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INTRODUCTION: Exposure to unfavorable environmental conditions during pregnancy, such as extreme heat and air pollution, has been linked to increased risk of stillbirth, defined as fetal mortality at or after 20 weeks gestation, however no studies have examined its association with social vulnerability. We examined associations between county-level stillbirth rates, environmental risk factors for stillbirth, and social vulnerability in the United States. METHODS: This ecologic study linked county-level data from three nationwide datasets on stillbirths (National Vital Statistics System), environmental conditions (North American Land Data Assimilation System and Environmental Protection Agency), and social vulnerability (Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Social Vulnerability Index). Poisson and negative binomial models were fit to the variables and produced rate ratios to estimate associations among stillbirth rates, environmental risk factors, and social vulnerability. RESULTS: Social vulnerability was positively associated withn stillbirth rates, annual average number of extreme heat days, and ambient concentration of particulate matter ≤ 2.5 μm in diameter (PM2.5). The average number of days that ozone and PM2.5 each exceeded regulatory standards were not associated with stillbirth rates or social vulnerability. A positive association between average annual PM2.5 concentration and stillbirth rates was detected; no other significant associations between environmental risk factors and stillbirth rates were observed. DISCUSSION: We found evidence of associations between social vulnerability and stillbirth rates, and between social vulnerability and environmental risk factors for stillbirth at the county level. Further research could inform understanding of how social vulnerability impacts the relationship between environmental exposures and stillbirth risk.

Background: Universal masking, with additional layered prevention strategies, was an essential tool for limiting the transmission of SARS-CoV-2 and ensuring a safe return to in-person learning for kindergarten through 12th grade (K-12) students and staff. Few studies have examined mask adherence in this setting and none have described types of masks worn or locations of mask adherence. This project sought to assess mask adherence, types worn, and location of mask adherence in K-12 settings. Methods: This study used direct in-person observations to measure the proportion of persons wearing masks correctly; type of masks worn; and location of mask adherence in 19 K-12 schools in Georgia. Results: A total of 16,222 observations were conducted. Among those observed, 85.2% wore masks, with 80.3% wearing the mask correctly. Persons in high school were less likely to wear masks correctly. Correct mask use was most often observed among persons wearing N95-type masks. The prevalence of persons wearing masks correctly in transitional spaces was 5% higher than in congregate spaces. Conclusion: In K-12 schools with a universal masking policy, correct mask adherence was high among individuals. Examining adherence to recommended prevention measures can provide K-12 schools feedback to inform targeted messaging and policies during future disease outbreaks.

School nurses are integral to creating safe environments in U.S. schools. Many experienced increased work burden and stress during the COVID-19 pandemic. CDC collaborated with the National Association of School Nurses and the National Association of State School Nurse Consultants to distribute a 121-item online, anonymous survey to school nurses nationwide during March 7-30, 2022. Among the 7,971 respondents, symptoms of depression, anxiety and PTSD, and suicidal ideation were measured, and prevalence ratios were used to identify associations with demographics, workplace characteristics, and support. Results found high levels of work-related stressors and indicated that employment characteristics, COVID-19-related job duties, and other workplace stressors and supports affected school nurse mental health. The survey findings underscore the mental health challenges many school nurses experienced during the 2021/2022 school year. The findings can inform supportive policies and practices to reduce workplace stressors and increase workplace supports for school nurses.

Objective: Despite widespread availability of COVID-19 vaccines, millions of Americans have not received the recommended vaccine doses. In the District of Columbia (DC), COVID-19 vaccination rates are lowest among residents who are Non-Hispanic (NH) Black and among school-aged children. We assessed COVID-19 vaccine hesitancy among staff and parents of students in DC K-12 public and public charter schools. Methods: We conducted a telephone-based survey from February 6 to April 16, 2022 to staff, students, and parents of students who participated in school-based COVID-19 screening testing. COVID-19-related survey items included: vaccination status, reasons for not getting vaccinated, perceived vaccine access, and trusted COVID-19 information sources. Utilizing time-to-event analyses, we evaluated differences across demographic groups. Results: The interview response rate was 25.8% (308/1193). Most unvaccinated participants were NH Black and ages 5 to 11 years. Median time from vaccine eligibility to uptake was 236 days for NH Black participants vs. 10 days for NH White participants. Vaccine safety was the top concern among unvaccinated participants. Government and healthcare providers were the most trusted COVID-19 information sources. Conclusions: Differences in timing of vaccine uptake among respondents and greater vaccine hesitancy among NH Black participants compared to other racial/ethnic groups highlight a need for continued tailored outreach and communication using trusted sources to convey the importance, benefits, and safety of COVID-19 vaccination.

U.S. national and state population-based estimates of adults living with autism spectrum disorder (ASD) are nonexistent due to the lack of existing surveillance systems funded to address this need. Therefore, we estimated national and state prevalence of adults 18-84 years living with ASD using simulation in conjunction with Bayesian hierarchal models. In 2017, we estimated that approximately 2.21% (95% simulation interval (SI) 1.95%, 2.45%) or 5,437,988 U.S. adults aged 18 and older have ASD, with state prevalence ranging from 1.97% (95% SI 1.55%, 2.45%) in Louisiana to 2.42% (95% SI 1.93%, 2.99%) in Massachusetts. Prevalence and case estimates of adults living with ASD (diagnosed and undiagnosed) can help states estimate the need for diagnosing and providing services to those unidentified.

We sought to integrate a brief computer and counseling support intervention into the routine practices of HIV clinics and evaluate effects on patients' viral loads. The project targeted HIV patients in care whose viral loads exceeded 1000 copies/ml at the time of recruitment. Three HIV clinics initiated the intervention immediately, and three other HIV clinics delayed onset for 16 months and served as concurrent controls for evaluating outcomes. The intervention components included a brief computer-based intervention (CBI) focused on antiretroviral therapy adherence; health coaching from project counselors for participants whose viral loads did not improve after doing the CBI; and behavioral screening and palm cards with empowering messages available to all patients at intervention clinics regardless of viral load level. The analytic cohort included 982 patients at intervention clinics and 946 patients at control clinics. Viral loads were assessed at 270 days before recruitment, at time of recruitment, and +270 days later. Results indicated that both the control and intervention groups had significant reductions in viral load, ending with approximately the same viral level at +270 days. There was no evidence that the CBI or the targeted health coaching was responsible for the viral reduction in the intervention group. Results may stem partially from statistical regression to the mean in both groups. Also, clinical providers at control and intervention clinics may have taken action (e.g., conversations with patients, referrals to case managers, adherence counselors, mental health, substance use specialists) to help their patients reduce their viral loads. In conclusion, neither a brief computer-based nor targeted health coaching intervention reduced patients' viral loads beyond levels achieved with standard of care services available to patients at well-resourced HIV clinics.

This article describes novel methods of applying the Ages and Stages Questionnaire--3rd edition (ASQ-3) to assess and quantify developmental delay among children following the 2015-2016 Zika virus outbreak in Brazil. Many of the children with Zika virus infection were expected to have severe developmental delay. However, administering the ASQ-3 to caregivers of these children according to standard protocol would have screened for the overall presence of delay but not the severity of delay. We adopted an amended protocol for administration of the ASQ-3 to quantify the developmental functioning of children severely affected by Zika virus infection in this investigation. Protocols for administering the ASQ-3 among this population were drafted in consultation with developmental measurement experts and are presented here. Specific developmental estimates are discussed, including developmental age equivalents, developmental quotients, and developmental quotient z scores. The calculations of these estimates are presented with examples in the context of the 2015-2016 Zika virus outbreak and associated microcephaly among prenatally infected children from 2 states in northeastern Brazil. Potential applications of these methods for estimating developmental ability among similar pediatric populations are discussed.

Background: Folate and vitamin B12 deficiencies in pregnant women are associated with increased risk for adverse maternal and infant health outcomes, including neural tube defects (NTDs). Methods: A population‐based cross‐sectional survey was conducted in two rural areas in Ambala District, Haryana, India in 2017 to assess baseline folate and vitamin B12 status among women of reproductive age (WRA) and predict the prevalence of NTDs. We calculated the prevalence of folate and vitamin B12 deficiency and insufficiency by demographic characteristics among 775 non‐pregnant, non‐lactating WRA (18–49 years). Using red blood cell (RBC) folate distributions and an established Bayesian model, we predicted NTD prevalence. All analyses were conducted using SAS‐callable SUDAAN Version 11.0.4 to account for complex survey design. Results: Among WRA, 10.1% (95% CI: 7.9, 12.7) and 9.3% (95% CI: 7.4, 11.6) had serum (<7 nmol/L) and RBC folate (<305 nmol/L) deficiency, respectively. The prevalence of RBC folate insufficiency (<748 nmol/L) was 78.3% (95% CI: 75.0, 81.3) and the predicted NTD prevalence was 21.0 (95% uncertainly interval: 16.9, 25.9) per 10,000 live births. Prevalences of vitamin B12 deficiency (<200 pg/mL) and marginal deficiency (≥200 pg/mL and ≤300 pg/mL) were 57.7% (95% CI: 53.9, 61.4) and 23.5% (95% CI: 20.4, 26.9), respectively. Conclusions: The magnitude of folate insufficiency and vitamin B12 deficiency in this Northern Indian population is a substantial public health concern. The findings from the survey help establish the baseline against which results from future post‐fortification surveys can be compared. [ABSTRACT FROM AUTHOR]

This paper examines the effects of attended and unattended demonstratives on text processing, comprehension, and writing quality in two studies. In the first study, participants (n = 45) read 64 mini-stories in a self-paced reading task and identified the main referent in the clauses. The sentences varied in the type of demonstratives (i.e., this, that, these, and those) contained in the sentences and whether the referent was followed by a demonstrative determiner and noun (i.e., an attended demonstrative) or a demonstrative pronoun (i.e., an unattended demonstrative). In the second study, 173 persuasive essays written by high school students were rated by expert judges on overall writing quality using a standardized rubric. Expert coders manually counted the number and types of demonstratives (attended and unattended demonstratives) in each essay. These counts were used to predict the human scores of essay quality. The findings demonstrate that the use of unattended demonstratives as anaphoric references is disadvantageous to both reading time and referent identification. However, these disadvantages become advantages in terms of essay quality likely because linguistic complexity is a strong indicator of high proficiency writing. From a text processing and comprehension viewpoint, the findings indicate, then, that anaphoric reference is not always beneficial and does not always create a more cohesive text. In contrast, from a writing context, the use of unattended demonstratives leads to a more linguistically complex text, which generally equates to a higher quality text.