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DSHS Authors: 2021 Research Articles by DSHS Staff

The following list includes peer-reviewed research articles that have been written by staff of the Texas Department of State Health Services. For more information about these articles or for a full-text copy, please contact the Medical and Research Library by email at library@dshs.texas.gov by calling 512-776-7559.

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2021 Articles (in date order with most recent first)

Pont SJ, Shuford JA, et al. Strategies to estimate prevalence of SARS-CoV-2 antibodies in a Texas vulnerable population: Results from Phase I of the Texas Coronavirus Antibody Response Survey. Front Public Health. 2021;9:753487. Published 2021 Dec 14. doi.org/10.3389/fpubh.2021.753487
Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and immunity remains uncertain in populations. The state of Texas ranks 2nd in infection with over 2.71 million cases and has seen a disproportionate rate of death across the state. The Texas CARES project was funded by the state of Texas to estimate the prevalence of SARS-CoV-2 antibody status in children and adults. Identifying strategies to understand natural as well as vaccine induced antibody response to COVID-19 is critical. 
Materials and Methods: The Texas CARES (Texas Coronavirus Antibody Response Survey) is an ongoing prospective population-based convenience sample from the Texas general population that commenced in October 2020. Volunteer participants are recruited across the state to participate in a 3-time point data collection Texas CARES to assess antibody response over time. We use the Roche Elecsys® Anti-SARS-CoV-2 Immunoassay to determine SARS-CoV-2 antibody status.0
Results: The crude antibody positivity prevalence in Phase I was 26.1% (80/307). The fully adjusted seroprevalence of the sample was 31.5%. Specifically, 41.1% of males and 21.9% of females were seropositive. For age categories, 33.5% of those 18-34; 24.4% of those 35-44; 33.2% of those 45-54; and 32.8% of those 55+ were seropositive. In this sample, 42.2% (89/211) of those negative for the antibody test reported having had a COVID-19 test. 
Conclusions: In this survey we enrolled and analyzed data for 307 participants, demonstrating a high survey and antibody test completion rate, and ability to implement a questionnaire and SARS-CoV-2 antibody testing within clinical settings. We were also able to determine our capability to estimate the cross-sectional seroprevalence within Texas's federally qualified community centers (FQHCs). The crude positivity prevalence for SARS-CoV-2 antibodies in this sample was 26.1% indicating potentially high exposure to COVID-19 for clinic employees and patients. Data will also allow us to understand sex, age and chronic illness variation in seroprevalence by natural and vaccine induced. These methods are being used to guide the completion of a large longitudinal survey in the state of Texas with implications for practice and population health.

Hughes MJ, Birhane MG, Dorough L, et al. Extensively drug-resistant typhoid fever in the United States. Open Forum Infect Dis. 2021;8(12):ofab572. Published 2021 Nov 16. doi.org/10.1093/ofid/ofab572
Cases of extensively drug-resistant (XDR) typhoid fever have been reported in the United States among patients who did not travel internationally. Clinicians should consider if and where the patient traveled when selecting empiric treatment for typhoid fever. XDR typhoid fever should be treated with a carbapenem, azithromycin, or both.

Mutebi JP, Godsey M, Rose D, et al. Entomological investigation following a Zika outbreak in Brownsville, Texas. J Am Mosq Control Assoc. 2021;37(4):286-290. doi.org/10.2987/21-6980
In November and December 2016, an outbreak of locally transmitted Zika occurred in Brownsville, TX. The Texas Department of State Health Services requested for a Centers for Disease Control and Prevention (CDC) Epi Aid, and as part of that Epi Aid a team of CDC entomologists was deployed in January 2017. The mission was to improve mosquito-based arbovirus surveillance and evaluate the possibility of continuing local Zika virus (ZIKV) transmission in the city. The mosquito-based arbovirus surveillance program was expanded from 4 to 40 BG-Sentinel traps evenly distributed throughout the city. Over a 2-wk period, 15 mosquito species were detected; the most abundant species were Culex quinquefasciatus, Aedes aegypti, and Ae. albopictus, which accounted for 66.7%, 16.2%, and 5.7% of the total mosquito collection, respectively. The relative abundance of Ae. aegypti (1.0 mosquitoes/trap/day) and Ae. albopictus (0.4 mosquitoes/trap/day) was very low and unlikely to initiate and/or sustain ZIKV transmission. Zika virus was not detected in the mosquitoes collected, suggesting no or extremely low ZIKV transmission at that time.

Wendel KA, Mauk K, Amsterdam L, et al. Enhancing gonococcal antimicrobial resistance surveillance in cisgender women, strengthening the US response to resistant gonorrhea, 2018 to 2019. Sex Transm Dis. 2021;48(12S Suppl 2):S104-S110. doi.org/10.1097/OLQ.0000000000001554
Background: Cisgender women have been underrepresented in antibiotic-resistant gonorrhea (ARGC) surveillance systems. Three of 8 project sites (City of Milwaukee [MIL], Guilford County [GRB], Denver County [DEN]), funded under the Centers for Disease Control and Prevention's Strengthening the US Response to Resistant Gonorrhea (SURRG), focused efforts to better include cisgender women in ARGC surveillance.
Methods: MIL, GRB, and DEN partnered with diverse health care settings and developed gonorrhea culture criteria to facilitate urogenital specimen collection in cisgender women and men. Regional laboratories within the Antibiotic Resistance Laboratory Network performed agar dilution antibiotic susceptibility testing (AST) of gonococcal isolates. Data from 2018 and 2019 were analyzed.
Results: In SURRG, 90.5% (11,464 of 12,667) of the cisgender women from whom urogenital culture specimens were collected were from MIL, GRB, and DEN. Of women in SURRG whose gonococcal isolates underwent AST, 70% were from these 3 sites. In these 3 sites, a substantial proportion of cisgender women with positive urogenital cultures and AST were from health care settings other than sexually transmitted disease (STD) clinics (non-STD clinics; MIL, 56.0%; GRB, 80.4%; and DEN, 23.5%). Isolates with AST were obtained from 5.1%, 10.2%, and 2.4% of all diagnosed gonorrhea cases among cisgender women in MIL, GRB, and DEN, respectively, and were more often susceptible to all antibiotics than those from cisgender men from each of these sites.
Conclusions: With focused efforts and partnerships with non-STD clinics, 3 SURRG sites were able to include robust ARGC surveillance from cisgender women. These findings may guide further efforts to improve gender equity in ARGC surveillance.

Ihongbe TO, Olayinka PO, Curry S. Association between bully victimization and vaping among Texas high school students. Am J Prev Med. 2021;61(6):910-918. doi.org/10.1016/j.amepre.2021.06.004
Introduction: Bullying and vaping among adolescents in Texas is a major public health concern. Bully victimization has been associated with substance use in adolescents; however, research examining the association between bully victimization and vaping in adolescents is sparse. This study aims to examine the independent association between bully victimization and vaping among Texas high school students.
Methods: Pooled data from the 2017 and 2019 Texas Youth Risk Behavior Survey (N=3,486) were analyzed in July 2020. Past-year bully victimization was categorized into 4 mutually exclusive groups: no bully victimization, school bully victimization only, cyberbully victimization only, and both school bully and cyberbully victimization. Current vape use was measured as a binary variable. Multivariable logistic regression was used to examine the association.
Results: In the total sample, the past-year prevalence of school bully victimization only, cyberbully victimization only, and both school bully and cyberbully victimization was 8.3%, 4.6%, and 7.7%, respectively. Approximately 1 in 7 students (14.5%) reported vaping during the past 30 days. Female students who experienced both school bullying and cyberbullying had 68% greater odds of vaping than female students who did not experience bullying (AOR=1.68, 95% CI=1.02, 3.41). Bully victimization was not significantly associated with vaping in male students.
Conclusions: Female Texas high school students who are victims of both school bullying and cyberbullying have a greater likelihood of vaping. Healthcare providers, school counselors, and educators should be aware of the association and sex differences that exist while developing intervention programs to address bullying and vaping in high school students.

Pont SJ, Kolsin J, McCormick DW, et al. Deaths in children and adolescents associated with COVID-19 and MIS-C in the United States. Pediatrics. 2021;148(5):e2021052273. doi.org/10.1542/peds.2021-052273
Objectives: To describe the demographics, clinical characteristics, and hospital course among persons <21 years of age with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated death.
Methods: We conducted a retrospective case series of suspected SARS-CoV-2-associated deaths in the United States in persons <21 years of age during February 12 to July 31, 2020. All states and territories were invited to participate. We abstracted demographic and clinical data, including laboratory and treatment details, from medical records.
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 <21 years of age occurred predominantly among Black (non-Hispanic) and Hispanic persons, male patients, and older adolescents. The most commonly reported underlying conditions were obesity, asthma, and developmental disorders. Decedents with coronavirus disease 2019 were more likely than those with MIS-C to have underlying medical conditions.

Erickson TA, Mayes B, Murray KO, Gunter SM. The epidemiology of human ehrlichiosis in Texas, 2008-2017. Ticks Tick Borne Dis. 2021;12(6):101788. doi.org/10.1016/j.ttbdis.2021.101788
Tick-borne diseases in the United States, including ehrlichiosis, represent a growing public health problem. The purpose of this study was to examine the contemporary epidemiology of human ehrlichiosis in Texas by analyzing cases reported to the Texas Department of State Health Services. In Texas, 101 cases of ehrlichiosis were reported during 2008-2017. We observed geographic grouping of cases as well as an increasing trend of reported cases occurring annually from 2009 to 2017. Notably, 27 cases occurred in 2008 in south Texas with unique patient characteristics in that they were younger, less likely to be hospitalized, and presented with disease earlier in the year than typically seen. Our findings highlight the importance of disease awareness and prevention of tick bites as well as further investigation into transmission risk and future disease patterns.

Washburn DJ, Callaghan T, Schmit C, Thompson E, Martinez D, Lafleur M. Community health worker roles and their evolving interprofessional relationships in the United States [published online ahead of print, 2021 Oct 15]. J Interprof Care. 2021;1-7. doi.org/10.1080/13561820.2021.1974362
In the United States, growing attention to the cost of care, the social determinants of health, prevention, and population health, signals a refocusing f efforts on value-based care. Just as Accountable Care Organizations and alternative payment models exemplify this shift in attention, so does the increasing integration of Community Health Workers (CHWs) into the US health are system. CHWs are often referred to as "bridge figures," helping clients to navigate what are oftentimes complicated pathways to access a variety of needed services. The integration of CHWs into interprofessional care teams is a process that takes time, and can lead to conflict as traditional care models are disrupted. Through focus groups with CHWs in rural and urban areas of four states, this work identifies and describes three early stages in the evolving interprofessional relationships between CHWs and other care providers. These stages are characterized by: (1) a lack of knowledge and understanding of CHW roles, (2) conflict and competition, and (3) engagement and integration of CHWs into patient care teams. A better understanding of the evolving process of CHW integration is critical to facilitate education and training that will more quickly encourage the development and efficacy of modern models of interprofessional care that include CHWs.

Tadese BK, Nutt A, Chaudhary I, Offiong C, Darkoh C. Regional outbreak of multidrug-resistant Klebsiella pneumoniae carbapenemase-producing Pseudomonas Aeruginosa [published online ahead of print, 2021 Oct 1]. Infect Control Hosp Epidemiol. 2021;1-3. doi.org/10.1017/ice.2021.394
Klebsiella pneumoniae carbapenemase-producing P. aeruginosa (KPC-CRPA) are rare in the United States. An outbreak of KPC-CRPA was investigated in Texas using molecular and epidemiologic methods and 17 cases of KPC-CRPA were identified. The isolates were genetically related and harbored the emerging P. aeruginosa multilocus sequence type 235, the first in the United States.

Dunn M, Peterson Johnson E, Smith B, Cooper M, Bhakta N. Perspectives on workforce development needs for community health workers (CHWs): Results from a statewide survey of CHW employers. J Community Health. 2021;46(5):1020-1028. doi.org/10.1007/s10900-021-00986-1
We conducted a survey of community health worker (CHW) employers in Texas to understand the employment context and workforce development needs of Texas CHWs. An electronic, mixed-methods survey was emailed to 841 CHW employers across Texas in Spring 2020. The survey consisted of 51 questions. The response rate was 22% (n = 182). Responses were analyzed using SPSS, Microsoft Excel, and N.Vivo. We found that most CHW employers directly employ their CHWs, and CHWs are typically part of a multidisciplinary healthcare team. Most respondents required their CHWs be certified by the state's health department and have at least a high school diploma or GED. The most common services that CHWs provide are health education/promotion and information referral. The main health issues that CHWs address are diabetes, hypertension, and mental/behavioral health. Current CHW workforce development needs include continued training on topics including chronic disease self-management and health promotion. CHW employers differ in their capacity to implement workforce development activities. There is significant variety in the employment context and workforce development needs of CHWs across Texas. Results reinforce previous findings on the need for specialized, continuing training for CHWs and the development of pathways, resources, and opportunities that could advance the CHW profession even more. These results can inform those interested in employing CHWs in their CHW program development. Findings from this study can be used to guide development of tailored curriculum for continuing education units, specialized certifications, or other professional development resources for CHWs.

Langlois PH, Canfield MA, et al. A comprehensive assessment of co-occurring birth defects among infants with non-syndromic anophthalmia or microphthalmia. Ophthalmic Epidemiol. 2021;28(5):428-435. doi.org/10.1080/09286586.2020.1862244
Purpose: Infants with anophthalmia or microphthalmia frequently have co-occurring birth defects. Nonetheless, there have been few investigations of birth defect patterns among these children. Such studies may identify novel multiple malformation syndromes, which could inform future research into the developmental processes that lead to anophthalmia/microphthalmia and assist physicians in determining whether further testing is appropriate.
Methods: This study includes cases with anophthalmia/microphthalmia identified by the Texas Birth Defects Registry from 1999 to 2014 without clinical or chromosomal diagnoses of recognized syndromes. We calculated adjusted observed-to-expected ratios for two - through five-way birth defect combinations involving anophthalmia/microphthalmia to estimate whether these combinations co-occur more often than would be expected if they were independent. We report combinations observed in ≥5 cases.
Results: We identified 653 eligible cases with anophthalmia/microphthalmia (514 [79%] with co-occurring birth defects), and 111 birth defect combinations, of which 44 were two-way combinations, 61 were three-way combinations, six were four-way combinations and none were five-way combinations. Combinations with the largest observed-to-expected ratios were those involving central nervous system (CNS) defects, head/neck defects, and orofacial clefts. We also observed multiple combinations involving cardiovascular and musculoskeletal defects.
Conclusion: Consistent with previous reports, we observed that a large proportion of children diagnosed with anophthalmia/microphthalmia have co-occurring birth defects. While some of these defects may be part of a sequence involving anophthalmia/microphthalmia (e.g., CNS defects), other combinations could point to as yet undescribed susceptibility patterns (e.g., musculoskeletal defects). Data from population-based birth defect registries may be useful for accelerating the discovery of previously uncharacterized malformation syndromes.

Shuford, JA, Neuman BW, Brashear WA, et al. Case report: Paucisymptomatic college-age population as a reservoir for potentially neutralization-resistant severe acute respiratory syndrome coronavirus 2 variants. Am J Trop Med Hyg. 2021;105(5):1227-1229. Published 2021 Sep 20. doi:10.4269/ajtmh.21-0542
To better understand the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant lineage distribution in a college campus population, we carried out viral genome surveillance over a 7-week period from January to March 2021. Among the sequences were three novel viral variants: BV-1 with a B.1.1.7/20I genetic background and an additional spike mutation Q493R, associated with a mild but longer-than-usual COVID-19 case in a college-age person, BV-2 with a T478K mutation on a 20B genetic background, and BV-3, an apparent recombinant lineage. This work highlights the potential of an undervaccinated younger population as a reservoir for the spread and generation of novel variants. This also demonstrates the value of whole genome sequencing as a routine disease surveillance tool.

Peprah S, Engels EA, Horner MJ, et al. Kaposi sarcoma incidence, burden, and prevalence in United States people with HIV, 2000-2015. Cancer Epidemiol Biomarkers Prev. 2021;30(9):1627-1633. doi:10.1158/1055-9965.EPI-21-0008
Background: The introduction of combination antiretroviral therapy (cART) has led to a significant reduction in Kaposi sarcoma (KS) incidence among people with HIV (PWH). However, it is unclear if incidence has declined similarly across key demographic and HIV transmission groups and the annual number of incident and prevalent KS cases remains unquantified.
Methods: Using population-based registry linkage data, we evaluated temporal trends in KS incidence using adjusted Poisson regression. Incidence and prevalence estimates were applied to CDC HIV surveillance data, to obtain the number of incident (2008-2015) and prevalent (2015) cases in the United States.
Results: Among PWH, KS rates were elevated 521-fold [95% confidence intervals (CI), 498-536] compared with the general population and declined from 109 per 100,000 person-years in 2000 to 47 per 100,000 person-years in 2015, at an annual percentage change of -6%. Rates declined substantially (P trend < 0.005) across all demographic and HIV transmission groups. Of the 5,306 new cases estimated between 2008 and 2015, 89% occurred among men who have sex with men. At the end of 2015, 1,904 PWH (0.20%) had been diagnosed with KS in the previous 5 years.
Conclusions: A consistent gradual decline in KS incidence has occurred among PWH in the United States during the current cART era. This decrease is uniform across key demographic and HIV transmission groups, though rates remain elevated relative to the general population.
Impact: Continued efforts to control HIV through early cART initiation and retention in care need to be maintained and possibly expanded to sustain declines.

Benavides E, Lupo PJ, Sosa M, et al. Urban-rural residence and birth defects prevalence in Texas: A phenome-wide association study. [published online ahead of print, 2021 Aug 16] [published correction appears in Pediatr Res. 2021 Oct 28;:]. Pediatr Res. 2021;10.1038/s41390-021-01700-6. doi.org/10.1038/s41390-021-01700-6
Background: Some assessments indicate the prevalence of certain birth defects varies by urban-rural status. We evaluated associations between urban-rural residence and a spectrum of birth defects, using a phenome-wide association study approach in Texas, a state with large urban centers and expansive rural areas.
Methods: Data for birth defects and livebirths during 1999-2015 were obtained from the Texas Birth Defects Registry and the Center for Health Statistics. Maternal residence was classified as urban or rural, and prevalence ratios (PR) and 95% confidence intervals (CI) were calculated for any defect and 140 specific defects by Poisson regression.
Results: Overall, birth defects were less frequent in rural compared to urban counties (PR = 0.88, 95% CI: 0.87-0.89). Twelve specific defects were less prevalent in rural counties, including ventricular septal defects (VSDs; PR = 0.76, 95% CI: 0.73-0.79) and hypospadias (PR = 0.86, 95% CI: 0.82-0.89). For some birth defects, including VSDs, there was evidence of decreasing prevalence with decreasing population size.
Conclusions: In our large population-based assessment, we demonstrated that several birth defects were less prevalent in rural counties, suggesting that characteristics of urban settings may be relevant to their etiologies, diagnosis, or surveillance. Further research is needed to identify specific exposures underlying these associations.
Impact: There are few studies of birth defects prevalence in urban versus rural settings. To address this, we investigated a comprehensive range of birth defects, including several rare defects that have not been previously studied, in a large and diverse population. We identified 12 structural birth defects that were less prevalent in rural areas. Findings suggest possible differential exposures among urban and rural women, and/or possible underdiagnosis of certain birth defects in rural areas. Findings highlight the need for further study of geographically referenced risk factors for birth defects, and of the completeness of birth defects ascertainment in rural areas.

Bollling, BG, Qualls WA, Tyler R, et al. Increasing public health mosquito surveillance in Hidalgo County, Texas to monitor vector and arboviral presence. Pathogens. 2021 Aug 13;10(8):1022. doi: 10.3390/pathogens10081022
From 2016 to 2018, Hidalgo County observed the emergence of Zika virus (ZIKV) infections along with sporadic cases of Dengue virus (DENV) and West Nile virus (WNV). Due to the emergence of ZIKV and the historical presence of other mosquito-borne illnesses, Hidalgo County obtained funding to enhance mosquito surveillance and educate residents on arboviruses and travel risks. During this time period, Hidalgo County mosquito surveillance efforts increased by 1.275%. This increase resulted in >8000 mosquitoes collected, and 28 mosquito species identified. Aedes aegypti, Ae albopictus and Culex quinquefasciatus made up approximately two-thirds of the mosquitoes collected in 2018 (4122/6171). Spatiotemporal shifts in vector species composition were observed as the collection period progressed. Significantly, temperature variations (p < 0.05) accounted for associated variations in vector abundance, whereas all other climate variables were not significant.

Belay ED, Abrams J, et al. Trends in geographic and temporal distribution of US children with multisystem inflammatory syndrome during the COVID-19 pandemic. JAMA Pediatr. 2021 Aug 1;175(8):837-845. doi.org/10.1001/jamapediatrics.2021.0630
Multiple inflammatory syndrome in children (MIS-C) occurs in association with the COVID-19 pandemic.
Objective: To describe the clinical characteristics and geographic and temporal distribution of the largest cohort of patients with MIS-C in the United States to date.
Design, setting, and participants: Cross-sectional analysis was conducted on clinical and laboratory data collected from patients with MIS-C. The analysis included patients with illness onset from March 2020 to January 2021 and met MIS-C case definition.
Main outcomes and measures: Geographic and temporal distribution of MIS-C was compared with that of COVID-19 nationally, by region, and level of urbanicity by county. Clinical and laboratory findings and changes over time were described by age group and by presence or absence of preceding COVID-19.
Results: A total of 1733 patients with MIS-C were identified; 994 (57.6%) were male and 1117 (71.3%) were Hispanic or non-Hispanic Black. Gastrointestinal symptoms, rash, and conjunctival hyperemia were reported by 53% (n = 931) to 67% (n = 1153) of patients. A total of 937 patients (54%) had hypotension or shock, and 1009 (58.2%) were admitted for intensive care. Cardiac dysfunction was reported in 484 patients (31.0%), pericardial effusion in 365 (23.4%), myocarditis in 300 (17.3%), and coronary artery dilatation or aneurysms in 258 (16.5%). Patients aged 0 to 4 years had the lowest proportion of severe manifestations, although 171 patients (38.4%) had hypotension or shock and 197 (44.3%) were admitted for intensive care. Patients aged 18 to 20 years had the highest proportions with myocarditis (17 [30.9%]), pneumonia (20 [36.4%]), acute respiratory distress syndrome (10 [18.2%]), and polymerase chain reaction positivity (39 [70.9%]). These older adolescents also had the highest proportion reporting preceding COVID-19-like illness (63%). Nationally, the first 2 MIS-C peaks followed the COVID-19 peaks by 2 to 5 weeks. The cumulative MIS-C incidence per 100 000 persons younger than 21 years was 2.1 and varied from 0.2 to 6.3 by state. Twenty-four patients (1.4%) died.
Conclusions and relevance: In this cross-sectional study of a large cohort of patients with MIS-C, 2 peaks that followed COVID-19 peaks by 2 to 5 weeks were identified. The geographic and temporal association of MIS-C with the COVID-19 pandemic suggested that MIS-C resulted from delayed immunologic responses to SARS-CoV-2 infection. The clinical manifestations varied by age and by presence or absence of preceding COVID-19.

Norkin SK, Benson S, et al. Inadequate engagement in HIV care among people with HIV newly diagnosed with a sexually transmitted disease: A multijurisdictional analysis. Sex Transm Dis. 2021 Aug 1;48(8):601-605. doi: 10.1097/OLQ.0000000000001381
Background: Esophageal atresia (EA) affects around 2.3-2.6 per 10,000 births world-wide. Infants born with this condition require surgical correction soon after birth. Most survival studies of infants with EA are locally or regionally based. We aimed to describe survival across multiple world regions.
Methods: We included infants diagnosed with EA between 1980 and 2015 from 24 birth defects surveillance programs that are members of the International Clearinghouse for Birth Defects Surveillance and Research. We calculated survival as the proportion of liveborn infants alive at 1 month, 1- and 5-years, among all infants with EA, those with isolated EA, those with EA and additional anomalies or EA and a chromosomal anomaly or genetic syndrome. We also investigated trends in survival over the decades, 1980s-2010s.
Results: We included 6,466 liveborn infants with EA. Survival was 89.4% (95% CI 88.1-90.5) at 1-month, 84.5% (95% CI 83.0-85.9) at 1-year and 82.7% (95% CI 81.2-84.2) at 5-years. One-month survival for infants with isolated EA (97.1%) was higher than for infants with additional anomalies (89.7%) or infants with chromosomal or genetic syndrome diagnoses (57.3%) with little change at 1- and 5-years. Survival at 1 month improved from the 1980s to the 2010s, by 6.5% for infants with isolated EA and by 21.5% for infants with EA and additional anomalies.
Conclusions: Almost all infants with isolated EA survived to 5 years. Mortality was higher for infants with EA and an additional anomaly, including chromosomal or genetic syndromes. Survival improved from the 1980s, particularly for those with additional anomalies.

Shuford JA, et al. Use of Drug-level Testing and Single-genome Sequencing to Unravel a Case of Human Immunodeficiency Virus Seroconversion on Pre-exposure Prophylaxis. Clin Infect Dis. 2021;72(11):2025-2028. doi.org/10.1093/cid/ciaa1011
Cases of seroconversion on pre-exposure prophylaxis (PrEP) should be carefully investigated, given their public health implications and rarity. We report a case of transmitted drug resistance causing seroconversion on PrEP in spite of high adherence, confirmed with dried blood spot and segmental hair drug-level testing and single-genome sequencing.

Canfield MA, et al. Survival of infants born with esophageal atresia among 24 international birth defects surveillance programs. Birth Defects Res. 2021 Jul 15;113(12):945-957. Epub 2021 Mar 18. doi: 10.1002/bdr2.1891
Esophageal atresia (EA) affects around 2.3-2.6 per 10,000 births world-wide. Infants born with this condition require surgical correction soon after birth. Most survival studies of infants with EA are locally or regionally based. We aimed to describe survival across multiple world regions.
We included infants diagnosed with EA between 1980 and 2015 from 24 birth defects surveillance programs that are members of the International Clearinghouse for Birth Defects Surveillance and Research. We calculated survival as the proportion of liveborn infants alive at 1 month, 1- and 5-years, among all infants with EA, those with isolated EA, those with EA and additional anomalies or EA and a chromosomal anomaly or genetic syndrome. We also investigated trends in survival over the decades, 1980s-2010s.
We included 6,466 liveborn infants with EA. Survival was 89.4% (95% CI 88.1-90.5) at 1-month, 84.5% (95% CI 83.0-85.9) at 1-year and 82.7% (95% CI 81.2-84.2) at 5-years. One-month survival for infants with isolated EA (97.1%) was higher than for infants with additional anomalies (89.7%) or infants with chromosomal or genetic syndrome diagnoses (57.3%) with little change at 1- and 5-years. Survival at 1 month improved from the 1980s to the 2010s, by 6.5% for infants with isolated EA and by 21.5% for infants with EA and additional anomalies.
Almost all infants with isolated EA survived to 5 years. Mortality was higher for infants with EA and an additional anomaly, including chromosomal or genetic syndromes. Survival improved from the 1980s, particularly for those with additional anomalies.

Langlois PH, Canfield MA, et al. Birth defect co-occurrence patterns in the Texas Birth Defects Registry. Pediatr Res. 2021 Jun 30. [published online ahead of print]. doi: 10.1038/s41390-021-01629-w
 The population-level landscape of co-occurring birth defects among infants without a syndromic diagnosis is not well understood.
Methods: We analyzed data from 40,771 infants with two or more major birth defects in the Texas Birth Defects Registry (TBDR; 1999-2014). We calculated adjusted observed-to-expected (O/E) ratios for all two, three, four, and five-way combinations of 138 major defects.
Results: Among 530 patterns with the highest adjusted O/E ratios (top 5% of 10,595 patterns), 66% included only defects co-occurring within one organ system and 28% were suggestive of known patterns (e.g., midline developmental defects). Of the remaining patterns, the combination of defects with the highest O/E ratio (193.8) encompassed the diaphragm, spine, spleen, and heart defects. Fourteen patterns involved heart and spine defects with or without rib defects. Ten additional patterns primarily involved two hallmark components of VACTERL association (specifically, vertebral defects, anal atresia, cardiac defects, renal, or limb defects, but not tracheoesophageal fistula).
Conclusions: Our analyses provide a description of the birth defect co-occurrence patterns in a multi-ethnic, population-based sample, and revealed several patterns of interest. This work complements prior work that has suggested etiologic connections between select defects (e.g., diaphragmatic hernia and heart and spleen anomalies; heart and spine defects).
Impact: In this large-scale, population-based study of birth defect co-occurrence patterns, we found several birth defect combinations of potential interest that warrant further investigation: congenital diaphragmatic hernia, heart, spine, and spleen defects and scimitar syndrome with vertebral defects. The majority of patterns of co-occurring defects observed more frequently than expected involved multiple defects within the same system and combinations suggestive of known associations. Nearly all of the top patterns (beyond the same system and those suggestive of known associations) involved organ systems that are components of the VACTERL association, with heart, spine, and rib defect patterns being the most common.

Rositch AF, Levinson K, et al. Epidemiology of cervical adenocarcinoma and squamous cell carcinoma among women living with HIV compared to the general population in the United States. Clin Infect Dis. 2021 Jun 18:ciab561. [published online ahead of print]. doi: 10.1093/cid/ciab561
 Cervical cancer risk overall is elevated among women living with HIV (WLH). However, it is unclear whether risks of cervical cancer are similarly elevated across histologic subtypes.
Methods: Data were utilized from the HIV/AIDS Cancer Match Study, a linkage of 12 US HIV and cancer registries during 1996-2016. Cervical cancers were categorized as adenocarcinoma (AC), squamous cell carcinoma (SCC) or other histologic type. Standardized incidence ratios were estimated to compare rates of AC and SCC in WLH compared to the general population. For WLH, risk factors for AC and SCC were evaluated using Poisson regression. All-cause 5-year survival was estimated by HIV status and histology.
Results: Overall, 62,615 cervical cancers were identified, including 609 in WLH. Compared to the general population, incidence of AC was 1.47-times higher (95%CI: 1.03-2.05) and incidence of SCC was 3.62-times higher among WLH (95%CI: 3.31-3.94). Among WLH, there was no difference in AC rates by race/ethnicity or HIV transmission group, although SCC rates were lower among White women (vs. Black, adjusted rate ratio (aRR)=0.53; 95%CI: 0.38-0.73) and higher among women who inject drugs (vs. heterosexual transmission; aRR=1.44; 95%CI: 1.17-1.78). Among WLH, 5-year overall survival was similar for AC (46.2%) and SCC (43.8%), but notably lower than women without HIV.
Conclusions: Among WLH, AC rates were modestly elevated whereas SCC rates were greatly elevated compared to the general population. These findings suggest that there may be differences in the impact of immunosuppression and HIV status in the development of AC compared to SCC, given their common etiology in HPV infection.

Canfield MA, et al. Sixth grade academic achievement among children conceived with IVF: a population-based study in Texas, USA. J Assist Reprod Genet. 2021 Jun;38(6):1481-1492. Epub 2021 Apr 2. doi: 10.1007/s10815-021-02170-9
 To compare academic achievement in reading and mathematics at the end of sixth grade and progress from third to sixth grade by children conceived with in vitro fertilization (IVF) to those conceived naturally.
Methods: This was a retrospective population-based cohort study of IVF-conceived singleton and twin children who took the 3rd grade and 6th grade public school standardized reading and mathematics testing in Texas.
Results: There were 6,623 children with reading scores in both the third and sixth grades and 6,374 children with mathematics scores in both the third and sixth grades. Mean (± SE) scaled test scores for IVF and control singleton children for reading were 1544.6 ± 3.4 and 1527.7 ± 1.9, respectively, in third grade and 1701.2 ± 3.6 and 1681.0 ± 2.0, respectively, in sixth grade; for mathematics, the scores were 1564.4 ± 3.7 and 1548.9 ± 2.1, respectively, in third grade and 1774.0 ± 4.2 and 1752.0 ± 2.3, respectively, in sixth grade. In multivariate models, singleton IVF children scored significantly higher than control children in reading and mathematics, averaging 17.7 ± 4.0 points and 20.1 ± 4.1 points higher, respectively, in reading in third and sixth grades and 17.8 ± 4.4 points and 25.0 ± 4.8 points higher, respectively, in mathematics in third and sixth grades.
Conclusions: Children conceived with IVF and aged 8-9 years and aged 10-12 years performed as well on third and sixth grade reading and mathematics assessments as their counterparts conceived naturally.

Langlois PH, Canfield MA, et al. Patterns of congenital anomalies among individuals with trisomy 13 in Texas. Am J Med Genet A. 2021 Jun;185(6):1787-1793. Epub 2021 Mar 22. doi: 10.1002/ajmg.a.62175
Few population-based studies have analyzed patterns of co-occurring birth defects among those with trisomy 13. We evaluated the frequency of all possible combinations of any one, two, three, or four additional co-occurring birth defects among 736 individuals with trisomy 13 using data from the Texas Birth Defects Registry for deliveries during 1999-2014. We calculated the observed-to-expected ratio for each combination, adjusting for the known tendency for birth defects to cluster non-specifically. To address potential ascertainment differences among live births and non-live births, we repeated analyses specifically among live births. The combination of defects with the largest observed-to-expected ratio was microcephalus, reduction deformities of brain (e.g., holoprosencephaly), anomalies of nose, and polydactyly. As expected, most of the highest 30 observed-to-expected ratios involved combinations with documented features of trisomy 13, including defects of the scalp (e.g., aplasia cutis) and heart. Results were similar among sensitivity analyses restricted to live births. Our findings may help further delineate the phenotypic spectrum for trisomy 13 and may inform future research related to improving screening and counseling for the condition.

Vallabhaneni S, Huang JY, et al. Antimicrobial susceptibility profiles to predict the presence of carbapenemase genes among carbapenem-resistant Pseudomonas aeruginosa isolates. J Clin Microbiol. 2021 May 19;59(6):e02874-20. doi: 10.1128/JCM.02874-20
Detection of carbapenem-resistant Pseudomonas aeruginosa (CRPA) with carbapenemase-producing (CP) genes is critical for preventing transmission. Our objective was to assess whether certain antimicrobial susceptibility testing (AST) profiles can efficiently identify CP-CRPA. We defined CRPA as P. aeruginosa with imipenem or meropenem MICs of ≥8 μg/ml; CP-CRPA was CRPA with CP genes (bla KPC/bla IMP/bla NDM/bla OXA-48/bla VIM). We assessed the sensitivity and specificity of AST profiles to detect CP-CRPA among CRPA isolates collected by CDC's Antibiotic Resistance Laboratory Network (AR Lab Network) and the Emerging Infections Program (EIP) during 2017 to 2019. Three percent (195/6,192) of AR Lab Network CRPA isolates were CP-CRPA. Among CRPA isolates, adding not susceptible (NS) to cefepime or ceftazidime to the definition had 91% sensitivity and 50% specificity for identifying CP-CRPA; adding NS to ceftolozane-tazobactam had 100% sensitivity and 86% specificity. Of 965 EIP CRPA isolates evaluated for CP genes, 7 were identified as CP-CRPA; 6 of the 7 were NS to cefepime and ceftazidime, and all 7 were NS to ceftolozane-tazobactam. Among 4,182 EIP isolates, clinical laboratory AST results were available for 96% of them for cefepime, 80% for ceftazidime, and 4% for ceftolozane-tazobactam. The number of CRPA isolates needed to test (NNT) to identify one CP-CRPA isolate decreased from 138 to 64 if the definition of NS to cefepime or ceftazidime was used and to 7 with NS to ceftolozane-tazobactam. Adding not susceptible to cefepime or ceftazidime to CRPA carbapenemase testing criteria would reduce the NNT by half and can be implemented in most clinical laboratories; adding not susceptible to ceftolozane-tazobactam could be even more predictive once AST for this drug is more widely available.

Sanchez R, Ranjit N, Kelder SH, Gill M, Hoelscher DM. Intention to lose weight and use of electronic cigarettes among adolescents. Prev Med Rep. 2021;23:101406. doi:10.1016/j.pmedr.2021.101406 
Electronic cigarette use among American adolescents is a major public health concern given the negative health consequences of nicotine in youth. Recent literature has shown that weight control may be one motivation for use in this population. This study examined associations between intention to lose weight and e-cigarette use among adolescents having overweight or obesity from an ethnically diverse sample of Texas youth by gender. We performed a cross-sectional analysis of a state representative sample of 9056 eighth and eleventh grade students from the 2015-2016 Texas School Physical Activity and Nutrition (Texas SPAN) study. Validated survey items assessed weight intentions and e-cigarette use. Staff collected anthropometric measures. Logistic regression analysis was conducted to assess the relationship between e-cigarette use and weight intentions with gender interaction, adjusting for grade, race/ethnicity, economic status, weight-behaviors and stratified by BMI class. More than half (50.9%) of the weighted sample were Hispanic and 12.5% were Non-Hispanic Black; 8.5% used e-cigarettes; and 50.0% intended to lose weight. Of the 40.2% of the sample having overweight or obesity, 82.9% intended to lose weight. Among respondents with obesity, use of e-cigarettes was significantly higher among males intending to lose weight than among females intending to lose weight (12% versus 6%, p = 0.007). These findings contrast with previous research suggesting that e-cigarette use in females is more likely to be motivated by an intent to lose weight. The ethnic diversity of the Texas SPAN population may explain this discrepancy.

Canfield MA, et al. Causes of neonatal and postneonatal death among infants with birth defects in Texas. Birth Defects Res. 2021 May 15;113(9):665-675. Epub 2021 Feb 15. doi: 10.1002/bdr2.1879
The proportion of deaths attributed to various causes has not been quantified among infants with birth defects. We sought to describe the causes of neonatal and postneonatal death among infants in the Texas Birth Defects Registry.
Methods: We calculated frequencies and percentages for both underlying causes and all causes (underlying or contributing) of neonatal (0-27 days) and postneonatal (28-364 days) death listed on death certificates among infants born alive with birth defects and delivered in Texas during 1999-2013 (n = 8,389 deaths). Analyses were repeated separately for infants with isolated, multiple, and syndromic defects.
Results: After birth defects, the most frequently listed causes of neonatal death were preterm/low birth weight (10%), circulatory system diseases (8%), and sepsis (5%). The leading postneonatal causes of death beyond birth defects were circulatory system diseases (32%), sepsis (11%), and renal failure (7%).
Conclusions: Improved understanding of the causes of mortality among infants with birth defects may help identify priorities for postnatal care. Our results suggest that potentially modifiable causes of death (e.g., circulatory system diseases, sepsis) contribute substantially to mortality in this population. Prioritizing continued improvements in prevention, diagnosis, and management of preventable conditions may reduce mortality among infants born with birth defects.

Buendia JR, Sears S, Griffin E, Mgbere OO. Prevalence and risk factors of type II diabetes mellitus among people living with HIV in Texas. AIDS Care. 2021 May 11:1-8. [published online ahead of print]. doi: 10.1080/09540121.2021.1925212
This study aimed to determine the prevalence and risk factors associated with type II diabetes mellitus (T2DM) among people living with HIV (PLWH). Cross-sectional data of 989 PLWH in Texas obtained from the 2015-2017 Texas and Houston Medical Monitoring Project were examined. T2DM was identified by formal medical chart diagnosis, insulin/oral hypoglycemic prescriptions, or most recent fasting blood glucose ≥126 mg/dL. T2DM adjusted prevalence ratios and 95% confidence intervals (CIs) were estimated using multiple logistic regression. Participants were mostly male (72%), ≥40 years (68%), overweight (31%) or obese (28%) and virally suppressed (62%). T2DM prevalence was 15% with variations by age, body mass index, education and health insurance (p < 0.05 for all). Compared to PLWH ≥60 years, 18-39-year-olds had significantly lower likelihood of T2DM (p < 0.001). Overweight and obese PLWH were 2.11 (95% CI: 1.23-3.63) and 3.89 times (95% CI: 2.30-6.56) more likely to have T2DM compared to normal weight PLWH. Over 1 in 6 PLWH in Texas had T2DM, with age and BMI as significant predictors. Since DM is a risk factor for cardiovascular disease and PLWH are living longer, increased education and lifestyle modification interventions are warranted to prevent T2DM development among PLWH.

Ivanova M, Oh B, Khan IUH, et al. Draft genome assemblies of two Campylobacter novaezeelandiae and four unclassified thermophilic campylobacter isolates from Canadian agricultural surface water. Microbiol Resour Announc. 2021 Apr 29;10(17):e00249-21. doi: 10.1128/MRA.00249-21
This report presents the draft genome sequences of two Campylobacter novaezeelandiae and four unclassified Campylobacter isolates from Canadian agricultural surface water. Phylogenomic analysis revealed that the six isolates formed unique clades, closely related to the disease-causing species C. jejuni, C. coli, and C. hepaticus.

Langlois PH, Canfield MA, et al. Birth defect co-occurrence patterns among infants with cleft lip and/or palate. Cleft Palate Craniofac J. 2021 Apr 28:10556656211010060. [published online ahead of print]. doi: 10.1177/10556656211010060
: To investigate 2- to 5-way patterns of defects co-occurring with orofacial clefts using data from a population-based registry.
Design: We used data from the Texas Birth Defects Registry for deliveries between 1999 and 2014 to Texas residents, including 1884 cases with cleft palate (CP) and 5289 cases with cleft lip with or without cleft palate (CL±P) without a known syndrome. We identified patterns of defects co-occurring with CP and with CL±P observed more frequently than would be expected if these defects occurred independently. We calculated adjusted observed-to-expected (O/E) ratios to account for the known tendency of birth defects to cluster nonspecifically.
Results: Among infants without a syndrome, 23% with CP and 21% with CL±P had at least 1 additional congenital anomaly. Several combinations of defects were observed much more often than expected. For example, the combination of CL±P, congenital hydrocephaly, anophthalmia, and other nose anomalies had an O/E ratio of 605. For both CP and CL±P, co-occurrence patterns with the highest O/E ratios involved craniofacial and brain abnormalities, and many included the skeletal, cardiovascular, and renal systems.
Conclusions: The patterns of defects we observed co-occurring with clefts more often than expected may help improve our understanding of the relationships between multiple defects. Further work to better understand some of the top defect combinations could reveal new phenotypic subgroups and increase our knowledge of the developmental mechanisms that underlie the respective defects.

Canfield MA, et al. Risks of nonchromosomal birth defects, small-for-gestational age birthweight, and prematurity with in vitro fertilization: effect of number of embryos transferred and plurality at conception versus at birth. J Assist Reprod Genet. 2021 Apr;38(4):835-846. Epub 2021 Feb 5. doi: 10.1007/s10815-021-02095-3
Purpose: Excess embryos transferred (ET) (> plurality at birth) and fetal heartbeats (FHB) at 6 weeks' gestation are associated with reductions in birthweight and gestation, but prior studies have been limited by small sample sizes and limited IVF data. This analysis evaluated associations between excess ET, excess FHB, and adverse perinatal outcomes, including the risk of nonchromosomal birth defects.
Methods: Live births conceived via IVF from Massachusetts, New York, North Carolina, and Texas included 138,435 children born 2004-2013 (Texas), 2004-2016 (Massachusetts and North Carolina), and 2004-2017 (New York) were classified by ET and FHB. Major birth defects were reported by statewide registries within the first year of life. Logistic regression was used to estimate adjusted odds ratios (AORs) and 95% CIs of the risks of a major nonchromosomal birth defect, small-for-gestational age birthweight (SGA), low birthweight (LBW), and preterm birth (≤36 weeks), by excess ET, and excess ET + excess FHB, by plurality at birth (singletons and twins).
Results: In singletons with [2 ET, FHB =1] and [≥3 ET, FHB=1], risks [AOR (95% CI)] were increased, respectively, for major nonchromosomal birth defects [1.13 (1.00-1.27) and 1.18 (1.00-1.38)], SGA [1.10 (1.03-1.17) and 1.15 (1.05-1.26)], LBW [1.09 (1.02-1.13) and 1.17 (1.07-1.27)], and preterm birth [1.06 (1.00-1.12) and 1.14 (1.06-1.23)]. With excess ET + excess FHB, risks of all adverse outcomes except major nonchromosomal birth defects increased further for both singletons and twins.
Conclusion: Excess embryos transferred are associated with increased risks for nonchromosomal birth defects, reduced birthweight, and prematurity in IVF-conceived births.

Garcia F, et al. Efficacy, pharmacokinetics, and safety over 48 weeks with ibalizumab-based therapy in treatment-experienced adults infected with HIV-1: A Phase 2a study. J Acquir Immune Defic Syndr. 2021 Apr 1;86(4):482-489. doi: 10.1097/QAI.0000000000002591
Ibalizumab, a humanized monoclonal antibody targeting CD4, blocks HIV-1 entry into cells and is the first Food and Drug Administration-approved long-acting agent for HIV-1 treatment. In this phase 2a study, 82 HIV-infected adults failing antiretroviral therapy were assigned an individually optimized background regimen (OBR) and randomized 1:1:1 to arm A (15 mg/kg ibalizumab q2wk), arm B (10 mg/kg weekly for 9 weeks, then q2wk), or placebo. Subjects with an inadequate response at week 16 were permitted to cross over to a new OBR plus 15 mg/kg ibalizumab q2wk. At week 16, viral load (VL) reduction was significantly greater than placebo (0.26 log10) in arms A (1.07 log10; P = 0.002) and B (1.33 log10; P < 0.001); CD4+ T cell counts increased significantly in arm A. After week 16, 11/27 (arm B) and 19/27 (placebo) subjects crossed over to OBR plus 15 mg/kg ibalizumab; 8/28 in arm A initiated a new OBR. Ibalizumab treatment resulted in VL reduction at week 24 (-0.77 and -1.19 log10 for arms A and B, respectively, versus -0.32 log10 for placebo) and 48 weeks (-0.54 and -0.77 versus -0.22 log10). Compared with placebo, VL differences were statistically significant for arm B at week 24 (P = 0.001) and week 48 (P = 0.027). CD4+ T cell counts increased significantly by week 48 in both arm A and arm B, relative to placebo. No ibalizumab-related serious adverse events were reported. The durable antiviral activity and tolerability of ibalizumab support its use in treating individuals harboring multidrug-resistant HIV-1.

Canfield MA, et al. Prevalence and mortality in children with congenital diaphragmatic hernia: a multicountry study. Ann Epidemiol. 2021 Apr;56:61-69.e3. Epub 2020 Nov 27. doi:10.1016/j.annepidem.2020.11.007
This study determined the prevalence, mortality, and time trends of children with congenital diaphragmatic hernia (CDH).
Methods: Twenty-five hospital- and population-based surveillance programs in 19 International Clearinghouse for Birth Defects Surveillance and Research member countries provided birth defects mortality data between 1974 and 2015. CDH cases included live births, stillbirths, or elective termination of pregnancy for fetal anomalies. Prevalence, cumulative mortality rates, and 95% confidence intervals (CIs) were calculated using Poisson regression and a Kaplan-Meier product-limit method. Joinpoint regression analyses were conducted to assess time trends.
Results: The prevalence of CDH was 2.6 per 10,000 total births (95% CI: 2.5-2.7), slightly increasing between 2001 and 2012 (average annual percent change = 0.5%; 95% CI:-0.6 to 1.6). The total percent mortality of CDH was 37.7%, with hospital-based registries having more deaths among live births than population-based registries (45.1% vs. 33.8%). Mortality rates decreased over time (average annual percent change = -2.4%; 95% CI: -3.8 to 1.1). Most deaths due to CDH occurred among 2- to 6-day-old infants for both registry types (36.3%, hospital-based; 12.1%, population-based).
Conclusions: The mortality of CDH has decreased over time. Mortality remains high during the first week and varied by registry type.

Garza E, et al. Epidemiology surveillance and capacity improvement: A characterization of Texas, 2017. Disaster Med Public Health Prep. 2021 Mar 17:1-8.  [published online ahead of print]. doi: 10.1017/dmp.2020.471
In response to increasing caseloads of foodborne illnesses and high consequence infectious disease investigations, the Texas Department of State Health Services (DSHS) requested funding from the Texas Legislature in 2013 and 2015 for a new state-funded epidemiologist (SFE) program.
Methods: Primary cross-sectional survey data were collected from 32 of 40 local health departments (LHDs) via an online instrument and analyzed to quantify roles, responsibilities, and training of epidemiologists in Texas in 2017 and compared to similar state health department assessments.
Results: Sixty-six percent of SFEs had epidemiology-specific training (eg, master's in public health) compared to 45% in state health department estimates. For LHDs included in this study, the mean number of epidemiologists per 100,000 was 0.73 in medium LHDs and 0.46 in large LHDs. SFE positions make up approximately 40% of the LHD epidemiology workforce of all sizes and 56% of medium-sized LHD epidemiology staff in Texas specifically.
Conclusions: Through this program, DSHS increased epidemiology capacity almost twofold from 0.28 to 0.47 epidemiologists per 100,000 people. These findings suggest that capacity funding programs like this improve epidemiology capacity in local jurisdictions and should be considered in other regions to improve general public health preparedness and epidemiology capacity.

Hall N, et al. Myopericarditis associated with smallpox vaccination among US Army personnel - Fort Hood, Texas, 2018. Disaster Med Public Health Prep. 2021 Mar 15:1-7.  [published online ahead of print]. doi: 10.1017/dmp.2020.478
In March 2018, the US Department of Defense (DOD) added the smallpox vaccination, using ACAM2000, to its routine immunizations, increasing the number of persons receiving the vaccine. The following month, Fort Hood reported a cluster of 5 myopericarditis cases. The Centers for Disease Control and Prevention and the DOD launched an investigation.
Methods: The investigation consisted of a review of medical records, establishment of case definitions, causality assessment, patient interviews, and active surveillance. A 2-sided exact rate ratio test was used to compare myopericarditis incidence rates.
Results: This investigation identified 4 cases of probable myopericarditis and 1 case of suspected myopericarditis. No alternative etiology was identified as a cause. No additional cases were identified. There was no statistically significant difference in incidence rates between the observed cluster (5.23 per 1000 vaccinated individuals, 95% CI: 1.7-12.2) and the ACAM2000 clinical trial outcomes for symptomatic persons, which was 2.29 per 1000 vaccinated individuals (95% CI: 0.3-8.3).
Conclusions: Vaccination with ACAM2000 is the presumptive cause of this cluster. Caution should be exercised before considering vaccination campaigns for smallpox given the clinical morbidity and costs incurred by a case of myopericarditis. Risk of myopericarditis should be carefully weighed with risk of exposure to smallpox.

Shuford JA, Prot E, Cuevas E, et al. Travel from the United Kingdom to the United States by a symptomatic patient infected with the SARS-CoV-2 B.1.1.7 variant - Texas, January 2021. MMWR Morb Mortal Wkly Rep. 2021 Mar 12;70(10):348-349. doi: 10.15585/mmwr.mm7010e2
In December 2020, the B.1.1.7 genetic variant of SARS-CoV-2, the virus that causes COVID-19, was first reported after emergence and rapid circulation in the United Kingdom (1). Evidence suggests that the B.1.1.7 variant is more efficiently transmitted than are other SARS-CoV-2 variants, and widespread circulation could thereby increase SARS-CoV-2 infection and hospitalization rates (1,2). The first reported SARS-CoV-2 B.1.1.7 variant case in the United States was confirmed by sequencing in Colorado on December 29, 2020.* This report describes a person who traveled from the United Kingdom to the United States after experiencing COVID-19-compatible symptoms† and was eventually confirmed to be infected with the B.1.1.7 variant.

Stoner D, et al. Cost-Effectiveness of the Wellness Incentives and Navigation (WIN) Program. Value Health. 2021 Mar;24(3):361-368. doi: 10.1016/j.jval.2020.06.019
Objectives: Promoting patient involvement in managing co-occurring physical and mental health conditions is increasingly recognized as critical to improving outcomes and controlling costs in this growing chronically ill population. The main objective of this study was to conduct an economic evaluation of the Wellness Incentives and Navigation (WIN) intervention as part of a longitudinal randomized pragmatic clinical trial for chronically ill Texas Medicaid enrollees with co-occurring physical and mental health conditions.
Methods: The WIN intervention used a personal navigator, motivational interviewing, and a flexible wellness expense account to increase patient activation, that is, the patient's knowledge, skills, and confidence in managing their self-care and co-occurring physical and mental health conditions. Regression models were fit to both participant-level quality-adjusted life years (QALYs) and total costs of care (including the intervention) controlling for demographics, health status, poverty, Medicaid managed care plan, intervention group, and baseline health utility and costs. Incremental costs and QALYs were calculated based on the difference in predicted costs and QALYs under intervention versus usual care and were used to calculate the incremental cost-effectiveness ratios (ICERs). Confidence intervals were calculated using Fieller's method, and sensitivity analyses were performed.
Results: The mean ICER for the intervention compared with usual care was $12,511 (95% CI $8,971-$16,842), with a sizable majority of participants (70%) having ICERs below $40,000. The WIN intervention also produced higher QALY increases for participants who were sicker at baseline compared to those who were healthier at baseline.
Conclusion: The WIN intervention shows considerable promise as a cost-effective intervention in this challenging chronically ill population.

Sardell R, Miller P, et al. Texas has the highest hepatocellular carcinoma incidence rates in the USA. Dig Dis Sci. 2021 Mar;66(3):912-916. doi: 10.1007/s10620-020-06231-4
Background: Texas is the second largest state by area and population in the USA and is reported to have high incidence and mortality rates for hepatocellular carcinoma (HCC). The reasons for the increasingly high burden of HCC in Texas are not clear.
Aims: We explored trends and demographic and regional variations in HCC incidence to better understand reasons for the high burden in Texas.
Methods: We analyzed Texas Cancer Registry incidence data from 2001 to 2015 and compared results to the U.S. National Program of Cancer Registries and SEER for the same period. Rates were stratified by sex, race/ethnicity, and age at diagnosis. Rates were also compared between the US/Mexico border region of Texas and the rest of Texas.
Results: Texas had the highest HCC age-adjusted incidence rate of all states, 13.2/100,000, which was 45% higher than the national average. In Texas and nationally, rates increased by 4% per year between 2001 and 2015. Rates in Texas were 26-37% greater than national rates for Hispanics, African-Americans, and non-Hispanic whites. Among Hispanics in states with the largest percentage of Hispanics, Texas-based Hispanics had the highest HCC incidence rate in 2015 (21.2/100,000) compared with Hispanics in New Mexico, California, Arizona, Nevada, and Florida. Incidence rates were highest in South Texas and US/Mexico border regions.
Conclusions: Increasing rates in the large Hispanic population may explain why Texas now has the highest HCC incidence rate in the USA.

Waldrup K, et al. Surveillance of Trypanosoma cruzi infection in triatomine vectors, feral dogs and cats, and wild animals in and around El Paso county, Texas, and New Mexico. PLoS Negl Trop Dis. 2021 Feb 18;15(2):e0009147. doi: 10.1371/journal.pntd.0009147
The causative agent of Chagas disease, Trypanosoma cruzi, is transmitted by triatomine vectors. The insect is endemic in the Americas, including the United States, where epidemiological studies are limited, particularly in the Southwestern region. Here, we have determined the prevalence of T. cruzi in triatomines, feral cats and dogs, and wild animals, the infecting parasite genotypes and the mammalian host bloodmeal sources of the triatomines at four different geographical sites in the U.S.-Mexico border, including El Paso County, Texas, and nearby cities in New Mexico. Using qualitative polymerase chain reaction to detect T. cruzi infections, we found 66.4% (n = 225) of triatomines, 45.3% (n = 95) of feral dogs, 39.2% (n = 24) of feral cats, and 71.4% (n = 7) of wild animals positive for T. cruzi. Over 95% of T. cruzi genotypes or discrete typing units (DTUs) identified were TcI and some TcIV. Furthermore, Triatoma rubida was the triatomine species most frequently (98.2%) collected in all samples analyzed. These findings suggest a high prevalence of T. cruzi infections among triatomines, and feral and wild animals in the studied sites. Therefore, our results underscore the urgent need for implementation of a systematic epidemiological surveillance program for T. cruzi infections in insect vectors, and feral and wild animals, and Chagas disease in the human population in the southwestern region of the United States.

Canfield MA, et al. Maternal hypertension-related genotypes and congenital heart defects. Am J Hypertens. 2021 Feb 18;34(1):82-91. doi: 10.1093/ajh/hpaa116
Background: Maternal hypertension has been associated with congenital heart defect occurrence in several studies. We assessed whether maternal genotypes associated with this condition were also associated with congenital heart defect occurrence.
Methods: We used data from the National Birth Defects Prevention Study to identify non-Hispanic white (NHW) and Hispanic women with (cases) and without (controls) a pregnancy in which a select simple, isolated heart defect was present between 1999 and 2011. We genotyped 29 hypertension-related single nucleotide polymorphisms (SNPs). We conducted logistic regression analyses separately by race/ethnicity to assess the relationship between the presence of any congenital heart defect and each SNP and an overall blood pressure genetic risk score (GRS). All analyses were then repeated to assess 4 separate congenital heart defect subtypes.
Results: Four hypertension-related variants were associated with congenital heart defects among NHW women (N = 1,568 with affected pregnancies). For example, 1 intronic variant in ARHGAP2, rs633185, was associated with conotruncal defects (odds ratio [OR]: 1.3, 95% confidence interval [CI]: 1.1-1.6). Additionally, 2 variants were associated with congenital heart defects among Hispanic women (N = 489 with affected pregnancies). The GRS had a significant association with septal defects (OR: 2.1, 95% CI: 1.2-3.5) among NHW women.
Conclusions: We replicated a previously reported association between rs633185 and conotruncal defects. Although additional hypertension-related SNPs were also associated with congenital heart defects, more work is needed to better understand the relationship between genetic risk for maternal hypertension and congenital heart defects occurrence.

Langlois P, Canfield M, et al. Patterns of co-occurring birth defects among infants with hypospadias [published correction appears in J Pediatr Urol. 2021 Aug;17(4):e1]. J Pediatr Urol. 2021;17(1):64.e1-64.e8. doi: 10.1016/j.jpurol.2020.11.015
Hypospadias, one of the most common male genital birth defects, occurs in 1 out of every 200 male births in the United States and is increasing in prevalence globally.
Objective: This study aimed to characterize the combinations of birth defects that co-occur with hypospadias more often than expected by chance, while accounting for the complex clustering patterns of congenital defects.
Study design: We analyzed cases with hypospadias and at least one additional co-occurring defect from the Texas Birth Defect Registry born between 1999 and 2014. For each combination, we calculated adjusted observed-to-expected (O/E) ratios, using Co-Occurring Defect Analysis (CODA).
Results: Among 16,442 cases with hypospadias and without known syndromes, 2,084 (12.7%) had at least one additional defect. Many of the birth defect combinations within the highest adjusted O/E ratios included cardiac, musculoskeletal, and additional urogenital defects. For example, a top combination with an adjusted O/E of 139.0 included renal agenesis and dysgenesis, reduction defects of the upper limb, and other anomalies of upper limb (including shoulder girdle). High adjusted O/E ratios were also observed in combinations that included defects outside of the urogenital developmental field. For instance, the combination with the highest O/E ratio included buphthalmos, and congenital cataract and lens anomalies (adjusted O/E ratio: 192.9). Similar results were obtained when we restricted our analyses to cases with second- or third-degree hypospadias.
Discussion: Many combinations in the top results were expected (e.g., multiple urogenital defects); however, some combinations with seemingly unrelated patterns of defects may suggest the presence of some etiologic mechanisms yet to be identified.
Conclusion: In summary, this study described patterns of co-occurring defect combinations with hypospadias that can inform further study and may provide insights for screening and diagnostic practices.

Johnson EP, et al. ChicagO Multiethnic Prevention and Surveillance Study (COMPASS): Increased response rates among African American residents in low socioeconomic status neighborhoods. Racial Ethn Health Disparities. 2021 Feb;8(1):186-198. doi: 10.1007/s40615-020-00770-2
African American (AA) populations experience persistent health disparities in the USA. Low representation in bio-specimen research precludes stratified analyses and creates challenges in studying health outcomes among AA populations. Previous studies examining determinants of bio-specimen research participation among minority participants have focused on individual-level barriers and facilitators. Neighborhood-level contextual factors may also inform bio-specimen research participation, possibly through social norms and the influence of social views and behaviors on neighbor's perspectives. We conducted an epidemiological study of residents in 5108 Chicago addresses to examine determinants of bio-specimen research participation among predominantly AA participants solicited for participation in the first 6 years of ChicagO Multiethnic Prevention and Surveillance Study (COMPASS). We used a door-to-door recruitment strategy by interviewers of predominantly minority race and ethnicity. Participants were compensated with a $50 gift card. We achieved response rates of 30.4% for non-AA addresses and 58.0% for AA addresses, with as high as 80.3% response among AA addresses in low socioeconomic status (SES) neighborhoods. After multivariable adjustment, we found approximately 3 times the odds of study participation among predominantly AA addresses in low vs. average SES neighborhoods (odds ratio (OR) = 3.06; 95% confidence interval (CI) = 2.20-4.24). Conversely, for non-AA addresses, we observed no difference in the odds of study participation in low vs. average SES neighborhoods (OR = 0.89; 95% CI = 0.69-1.14) after multivariable adjustment. Our findings suggest that AA participants in low SES neighborhoods may be recruited for bio-specimen research through door-to-door approaches with compensation. Future studies may elucidate best practices to improve bio-specimen research participation among minority populations.

Pont, SJ, et al. School-based gardening, cooking and nutrition intervention increased vegetable intake but did not reduce BMI: Texas sprouts - a cluster randomized controlled trial. Int J Behav Nutr Phys Act. 2021 Jan 23;18(1):18. doi: 10.1186/s12966-021-01087-x
Although school garden programs have been shown to improve dietary behaviors, there has not been a cluster-randomized controlled trial (RCT) conducted to examine the effects of school garden programs on obesity or other health outcomes. The goal of this study was to evaluate the effects of a one-year school-based gardening, nutrition, and cooking intervention (called Texas Sprouts) on dietary intake, obesity outcomes, and blood pressure in elementary school children.
Methods: This study was a school-based cluster RCT with 16 elementary schools that were randomly assigned to either the Texas Sprouts intervention (n = 8 schools) or to control (delayed intervention, n = 8 schools). The intervention was one school year long (9 months) and consisted of: a) Garden Leadership Committee formation; b) a 0.25-acre outdoor teaching garden; c) 18 student gardening, nutrition, and cooking lessons taught by trained educators throughout the school-year; and d) nine monthly parent lessons. The delayed intervention was implemented the following academic year and received the same protocol as the intervention arm. Child outcomes measured were anthropometrics (i.e., BMI parameters, waist circumference, and body fat percentage via bioelectrical impedance), blood pressure, and dietary intake (i.e., vegetable, fruit, and sugar sweetened beverages) via survey. Data were analyzed with complete cases and with imputations at random. Generalized weighted linear mixed models were used to test the intervention effects and to account for clustering effect of sampling by school.
Results: A total of 3135 children were enrolled in the study (intervention n = 1412, 45%). Average age was 9.2 years, 64% Hispanic, 47% male, and 69% eligible for free and reduced lunch. The intervention compared to control resulted in increased vegetable intake (+ 0.48 vs. + 0.04 frequency/day, p = 0.02). There were no effects of the intervention compared to control on fruit intake, sugar sweetened beverages, any of the obesity measures or blood pressure.
Conclusion: While this school-based gardening, nutrition, and cooking program did not reduce obesity markers or blood pressure, it did result in increased vegetable intake. It is possible that a longer and more sustained effect of increased vegetable intake is needed to lead to reductions in obesity markers and blood pressure.
Clinical trials number: NCT02668744

Le M, et al. Prevalence of structural birth defects among infants with Down syndrome, 2013-2017: A US population-based study. Birth Defects Res. 2021 Jan 15;113(2):189-202. doi: 10.1002/bdr2.1854
Down syndrome is the most common chromosomal disorder at birth and is often accompanied by structural birth defects. Current data on major structural defects in this population are limited.
States and territorial population-based surveillance programs submitted data on identified cases of Down syndrome and identified structural birth defects during 2013-2017. We estimated prevalence by program type and maternal and infant characteristics. Among programs with active case ascertainment, we estimated the prevalence of birth defects by organ system and for specific defects by maternal age (<35, ≥35) and infant sex.
We identified 13,376 cases of Down syndrome. Prevalence among all programs was 12.7 per 10,000 live births. Among these children, 75% had at least one reported co-occurring birth defect diagnosis code. Among 6,210 cases identified by active programs, 66% had a cardiovascular defect with septal defects being the most common: atrial (32.5%), ventricular (20.6%), and atrioventricular (17.4%). Defect prevalence differed by infant sex more frequently than by maternal age. For example, atrioventricular septal defects were more common in female children (20.1% vs. 15.1%) while limb deficiencies were more prevalent in male children (0.4% vs. 0.1%).
Our study provides updated prevalence estimates for structural defects, including rare defects, among children with Down syndrome using one of the largest and most recent cohorts to date. These data may aid clinical care and surveillance.

Langlois PH, et al. Associations between cumulative environmental quality and ten selected birth defects in Texas. Birth Defects Res. 2021 Jan 15;113(2):161-172. doi: 10.1002/bdr2.1788
Causes of most birth defects are largely unknown. Genetics, maternal factors (e.g., age, smoking) and environmental exposures have all been linked to some birth defects, including neural tube, oral cleft, limb reduction, and gastroschisis; however, the contribution of cumulative exposures across several environmental domains in association with these defects is not well understood.
The Environmental Quality Index (EQI) and its domains (air, water, land, sociodemographic, built) were used to estimate county-level cumulative environmental exposures from 2006-2010 and matched to birth defects identified from Texas Birth Defects Registry and live birth records from births in years 2007-2010 (N = 1,610,709). Poisson regression models estimated prevalence ratios (PR) and 95% confidence intervals (CI) for associations between 10 birth defects and the EQI.
We observed some positive associations between worst environmental quality and neural tube, anencephaly, spina bifida, oral cleft, cleft palate, cleft lip with and without cleft palate, and gastroschisis [PR range: 1.12-1.55], but near null associations with limb reduction defects. Among domain specific results, we observed the strongest positive associations with the sociodemographic domain across birth defects but varied positive associations among the air and water domains, and negative or null associations with the land and built domains. Overall, few exposure-response patterns were evident.
Conclusions: Our results highlight the complexities of cumulative, simultaneous environmental exposures in the prevalence rates of 10 selected birth defects. We were able to explore the impact of overall and domain specific environmental quality on birth defects and identify potential domain specific drivers of these associations.

Ethen MK, Canfield MA, et al. The risk of birth defects with conception by ART. Hum Reprod. 2021 Jan 1;36(1):116-129. doi: 10.1093/humrep/deaa272
Study question: What is the association between ART conception and treatment parameters and the risk of birth defects?
Summary answer: 
Compared to naturally conceived singleton infants, the risk of a major nonchromosomal defect among ART singletons conceived with autologous oocytes and fresh embryos without use of ICSI was increased by 18%, with increases of 42% and 30% for use of ICSI with and without male factor diagnosis, respectively.
What is known already: Prior studies have indicated that infertility and ART are associated with an increased risk of birth defects but have been limited by small sample size and inadequate statistical power, failure to differentiate results by plurality, differences in birth defect definitions and methods of ascertainment, lack of information on ART treatment parameters or study periods spanning decades resulting in a substantial historical bias as ART techniques have improved.
Study size, design, duration: This was a population-based cohort study linking ART cycles reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) from 1 January 2004 to 31 December 2015 that resulted in live births from 1 September 2004 to 31 December 2016 in Massachusetts and North Carolina and from 1 September 2004 to 31 December 2015 for Texas and New York: these were large and ethnically diverse States, with birth defect registries utilizing the same case definitions and data collected, and with high numbers of ART births annually. A 10:1 sample of non-ART births were chosen within the same time period as the ART birth. Naturally conceived ART siblings were identified through the mother's information. Non-ART children were classified as being born to women who conceived with ovulation induction (OI)/IUI when there was an indication of infertility treatment on the birth certificate, but the woman did not link to the SART CORS; all others were classified as being naturally conceived.
Participants/materials, setting, methods: The study population included 135 051 ART children (78 362 singletons and 56 689 twins), 23 647 naturally conceived ART siblings (22 301 singletons and 1346 twins) and 9396 children born to women treated with OI/IUI (6597 singletons and 2799 twins) and 1 067 922 naturally conceived children (1 037 757 singletons and 30 165 twins). All study children were linked to their respective State birth defect registries to identify major defects diagnosed within the first year of life. We classified children with major defects as either chromosomal (i.e. presence of a chromosomal defect with or without any other major defect) or nonchromosomal (i.e. presence of a major defect but having no chromosomal defect), or all major defects (chromosomal and nonchromosomal). Logistic regression models were used to generate adjusted odds ratios (AORs) and 95% CI to evaluate the risk of birth defects due to conception with ART (using autologous oocytes and fresh embryos), and with and without the use of ICSI in the absence or presence of male factor infertility, with naturally conceived children as the reference. Analyses within the ART group were stratified by combinations of oocyte source (autologous, donor) and embryo state (fresh, thawed), with births from autologous oocytes and fresh embryos as the reference. Analyses limited to fresh embryos were stratified by oocyte source (autologous, donor) and the use of ICSI. Triplets and higher-order multiples were excluded.
Main results and the role of chance: A total of 21 998 singleton children (1.9%) and 3037 twin children (3.3%) had a major birth defect. Compared to naturally conceived children, ART singletons (conceived from autologous oocytes, fresh embryos without the use of ICSI) had increased risks of a major nonchromosomal birth defect (AOR 1.18, 95% 1.05, 1.32), cardiovascular defects (AOR 1.20, 95% CI 1.03, 1.40), and any birth defect (AOR 1.18, 95% CI 1.09, 1.27). Compared to naturally conceived children, ART singletons conceived (from autologous oocytes, fresh embryos) with the use of ICSI, the risks were increased for a major nonchromosomal birth defect (AOR 1.30, 95% CI 1.16, 1.45 without male factor diagnosis; AOR 1.42, 95% CI 1.28, 1.57 with male factor diagnosis); blastogenesis defects (AOR 1.49, 95% CI 1.08, 2.05 without male factor; AOR 1.56, 95% CI 1.17, 2.08 with male factor); cardiovascular defects (AOR 1.28, 95% CI 1.10,1.48 without male factor; AOR 1.45, 95% CI 1.27, 1.66 with male factor); in addition, the risk for musculoskeletal defects was increased (AOR 1.34, 95% CI 1.01, 1.78 without male factor) and the risk for genitourinary defects in male infants was increased (AOR 1.33, 95% CI 1.08, 1.65 with male factor). Comparisons within ART singleton births conceived from autologous oocytes and fresh embryos indicated that the use of ICSI was associated with increased risks of a major nonchromosomal birth defect (AOR 1.18, 95% CI 1.03, 1.35), blastogenesis defects (AOR 1.65, 95% CI 1.08, 2.51), gastrointestinal defects (AOR 2.21, 95% CI 1.28, 3.82) and any defect (AOR 1.11, 95% CI 1.01, 1.22). Compared to naturally conceived children, ART singleton siblings had increased risks of musculoskeletal defects (AOR 1.32, 95% CI 1.04, 1.67) and any defect (AOR 1.15, 95% CI 1.08, 1.23). ART twins (conceived with autologous oocytes, fresh embryos, without ICSI) were at increased risk of chromosomal defects (AOR 1.89, 95% CI 1.10, 3.24) and ART twin siblings were at increased risk of any defect (AOR 1.26, 95% CI 1.01, 1.57). The 18% increased risk of a major nonchromosomal birth defect in singleton infants conceived with ART without ICSI (∼36% of ART births), the 30% increased risk with ICSI without male factor (∼33% of ART births), and the 42% increased risk with ICSI and male factor (∼31% of ART births) translates into an estimated excess of 386 major birth defects among the 68 908 singleton children born by ART in 2017.
Limitations, reasons for caution: In the SART CORS database, it was not possible to differentiate method of embryo freezing (slow freezing vs vitrification), and data on ICSI was only available in the fresh embryo ART group. In the OI/IUI group, it was not possible to differentiate type of non-ART treatment utilized, and in both the ART and OI/IUI groups, data were unavailable on duration of infertility.
Wider implications of the findings: The use of ART is associated with increased risks of a major nonchromosomal birth defect, cardiovascular defect and any defect in singleton children, and chromosomal defects in twins; the use of ICSI further increases this risk, the most with male factor infertility. These findings support the judicious use of ICSI only when medically indicated. The relative contribution of ART treatment parameters versus the biology of the subfertile couple to this increased risk remains unclear and warrants further study.
Study finding/competing interest(s): This project was supported by grant R01 HD084377 from the National Institute of Child Health and Human Development. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Child Health and Human Development, or the National Institutes of Health, nor any of the State Departments of Health which contributed data. E.W. is a contract vendor for SART; all other authors report no conflicts.

Langlois PH, Canfield MA, et al. Risk factors and time trends for isolated craniosynostosis. Birth Defects Res. 2021 Jan 1;113(1):43-54. doi: 10.1002/bdr2.1824
We sought to investigate associations between maternal/infant characteristics and isolated craniosynostosis as well as its subtypes sagittal, metopic, and coronal synostosis, and assess trends in the prevalence of these conditions.
Methods: We identified cases in the Texas Birth Defects Registry from 1999 to 2014. We used Poisson regression to identify associations between maternal/infant characteristics and craniosynostosis. We used joinpoint regression and unadjusted Poisson regression to evaluate temporal trends. Finally, we computed adjusted Poisson models to evaluate whether temporal trends were evident after accounting for changes in the population distributions of maternal/infant characteristics over time.
Results: Relative to all live births in the general population, cases were more frequently male or preterm. Mothers of cases were more frequently non-Hispanic white and more frequently obese. Non-Hispanic black or Hispanic maternal race/ethnicity was associated with a lower prevalence of all craniosynostosis subtypes. Previous live births were associated with sagittal synostosis; residence on the U.S.-Mexico border was associated with sagittal and coronal synostosis. The prevalence of any isolated craniosynostosis increased (average annual percent change estimated from joinpoint regression [AAPC]: 2.9%), as did the prevalences of sagittal (AAPC: 3.3%) and metopic synostosis (AAPC: 5.4%). In crude Poisson models, the same temporal trends were observed, however these were attenuated after adjusting for maternal/infant characteristics.
Conclusions: Prevalence of isolated craniosynostosis increased from 1999 to 2014. The largest AAPC was observed for metopic synostosis. Changes in the population distribution of associated maternal/infant characteristics may explain these trends.

Langlois PH, et al. Comprehensive assessment of the associations between maternal diabetes and structural birth defects in offspring: A phenome-wide association study. Ann Epidemiol. 2021 Jan;53:14-20.e8. doi: 10.1016/j.annepidem.2020.08.006
Our objective was to comprehensively evaluate the risk of a broad range of birth defects among offspring of women with diabetes, overall and stratified by pregestational versus gestational diagnosis, using the phenome-wide association (PheWAS) methodology.
We performed a registry linkage study of all live births (>6,500,000) and birth defects cases (>290,000) in Texas, 1999-2015. We ascertained diabetes from birth and fetal death certificates. We calculated prevalence rate ratios (PRR) for phenotypes with ≥10 cases among exposed offspring (n = 130).
Diabetes was associated with the prevalence of any defect (PRR 1.40, 95% confidence interval [CI] 1.38-1.42), multiple defects (PRR 1.86, 95% CI 1.81-1.91), and 60 specific phenotypes, including novel (hypospadias, mitral stenosis) and previously reported phenotypes (renal a-/dysgenesis, spinal anomalies). Pregestational diabetes was a stronger risk factor for any defect (PRR 2.00, 95% CI 1.93-2.07), multiple defects (PRR 3.27, 95% CI 3.11-3.44), and the 60 specific phenotypes evaluated. Gestational diabetes was associated with any defect (PRR 1.21, 95% CI 1.19-1.23) and 47 specific birth defects phenotypes, although associations were weaker than for pregestational diabetes.
The PheWAS is an efficient way to identify risk factors for disease using population-based registry data. Pregestational diabetes is associated with a broader range of phenotypes than previously reported. Because diabetes is diagnosed in 1% of women prior to pregnancy and 6%-9% during pregnancy, our results highlight a significant public health concern.

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Last updated May 18, 2022