrome. Methods Hospitals in New York State reported cases of Kawasaki’s disease, toxic shock syndrome, myocarditis, and potential MIS-C in hospitalized patients younger than 21 years of age and sent medical records to the NYSDOH. We carried out descriptive analyses that summarized the clinical presentation, complications, and outcomes of patients who met the NYSDOH case definition for MIS-C between March 1 and May 10, 2020. Results As of May 10, 2020, a total of 191 potential cases were reported to the NYSDOH. Of 95 patients with confirmed MIS-C (laboratory-confirmed acute or recent severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] infection) and 4 with suspected MIS-C (met clinical and epidemiologic criteria), 53 (54%) were male; 31 of 78 (40%) were black, and 31 of 85 (36%) were Hispanic. A total of 31 patients (31%) were 0 to 5 years of age, 42 (42%) were 6 to 12 years of age, and 26 (26%) were 13 to 20 years of age. All presented with subjective fever or chills; 97% had tachycardia, 80% had gastrointestinal symptoms, 60% had rash, 56% had conjunctival injection, and 27% had mucosal changes. Elevated levels of C-reactive protein, d-dimer, and troponin were found in 100%, 91%, and 71% of the patients, respectively; 62% received vasopressor support, 53% had evidence of myocarditis, 80% were admitted to an intensive care unit, and 2 died. The median length of hospital stay was 6 days. Conclusions The emergence of multisystem inflammatory syndrome in children in New York State coincided with widespread SARS-CoV-2 transmission; this hyperinflammatory syndrome with dermatologic, mucocutaneous, and gastrointestinal manifestations was associated with cardiac dysfunction.

Background As of January 7, 2020, a total of 2558 hospitalized patients with nonfatal cases and 60 patients with fatal cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) had been reported to the Centers for Disease Control and Prevention (CDC). Methods In a national study, we compared the characteristics of patients with fatal cases of EVALI with those of patients with nonfatal cases to improve the ability of clinicians to identify patients at increased risk for death from the condition. Health departments reported cases of EVALI to the CDC and included, when available, data from medical-record abstractions and patient interviews. Analyses included all the patients with fatal or nonfatal cases of EVALI that were reported to the CDC as of January 7, 2020. We also present three case reports of patients who died from EVALI to illustrate the clinical characteristics common among such patients. Results Most of the patients with fatal or nonfatal cases of EVALI were male (32 of 60 [53%] and 1666 of 2498 [67%], respectively). The proportion of patients with fatal or nonfatal cases was higher among those who were non-Hispanic white (39 of 49 [80%] and 1104 of 1818 [61%], respectively) than among those in other race or ethnic groups. The proportion of patients with fatal cases was higher among those 35 years of age or older (44 of 60 [73%]) than among those younger than 35 years, but the proportion with nonfatal cases was lower among those 35 years of age or older (551 of 2514 [22%]). Among the patients who had an available medical history, a higher proportion of those with fatal cases than those with nonfatal cases had a history of asthma (13 of 57 [23%] vs. 102 of 1297 [8%]), cardiac disease (26 of 55 [47%] vs. 115 of 1169 [10%]), or a mental health condition (32 of 49 [65%] vs. 575 of 1398 [41%]). A total of 26 of 50 patients (52%) with fatal cases had obesity. Half the patients with fatal cases (25 of 54 [46%]) were seen in an outpatient setting before hospitalization or death. Conclusions Chronic conditions, including cardiac and respiratory diseases and mental health conditions, were common among hospitalized patients with EVALI.

INTRODUCTION The role of screening and treatment for abnormal vaginal flora (AVF) on adverse pregnancy outcomes remains unclear. Using data from women who participated in a population-based cluster randomized trial who were screened and treated for AVF, we report risk factors for AVF and association of persistent AVF with adverse perinatal outcomes. MATERIAL AND METHODS Pregnant women (n = 4221)

This study aimed to analyze prenatal human immunodeficiency virus (HIV) testing rates over time and describe the impact of state HIV testing laws on prenatal testing.During 2004-2011, self-reported prenatal HIV testing data for women with live births in 35 states and New York City were collected. Prevalence of testing was estimated overall and by state and year. An annual percent change was calculated in states with at least 6 years of data to analyze testing changes over time. An attorney-coder used WestlawNext to identify states with laws that direct prenatal care providers to screen all pregnant women or direct all women to be tested for HIV and document changes in laws to meet this threshold.The overall prenatal HIV testing rate for 2004 through 2011 combined was 75.7%. State-level data showed a wide range of testing rates (43.2%-92.8%) for 2004 through 2011 combined. In areas with 6 years of data, 4 experienced an annual drop in testing (Alaska, Arkansas, Colorado, and Illinois). States that changed laws to meet the threshold generally had the highest testing rates, averaging 80%, followed by states with a preexisting law, at approximately 70%. States with no law, or no law meeting the threshold, had an average prenatal testing rate of 65%.Prenatal HIV testing remained stable between 2004 and 2011 but remained below universal recommendations. Testing varied widely across states and was generally higher in areas that changed their laws to meet the threshold or had preexisting prenatal HIV testing laws, compared with those with no or limited prenatal HIV testing language.

The Centers for Disease Control and Prevention and the American Congress of Obstetricians and Gynecologists recommend universal prenatal HIV testing to prevent perinatal HIV transmission in the U.S.; since the 1990s perinatal HIV transmission has declined. In 2006, 74% of women with a recent live birth reported testing for HIV prenatally or at delivery. We used Pregnancy Risk Assessment Monitoring System data from 36 states and New York City from 2004 to 2013 (N = 387,424) to assess characteristics associated with lack of self-reported testing and state-to-state variability in these associations. Overall, 75.2% (95% confidence interval [CI] 75.0–75.5) of women with a recent live birth reported an HIV test. There were significant differences in testing prevalence by state, ranging from 91.8% (95% CI 91.0–92.6) in New York to 42.3% (95% CI 41.7–43.5) in Utah. In adjusted analysis, characteristics associated with no reported testing included being married, white, non-Hispanic, multiparous, not smoking during pregnancy, and having neither Medicaid nor Special Supplemental Nutritional Program for Women, Infants, and Children. White married women were 57% (adjusted prevalence ratio [aPR] 1.57, 95% CI 1.52–1.63) more likely to report no test compared to white unmarried women. Multiparous married women were 57% (aPR 1.57, 95% CI 1.51–1.64) more likely to report no test compared to multiparous unmarried women. Women who were married, white, non-Hispanic, and multiparous women were 23% less likely to be tested than other women combined. Marital status was significantly associated with lower prevalence of testing in 35 of the 37 reporting areas, and race was significant in 30 of 35 states with race information. The prevalence of reported HIV testing during pregnancy or at delivery remains below 80%. Opportunities exist to increase HIV testing among pregnant women, particularly among certain subpopulations.

Teen* childbearing (one or more live births before age 20 years) can have negative health, social, and economic consequences for mothers and their children (1). Repeat teen births (two or more live births before age 20 years) can constrain the mother's ability to take advantage of educational and workforce opportunities (2), and are more likely to be preterm or of low birthweight than first teen births (3). Despite the historic decline in the U.S. teen birth rate during 1991-2015, from 61.8 to 22.3 births per 1,000 females aged 15-19 years (4), many teens continue to have repeat births (3). The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics both recommend that clinicians counsel women (including teens) during prenatal care about birth spacing and postpartum contraceptive use (5), including the safety and effectiveness of long-acting reversible methods that can be initiated immediately postpartum. To expand upon prior research assessing patterns and trends in repeat childbearing and postpartum contraceptive use among teens with a recent live birth (i.e., 2-6 months after delivery) (3), CDC analyzed data from the National Vital Statistics System natality files (2004 and 2015) and the Pregnancy Risk Assessment Monitoring System (PRAMS; 2004-2013). The number and proportion of teen births that were repeat births decreased from 2004 (82,997; 20.1%) to 2015 (38,324; 16.7%); in 2015, the percentage of teen births that were repeat births varied by state from 10.6% to 21.4%. Among sexually active teens with a recent live birth, postpartum use of the most effective contraceptive methods (intrauterine devices and contraceptive implants) increased from 5.3% in 2004 to 25.3% in 2013; however, in 2013, approximately one in three reported using either a least effective method (15.7%) or no method (17.2%). Strategies that comprehensively address the social and health care needs of teen parents can facilitate access to and use of effective methods of contraception and help prevent repeat teen births.

Importance Increased use of long-acting reversible contraception (LARC; intrauterine devices [IUDs] and implants) has likely contributed to declining US teenage pregnancy and birth rates, yet sexually transmitted infection (STI) rates among teenagers remain high. While LARC methods are highly effective for pregnancy prevention, they, as with all nonbarrier methods, do not protect against STIs, including HIV. Studies of the general adolescent population suggest condom use is lower among LARC vs non-LARC hormonal methods users (birth control pill, contraceptive patch, vaginal ring, or injection). Despite the high use of LARC among postpartum teenagers, no studies have examined whether condom use differs by contraceptive method in this population. Objective To compare condom use among sexually active postpartum teenagers using LARC vs those using non-LARC hormonal methods. Design, Setting, and Participants Cross-sectional analysis using 2012 to 2015 data from the Pregnancy Risk Assessment Monitoring System (PRAMS), a multisite and population-based surveillance system that collects data on maternal attitudes, behaviors, and experiences before, during, and shortly after pregnancy. We used data from 37 sites. Using multivariable survey-weighted logistic regression, we assessed the association of condom use by contraceptive methods. Participants were teenage mothers (≤19 years) with a recent live birth reporting LARC or non-LARC hormonal method use. Data were analyzed between March 2018 and April 2018. Main Outcomes and Measures Condom use with LARC vs condom use with non-LARC hormonal methods. Results Among the 5480 (weighted N = 245 847) postpartum teenage mothers in our sample, most were aged 18 to 19 years, unmarried, had current Medicaid coverage, were first-time mothers, had reported their pregnancy was unintended, and almost half were non-Hispanic white. Overall, condom use was reported by 28.8% of these teenagers. Users of LARC compared with non-LARC hormonal methods were half as likely to use condoms (17.8% vs 35.6%; adjusted prevalence ratio [aPR], 0.50; 95% CI, 0.41-0.60). Users of IUDs (15.1%) were less likely to report condom use than those using an implant (21.5%; aPR, 0.70; 95% CI, 0.51-0.98), patch, ring, or injection users (24.9%; aPR, 0.61; 95% CI, 0.47-0.79), and pill users (47.2%; aPR, 0.32; 95% CI, 0.25-0.40). Conclusions and Relevance Self-reported condom use was low overall among postpartum teenage mothers and lower among users of LARC vs non-LARC hormonal methods. Given the high rates of STIs among teenage mothers combined with higher use of LARC among postpartum teenaged mothers, interventions to promote condom use for STI/HIV prevention during the postpartum period are critically important.

BACKGROUND Early antiretroviral therapy (ART) initiation in HIV-infected infants significantly improves survival but is often delayed in resource-limited settings. Adding HIV testing of infants at birth to the current recommendation of testing at age 4-6 weeks may improve testing rates and decrease time to ART initiation. We modeled the benefit of adding HIV testing at birth to the current 6-week testing algorithm. METHODS Microsoft Excel was used to create a decision-tree model of the care continuum for the estimated 1,400,000 HIV-infected women and their infants in sub-Saharan Africa in 2012. The model assumed average published rates for facility births (42.9%), prevention of mother-to-child HIV transmission utilization (63%), mother-to-child-transmission rates based on prevention of mother-to-child HIV transmission regimen (5%-40%), return of test results (41%), enrollment in HIV care (52%), and ART initiation (54%). We conducted sensitivity analyses to model the impact of key variables and applied the model to specific country examples. RESULTS Adding HIV testing at birth would increase the number of infants on ART by 204% by age 18 months. The greatest increase is seen in early ART initiations (543% by age 3 months). The increase would lead to a corresponding increase in survival at 12 months of age, with 5108 fewer infant deaths (44,550, versus 49,658). CONCLUSION Adding HIV testing at birth has the potential to improve the number and timing of ART initiation of HIV-infected infants, leading to a decrease in infant mortality. Using this model, countries should investigate a combination of HIV testing at birth and during the early infant period.

Teen childbearing can have negative health, economic, and social consequences for mothers and their children (1) and costs the United States approximately $9.4 billion annually (2). During 1991-2014, the birth rate among teens aged 15-19 years in the United States declined 61%, from 61.8 to 24.2 births per 1,000, the lowest rate ever recorded (3). Nonetheless, in 2014, the teen birth rate remained approximately twice as high for Hispanic and non-Hispanic black (black) teens compared with non-Hispanic white (white) teens (3), and geographic and socioeconomic disparities remain (3,4), irrespective of race/ethnicity. Social determinants associated with teen childbearing (e.g., low parental educational attainment and limited opportunities for education and employment) are more common in communities with higher proportions of racial and ethnic minorities (4), contributing to the challenge of further reducing disparities in teen births. To examine trends in births for teens aged 15-19 years by race/ethnicity and geography, CDC analyzed National Vital Statistics System (NVSS) data at the national (2006-2014), state (2006-2007 and 2013-2014), and county (2013-2014) levels. To describe socioeconomic indicators previously associated with teen births, CDC analyzed data from the American Community Survey (ACS) (2010-2014). Nationally, from 2006 to 2014, the teen birth rate declined 41% overall with the largest decline occurring among Hispanics (51%), followed by blacks (44%), and whites (35%). The birth rate ratio for Hispanic teens and black teens compared with white teens declined from 2.9 to 2.2 and from 2.3 to 2.0, respectively. From 2006-2007 to 2013-2014, significant declines in teen birth rates and birth rate ratios were noted nationally and in many states. At the county level, teen birth rates for 2013-2014 ranged from 3.1 to 119.0 per 1,000 females aged 15-19 years; ACS data indicated unemployment was higher, and education attainment and family income were lower in counties with higher teen birth rates. State and county data can be used to understand disparities in teen births and implement community-level interventions that address the social and structural conditions associated with high teen birth rates.

OBJECTIVES: With this study, we explore communication about consistent and correct condom use among African American and Latino male adolescents ages 15 to 19 and their fathers. METHODS: Twenty-five father-son dyads completed semistructured interviews designed to elicit specific preferences for teaching and learning about consistent and correct condom use and strategies for addressing common condom use errors and problems. For analysis, we used in vivo coding and vertical and horizontal analysis techniques. RESULTS: Fathers and sons agreed that communication about condom use is feasible and acceptable. However, fathers tended to convey vague messages regarding protecting oneself from the negative consequences of sexual activity. Furthermore, both fathers and sons reported barriers hindering conversations. Secondly, the style and frequency of condom use conversations can help overcome barriers and support father-son relationship management. Talking frequently in 1-on-1 settings and using strategies to reduce discomfort made communication easier. Lastly, fathers and sons reported distinct preferences for teaching and learning about condom use. Sons wanted fathers to give specific guidance on the use and management of condoms. Fathers expressed interest in opportunities for improving their own condom knowledge and skills. Fathers identified gaps in their own condom use knowledge as a limitation to effective instruction of their sons. CONCLUSIONS: A father-focused communication intervention about condom use is feasible and acceptable. Enhancing the intergenerational benefits of father-son communication by addressing specific father-son preferences and learning needs for condom use instruction, as well as communication barriers, represents a novel mechanism for reducing male sexual reproductive health disparities.

Background: In 2012, Rwanda introduced a Treat All approach for HIV-infected children younger than 5 years. We compared antiretroviral therapy (ART) initiation, outcomes, and retention, before and after this change. Methods: We conducted a retrospective study of children enrolled into care between June 2009 and December 2011 [Before Treat All (BTA) cohort] and between July 2012 and April 2015 [Treat All (TA) cohort]. Setting: Medical records of a nationally representative sample were abstracted for all eligible aged 18–60 months from 100 Rwandan public health facilities. Results: We abstracted 374 medical records: 227 in the BTA and 147 in the TA cohorts. Mean (SD) age at enrollment was [3 years (1.1)]. Among BTA, 59% initiated ART within 1 year, vs. 89% in the TA cohort. Median time to ART initiation was 68 days (interquartile range 14–494) for BTA and 9 days (interquartile range 0–28) for TA (P < 0.0001), with 9 (5%) undergoing same-day initiation in BTA compared with 50 (37%) in TA (P < 0.0001). Before ART initiation, 59% in the BTA reported at least one health condition compared with 35% in the TA cohort (P < 0.0001). Although overall loss to follow-up was similar between cohorts (BTA: 13%, TA: 8%, P = 0.18), loss to follow-up before ART was significantly higher in the BTA (8%) compared with the TA cohort (2%) (P = 0.02). Conclusions: Nearly 90% of Rwandan children started on ART within 1 year of enrollment, most within 1 month, with greater than 90% retention after implementation of TA. TA was also associated with fewer morbidities.

Youth-friendly family planning services may improve youth reproductive health outcomes. A systematic review conducted in 2011 was updated in 2016 to incorporate recent data examining the effects of youth-friendly family planning services on reproductive health outcomes and the facilitators and barriers facing young people in accessing family planning services.PubMed, POPLINE, EMBASE, and other databases were used to identify relevant articles published from March 2011 through April 2016.Eighteen studies met inclusion criteria and were added to 19 studies from the review conducted in 2011. Of these, seven assessed the effect of youth-friendly services on outcomes: two showed a positive effect on reducing teen pregnancy, three on contraceptive use, and three on knowledge and patient satisfaction (not mutually exclusive). Facilitators or barriers were described in 32 studies. However, none were RCTs and most were at high risk for bias due to selection, self-report, and recall bias among others.The studies in this review suggest some positive effects of youth-friendly family planning services on reproductive health outcomes, but the need for more rigorous research persists. This review identified numerous factors relevant to young people's access to family planning services, reaffirming findings from the initial review: young people value confidentiality, supportive provider interaction, specialized provider training, and the removal of logistic barriers. Further, it illuminates the importance young people place on receiving comprehensive, client-centered family planning counseling. These findings should be considered when developing, implementing, and evaluating reproductive health services for young people.This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Purpose Despite recent declines, teen unintended pregnancy and sexually transmitted infections in the United States remain at levels higher than comparable nations. Initiatives to prevent teen pregnancy have focused primarily on female adolescents; how to effectively engage young men to reduce their risk of fathering a teen pregnancy has not been well studied. We proposed to adapt an innovative computer-assisted motivational interviewing (CAMI) intervention, originally designed and tested with young women, for use with young men, aged 15–24 years, to reduce their risk of fathering a teen pregnancy. This manuscript describes the design of a CAMI intervention for young men aimed at preventing teen pregnancy and improving fitness. Methods This randomized controlled trial will recruit 945 sexually active young men between the ages of 15 and 24 years from three health centers in New York City. Participants will be assigned by permuted block randomization to two study arms: one aimed at reducing involvement in unintended teen pregnancy (CAMI-teen pregnancy prevention) and the other at improving overall fitness (CAMI-Fitness). Except for topic, both intervention arms will provide four sessions of Motivational Interviewing coaching and use a mobile app to track behavior and set goals. We will assess young men's sexual and reproductive health behaviors and fitness at baseline, 12, 24, 36, and 64 weeks using a mobile device app created for the study. Results Pending ongoing study. Conclusions Results from the study are expected to enhance our understanding of the efficacy of CAMI to enhance young men's reproductive health and fitness behaviors.

Addressing and enabling the role of males in contraceptive choices may facilitate efforts to reduce unintended pregnancy rates and disparities in the United States, but little is known about males’ ability to report their partners’ contraceptive use. Data from the 2011-2013 National Survey of Family Growth from 2,238 males aged 15 to 44 years who had vaginal sex with a noncohabiting or nonmarital partner and were not seeking pregnancy were examined to tabulate the proportion of males able to report whether their partner used a specific contraceptive method use at last sex (PCM) by sociodemographic and sexual history characteristics. Logistic regression was used to assess odds of being unable to report PCM, adjusting for age and sexual history factors. Most (95.0%) were able to report PCM, with no difference by age group (chi-square = 7.27, p = .281) in unadjusted analyses. Males with a new sex partner (14.8% of the sample), compared with those with an established sex partner, had significantly higher odds of being unable to report PCM in bivariate (11.7% vs. 3.7%, chi-square = 39.39, p < .001) and multivariable (adjusted odds ratio [AOR]: 3.17, 95% confidence interval [CI: 1.74, 5.65]) analyses. Those whose last sexual encounter was more than 3 months ago also had higher odds of being unable to report in bivariate ( OR: 1.74, 95% CI [1.05, 2.87]) and multivariable analyses (AOR: 2.04, 95% CI [1.04, 4.03]). Most men were able report PCM, but reporting was significantly lower among men with new sex partners. To inform future research and evaluation relying on male report, validation studies comparing male report with partner report, specifically among new couples, are needed.

Didanosine (ddI) is a nucleoside reverse transcriptase inhibitor associated with adverse events and public health concerns which have diminished its place in HIV clinical practice, particularly in resource-rich settings. While international guidelines do not contain ddI-containing regimens in preferred first- or second-line antiretroviral therapy (ART), there is no guidance for management of patients currently on ddI. In 2012 at least 20 countries purchased a total of $1–2 million of ddI. Drug purchase data in that year show 3.2–10.3 times higher costs for ddI compared to lamivudine (3TC). Given issues of multiple toxicities, monitoring, drug interactions, inconvenience, and virologic efficacy, as well as cost and formulary concerns, national (including resource-limited setting) ART programmes should consider complete phase-out of ddI.

Among 1,683 persons in the United States who developed malaria following international travel during 2012, more than half acquired disease in one of 16 countries in West Africa. Since March 2014, West Africa has experienced the world's largest epidemic of Ebola virus disease (Ebola), primarily affecting Guinea, Sierra Leone, and Liberia; in 2014, approximately 20,000 Ebola cases were reported. Both Ebola and malaria are often characterized by fever and malaise and can be clinically indistinguishable, especially early in the course of disease. Immediate laboratory testing is critical for diagnosis of both Ebola and malaria, so that appropriate lifesaving treatment can be initiated. CDC recommends prompt malaria testing of patients with fever and history of travel to an area that is endemic for malaria, using blood smear microscopy, with results available within a few hours. Empiric treatment of malaria is not recommended by CDC. Reverse transcription-polymerase chain reaction (RT-PCR) testing is recommended to diagnose Ebola. During the Ebola outbreak in West Africa, CDC received reports of delayed laboratory testing for malaria in travelers returning to the United States because of infection control concerns related to Ebola. CDC reviewed documented calls to its malaria consultation service and selected three patient cases to present as examples of deficiencies in the evaluation and treatment of malaria among travelers returning from Africa during the Ebola epidemic.

Quantitative plasma viral load (VL) at 1000 copies /mL was recommended as the threshold to confirm antiretroviral therapy (ART) failure by the World Health Organization (WHO). Because of ongoing challenges of using plasma for VL testing in resource-limited settings (RLS), especially for children, this study collected 717 DBS and paired plasma samples from children receiving ART ≥1 year in Mozambique and compared the performance of DBS using Abbott’s VL test with a paired plasma sample using Roche’s VL test. At a cut-off of 1000 copies/mL, sensitivity of DBS using Abbott DBS VL test was 79.9%, better than 71.0% and 63.9% at 3000 and 5000 copies/mL, respectively. Specificities were 97.6%, 98.8%, 99.3% at 1000, 3000, and 5000 copies/mL, respectively. The Kappa value at 1000 copies/mL, 0.80 (95% CI: 0.73, 0.87), was higher than 0.73 (95% CI: 0.66, 0.80) and 0.66 (95% CI: 0.59, 0.73) at 3000, 5000 copies/mL, respectively, also indicating better agreement. The mean difference between the DBS and plasma VL tests with 95% limits of agreement by Bland-Altman was 0.311 (-0.908, 1.530). Among 73 children with plasma VL between 1000 to 5000 copies/mL, the DBS results were undetectable in 53 at the 1000 copies/mL threshold. While one DBS sample in the Abbott DBS VL test may be an alternative method to confirm ART failure at 1000 copies/mL threshold when a plasma sample is not an option for treatment monitoring, because of sensitivity concerns between 1,000 and 5,000 copies/ml, two DBS samples may be preferred accompanied by careful patient monitoring and repeat testing.

Seeking to reduce teen pregnancy and births in communities with rates above the national average, the Centers for Disease Control and Prevention, in partnership with the U.S. Department of Health and Human Services Office of Adolescent Health Teen Pregnancy Prevention Program, developed a joint funding opportunity through which grantees worked to implement and test an approach involving community-wide teen pregnancy prevention initiatives. Once these projects had been in the field for 2.5 years, Centers for Disease Control and Prevention staff developed plans for a supplemental issue of the Journal of Adolescent Health to present findings from and lessons learned during implementation of the community-wide initiatives. When the articles included in the supplemental issue are considered together, common themes emerge, particularly those related to initiating, building, and maintaining strong partnerships. Themes seen across articles include the importance of (1) sharing local data with partners to advance initiative implementation, (2) defining partner roles from the beginning of the initiatives, (3) developing teams that include community partners to provide direction to the initiatives, and (4) addressing challenges to maintaining strong partnerships including partner staff turnover and delays in implementation.