Genomic surveillance reveals dynamic shifts in the connectivity of COVID-19 epidemics.

The maturation of genomic surveillance in the past decade has enabled tracking of the emergence and spread of epidemics at an unprecedented level. During the COVID-19 pandemic, for example, genomic data revealed that local epidemics varied considerably in the frequency of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) lineage importation and persistence, likely due to a combination of COVID-19 restrictions and changing connectivity. Here, we show that local COVID-19 epidemics are driven by regional transmission, including across international boundaries, but can become increasingly connected to distant locations following the relaxation of public health interventions. By integrating genomic, mobility, and epidemiological data, we find abundant transmission occurring between both adjacent and distant locations, supported by dynamic mobility patterns. We find that changing connectivity significantly influences local COVID-19 incidence. Our findings demonstrate a complex meaning of "local" when investigating connected epidemics and emphasize the importance of collaborative interventions for pandemic prevention and mitigation.

Wastewater sequencing reveals early cryptic SARS-CoV-2 variant transmission.

As SARS-CoV-2 continues to spread and evolve, detecting emerging variants early is critical for public health interventions. Inferring lineage prevalence by clinical testing is infeasible at scale, especially in areas with limited resources, participation, or testing and/or sequencing capacity, which can also introduce biases1-3. SARS-CoV-2 RNA concentration in wastewater successfully tracks regional infection dynamics and provides less biased abundance estimates than clinical testing4,5. Tracking virus genomic sequences in wastewater would improve community prevalence estimates and detect emerging variants. However, two factors limit wastewater-based genomic surveillance: low-quality sequence data and inability to estimate relative lineage abundance in mixed samples. Here we resolve these critical issues to perform a high-resolution, 295-day wastewater and clinical sequencing effort, in the controlled environment of a large university campus and the broader context of the surrounding county. We developed and deployed improved virus concentration protocols and deconvolution software that fully resolve multiple virus strains from wastewater. We detected emerging variants of concern up to 14 days earlier in wastewater samples, and identified multiple instances of virus spread not captured by clinical genomic surveillance. Our study provides a scalable solution for wastewater genomic surveillance that allows early detection of SARS-CoV-2 variants and identification of cryptic transmission.

Sentinel Cards Provide Practical SARS-CoV-2 Monitoring in School Settings.

A promising approach to help students safely return to in person learning is through the application of sentinel cards for accurate high resolution environmental monitoring of SARS-CoV-2 traces indoors. Because SARS-CoV-2 RNA can persist for up to a week on several indoor surface materials, there is a need for increased temporal resolution to determine whether consecutive surface positives arise from new infection events or continue to report past events. Cleaning sentinel cards after sampling would provide the needed resolution but might interfere with assay performance. We tested the effect of three cleaning solutions (BZK wipes, Wet Wipes, RNase Away) at three different viral loads: "high" (4 × 104 GE/mL), "medium" (1 × 104 GE/mL), and "low" (2.5 × 103 GE/mL). RNase Away, chosen as a positive control, was the most effective cleaning solution on all three viral loads. Wet Wipes were found to be more effective than BZK wipes in the medium viral load condition. The low viral load condition was easily reset with all three cleaning solutions. These findings will enable temporal SARS-CoV-2 monitoring in indoor environments where transmission risk of the virus is high and the need to avoid individual-level sampling for privacy or compliance reasons exists. IMPORTANCE Because SARS-CoV-2, the virus that causes COVID-19, persists on surfaces, testing swabs taken from surfaces is useful as a monitoring tool. This approach is especially valuable in school settings, where there are cost and privacy concerns that are eliminated by taking a single sample from a classroom. However, the virus persists for days to weeks on surface samples, so it is impossible to tell whether positive detection events on consecutive days are a persistent signal or new infectious cases and therefore whether the positive individuals have been successfully removed from the classroom. We compare several methods for cleaning "sentinel cards" to show that this approach can be used to identify new SARS-CoV-2 signals day to day. The results are important for determining how to monitor classrooms and other indoor environments for SARS-CoV-2 virus.

Implementation of Practical Surface SARS-CoV-2 Surveillance in School Settings.

Surface sampling for SARS-CoV-2 RNA detection has shown considerable promise to detect exposure of built environments to infected individuals shedding virus who would not otherwise be detected. Here, we compare two popular sampling media (VTM and SDS) and two popular workflows (Thermo and PerkinElmer) for implementation of a surface sampling program suitable for environmental monitoring in public schools. We find that the SDS/Thermo pipeline shows superior sensitivity and specificity, but that the VTM/PerkinElmer pipeline is still sufficient to support surface surveillance in any indoor setting with stable cohorts of occupants (e.g., schools, prisons, group homes, etc.) and may be used to leverage existing investments in infrastructure. IMPORTANCE The ongoing COVID-19 pandemic has claimed the lives of over 5 million people worldwide. Due to high density occupancy of indoor spaces for prolonged periods of time, schools are often of concern for transmission, leading to widespread school closings to combat pandemic spread when cases rise. Since pediatric clinical testing is expensive and difficult from a consent perspective, we have deployed surface sampling in SASEA (Safer at School Early Alert), which allows for detection of SARS-CoV-2 from surfaces within a classroom. In this previous work, we developed a high-throughput method which requires robotic automation and specific reagents that are often not available for public health laboratories such as the San Diego County Public Health Laboratory (SDPHL). Therefore, we benchmarked our method (Thermo pipeline) against SDPHL's (PerkinElmer) more widely used method for the detection and prediction of SARS-CoV-2 exposure. While our method shows superior sensitivity (false-negative rate of 9% versus 27% for SDPHL), the SDPHL pipeline is sufficient to support surface surveillance in indoor settings. These findings are important since they show that existing investments in infrastructure can be leveraged to slow the spread of SARS-CoV-2 not in just the classroom but also in prisons, nursing homes, and other high-risk, indoor settings.

Industry-specific prevalence of elevated blood lead levels among Pennsylvania workers, 2007-2018.

OBJECTIVES: To use industry-specific denominators to more accurately examine trends in prevalence rates for occupational cases of elevated blood lead levels (eBLLs) in Pennsylvania. METHODS: We used adult (aged ≥16 years) blood lead level data from Pennsylvania (2007-2018) and industry-specific denominator data from the US Census Bureau's County Business Patterns to calculate prevalence rates for eBLLs, defined as ≥25 µg/dL. RESULTS: Of the 19 904 cases with eBLLs, 92% were due to occupational lead exposure, with 83% from workers in the battery manufacturing industry. In 2018, the prevalence rate of eBLLs for battery manufacturing (8036.4 cases per 100 000 employed battery manufacturing workers) was 543 times the overall Pennsylvania prevalence rate. The prevalence rate for battery manufacturing steeply declined 71% from 2007 to 2018. CONCLUSIONS: The battery manufacturing industry had the highest burden of occupational lead exposure in Pennsylvania, illustrating the importance of using industry-specific denominators to accurately identify sources of lead exposure. Although the prevalence rate of eBLLs declined over time, lead exposure remains a major concern among battery manufacturing workers.

SARS-CoV-2 Distribution in Residential Housing Suggests Contact Deposition and Correlates with Rothia sp.

Monitoring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on surfaces is emerging as an important tool for identifying past exposure to individuals shedding viral RNA. Our past work demonstrated that SARS-CoV-2 reverse transcription-quantitative PCR (RT-qPCR) signals from surfaces can identify when infected individuals have touched surfaces and when they have been present in hospital rooms or schools. However, the sensitivity and specificity of surface sampling as a method for detecting the presence of a SARS-CoV-2 positive individual, as well as guidance about where to sample, has not been established. To address these questions and to test whether our past observations linking SARS-CoV-2 abundance to Rothia sp. in hospitals also hold in a residential setting, we performed a detailed spatial sampling of three isolation housing units, assessing each sample for SARS-CoV-2 abundance by RT-qPCR, linking the results to 16S rRNA gene amplicon sequences (to assess the bacterial community at each location), and to the Cq value of the contemporaneous clinical test. Our results showed that the highest SARS-CoV-2 load in this setting is on touched surfaces, such as light switches and faucets, but a detectable signal was present in many untouched surfaces (e.g., floors) that may be more relevant in settings, such as schools where mask-wearing is enforced. As in past studies, the bacterial community predicts which samples are positive for SARS-CoV-2, with Rothia sp. showing a positive association. IMPORTANCE Surface sampling for detecting SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is increasingly being used to locate infected individuals. We tested which indoor surfaces had high versus low viral loads by collecting 381 samples from three residential units where infected individuals resided, and interpreted the results in terms of whether SARS-CoV-2 was likely transmitted directly (e.g., touching a light switch) or indirectly (e.g., by droplets or aerosols settling). We found the highest loads where the subject touched the surface directly, although enough virus was detected on indirectly contacted surfaces to make such locations useful for sampling (e.g., in schools, where students did not touch the light switches and also wore masks such that they had no opportunity to touch their face and then the object). We also documented links between the bacteria present in a sample and the SARS-CoV-2 virus, consistent with earlier studies.

Wastewater sequencing uncovers early, cryptic SARS-CoV-2 variant transmission.

As SARS-CoV-2 continues to spread and evolve, detecting emerging variants early is critical for public health interventions. Inferring lineage prevalence by clinical testing is infeasible at scale, especially in areas with limited resources, participation, or testing/sequencing capacity, which can also introduce biases. SARS-CoV-2 RNA concentration in wastewater successfully tracks regional infection dynamics and provides less biased abundance estimates than clinical testing. Tracking virus genomic sequences in wastewater would improve community prevalence estimates and detect emerging variants. However, two factors limit wastewater-based genomic surveillance: low-quality sequence data and inability to estimate relative lineage abundance in mixed samples. Here, we resolve these critical issues to perform a high-resolution, 295-day wastewater and clinical sequencing effort, in the controlled environment of a large university campus and the broader context of the surrounding county. We develop and deploy improved virus concentration protocols and deconvolution software that fully resolve multiple virus strains from wastewater. We detect emerging variants of concern up to 14 days earlier in wastewater samples, and identify multiple instances of virus spread not captured by clinical genomic surveillance. Our study provides a scalable solution for wastewater genomic surveillance that allows early detection of SARS-CoV-2 variants and identification of cryptic transmission.

SARS-CoV-2 Distribution in Residential Housing Suggests Contact Deposition and Correlates with Rothia sp.

Monitoring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on surfaces is emerging as an important tool for identifying past exposure to individuals shedding viral RNA. Our past work has demonstrated that SARS-CoV-2 reverse transcription-quantitative PCR (RT-qPCR) signals from surfaces can identify when infected individuals have touched surfaces such as Halloween candy, and when they have been present in hospital rooms or schools. However, the sensitivity and specificity of surface sampling as a method for detecting the presence of a SARS-CoV-2 positive individual, as well as guidance about where to sample, has not been established. To address these questions, and to test whether our past observations linking SARS-CoV-2 abundance to Rothia spp. in hospitals also hold in a residential setting, we performed detailed spatial sampling of three isolation housing units, assessing each sample for SARS-CoV-2 abundance by RT-qPCR, linking the results to 16S rRNA gene amplicon sequences to assess the bacterial community at each location and to the Cq value of the contemporaneous clinical test. Our results show that the highest SARS-CoV-2 load in this setting is on touched surfaces such as light switches and faucets, but detectable signal is present in many non-touched surfaces that may be more relevant in settings such as schools where mask wearing is enforced. As in past studies, the bacterial community predicts which samples are positive for SARS-CoV-2, with Rothia sp. showing a positive association. IMPORTANCE: Surface sampling for detecting SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is increasingly being used to locate infected individuals. We tested which indoor surfaces had high versus low viral loads by collecting 381 samples from three residential units where infected individuals resided, and interpreted the results in terms of whether SARS-CoV-2 was likely transmitted directly (e.g. touching a light switch) or indirectly (e.g. by droplets or aerosols settling). We found highest loads where the subject touched the surface directly, although enough virus was detected on indirectly contacted surfaces to make such locations useful for sampling (e.g. in schools, where students do not touch the light switches and also wear masks so they have no opportunity to touch their face and then the object). We also documented links between the bacteria present in a sample and the SARS-CoV-2 virus, consistent with earlier studies.

Analysis of SARS-CoV-2 RNA Persistence across Indoor Surface Materials Reveals Best Practices for Environmental Monitoring Programs.

Environmental monitoring in public spaces can be used to identify surfaces contaminated by persons with coronavirus disease 2019 (COVID-19) and inform appropriate infection mitigation responses. Research groups have reported detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on surfaces days or weeks after the virus has been deposited, making it difficult to estimate when an infected individual may have shed virus onto a SARS-CoV-2-positive surface, which in turn complicates the process of establishing effective quarantine measures. In this study, we determined that reverse transcription-quantitative PCR (RT-qPCR) detection of viral RNA from heat-inactivated particles experiences minimal decay over 7 days of monitoring on eight out of nine surfaces tested. The properties of the studied surfaces result in RT-qPCR signatures that can be segregated into two material categories, rough and smooth, where smooth surfaces have a lower limit of detection. RT-qPCR signal intensity (average quantification cycle [Cq]) can be correlated with surface viral load using only one linear regression model per material category. The same experiment was performed with untreated viral particles on one surface from each category, with essentially identical results. The stability of RT-qPCR viral signal demonstrates the need to clean monitored surfaces after sampling to establish temporal resolution. Additionally, these findings can be used to minimize the number of materials and time points tested and allow for the use of heat-inactivated viral particles when optimizing environmental monitoring methods. IMPORTANCE Environmental monitoring is an important tool for public health surveillance, particularly in settings with low rates of diagnostic testing. Time between sampling public environments, such as hospitals or schools, and notifying stakeholders of the results should be minimal, allowing decisions to be made toward containing outbreaks of coronavirus disease 2019 (COVID-19). The Safer At School Early Alert program (SASEA) (https://saseasystem.org/), a large-scale environmental monitoring effort in elementary school and child care settings, has processed >13,000 surface samples for SARS-CoV-2, detecting viral signals from 574 samples. However, consecutive detection events necessitated the present study to establish appropriate response practices around persistent viral signals on classroom surfaces. Other research groups and clinical labs developing environmental monitoring methods may need to establish their own correlation between RT-qPCR results and viral load, but this work provides evidence justifying simplified experimental designs, like reduced testing materials and the use of heat-inactivated viral particles.

Comparison of heat-inactivated and infectious SARS-CoV-2 across indoor surface materials shows comparable RT-qPCR viral signal intensity and persistence.

Environmental monitoring in public spaces can be used to identify surfaces contaminated by persons with COVID-19 and inform appropriate infection mitigation responses. Research groups have reported detection of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) on surfaces days or weeks after the virus has been deposited, making it difficult to estimate when an infected individual may have shed virus onto a SARS-CoV-2 positive surface, which in turn complicates the process of establishing effective quarantine measures. In this study, we determined that reverse transcription-quantitative polymerase chain reaction (RT-qPCR) detection of viral RNA from heat-inactivated particles experiences minimal decay over seven days of monitoring on eight out of nine surfaces tested. The properties of the studied surfaces result in RT-qPCR signatures that can be segregated into two material categories, rough and smooth, where smooth surfaces have a lower limit of detection. RT-qPCR signal intensity (average quantification cycle (Cq)) can be correlated to surface viral load using only one linear regression model per material category. The same experiment was performed with infectious viral particles on one surface from each category, with essentially identical results. The stability of RT-qPCR viral signal demonstrates the need to clean monitored surfaces after sampling to establish temporal resolution. Additionally, these findings can be used to minimize the number of materials and time points tested and allow for the use of heat-inactivated viral particles when optimizing environmental monitoring methods.

Prevalence of Diagnosed Diabetes Among Employed US Adults by Demographic Characteristics and Occupation, 36 States, 2014 to 2018.

OBJECTIVE: To assess the prevalence of diagnosed diabetes among employed US adults from 36 states by occupation group using data from 2014 to 2018 Behavioral Risk Factor Surveillance System. METHODS: Prevalence of diabetes was calculated by 22 broad and 93 detailed occupation groups among a sample of 366,633 employed respondents. Wald chi-square values were used to determine the significance of associations between diabetes and occupation groups after adjusting for sex, age, and race/ethnicity. RESULTS: The prevalence of diabetes was 6.4% among employed US adults. The three broad occupation groups with the highest adjusted prevalence of diabetes were protective services (8.9%), farming, fishing, and forestry (8.8%), and community and social services (8.4%). CONCLUSIONS: Prevalence of diabetes differed by occupation. Work-related factors (eg, shift work, job stress) should be further examined in relation to risk of developing diabetes.

Development of Job Exposure Matrices to Estimate Occupational Exposure to Solar and Artificial Ultraviolet Radiation.

OBJECTIVES: Job exposure matrices (JEMs) are important tools for estimating occupational exposures in study populations where only information on industry and occupation (I&O) are available. JEMs The objective of this work was to create JEMs for solar and artificial ultraviolet radiation (UVR) using a US standardized coding scheme. METHODS: Using U.S. Census Bureau industry and occupation codes, separate lists of I&O pairs were developed for solar and artificial UVR by a panel of Certified Industrial Hygienists who assigned exposure ratings to I&O pairs with potential exposure. Parameters for exposure included prevalence (P) and frequency (F) for solar UVR and P, F, and intensity (I) for artificial UVR. Prevalence, or percent of all workers employed in an I&O pair who were exposed, was categorically rated: 0 to <1, 1 to <20; 20 to <80, and ≥80. Frequency of exposure, defined by the number of hours per week workers were exposed, was categorically rated: 0 to <5, 5 to <20, 20 to <35, and ≥35 h per week. For artificial UVR only, intensity of exposure was assigned three ratings: low, low with rare excursions, and >low under normal conditions. Discrepant ratings were resolved via consensus. RESULTS: After excluding I&O pairs assigned P and F ratings of 0 (solar UVR) and P, F, and I ratings of 0 (artificial UVR) from the JEM, 9206 I&O pairs were rated for solar UVR and 2010 I&O pairs for artificial UVR. For solar UVR, 723 (7.9% of all rated pairs) had ratings in the highest category for P and F; this group included 45 occupations in varied industries. Construction and extraction occupations represented most of the occupations (n = 20; 44%), followed by farming, fishing, and forestry occupations (n = 6; 13%). For artificial UVR, 87 I&O pairs (4.3% of all rated pairs) had maximum ratings for P, F, and I; these comprised a single occupation (welding, soldering, and brazing workers) in diverse industries. CONCLUSIONS: JEMs for solar and artificial UVR were developed for a broad range of I&O pairs in the US population and are available for use by researchers conducting occupational epidemiological studies.

Using mobile multimedia platforms in teaching dental diagnosis.

OBJECTIVE: Mobile Multimedia Platforms (MMPs) are prolific tools that can be used by individuals and corporations to share content. However, few studies have shown the effectiveness of MMPs as educational tools. Through this study, we aimed to evaluate the effectiveness of MMPs in improving basic dental diagnostic skills. In addition, we captured student feedback on the use of MMPs in a dental curriculum. METHOD: In this voluntary interventional study on 89 senior dental students, we created pilot learning modules through an MMP called Instagram Stories to teach dental diagnosis. We evaluated the efficacy of the modules through diagnostic tests that were given to dental students who were close to graduating. RESULTS: The students showed a significant increase in diagnostic test scores from 49% to 73% (p < 0.05) after the use of an MMP. Furthermore, the students' feedback on the MMP indicated that most students found it easy and enjoyable to use. CONCLUSION: Our study data show that MMPs may be used to improve training in basic dental diagnostic skills and can serve as an adjunct teaching tool. Moreover, MMP modules can potentially enrich professional education in developing countries where access to educational resources is limited.

Type II Restriction of Bacteriophage DNA With 5hmdU-Derived Base Modifications.

To counteract bacterial defense systems, bacteriophages (phages) make extensive base modifications (substitutions) to block endonuclease restriction. Here we evaluated Type II restriction of three thymidine (T or 5-methyldeoxyuridine, 5mdU) modified phage genomes: Pseudomonas phage M6 with 5-(2-aminoethyl)deoxyuridine (5-NedU), Salmonella phage ViI (Vi1) with 5-(2-aminoethoxy)methyldeoxyuridine (5-NeOmdU) and Delftia phage phi W-14 (a.k.a. ΦW-14) with α-putrescinylthymidine (putT). Among >200 commercially available restriction endonucleases (REases) tested, phage M6, ViI, and phi W-14 genomic DNAs (gDNA) show resistance against 48.4, 71.0, and 68.8% of Type II restrictions, respectively. Inspection of the resistant sites indicates the presence of conserved dinucleotide TG or TC (TS, S=C, or G), implicating the specificity of TS sequence as the target that is converted to modified base in the genomes. We also tested a number of DNA methyltransferases (MTases) on these phage DNAs and found some MTases can fully or partially modify the DNA to confer more resistance to cleavage by REases. Phage M6 restriction fragments can be efficiently ligated by T4 DNA ligase. Phi W-14 restriction fragments show apparent reduced rate in E. coli exonuclease III degradation. This work extends previous studies that hypermodified T derived from 5hmdU provides additional resistance to host-encoded restrictions, in parallel to modified cytosines, guanine, and adenine in phage genomes. The results reported here provide a general guidance to use REases to map and clone phage DNA with hypermodified thymidine.

Availability of and Participation in Workplace Health Promotion Programs by Sociodemographic, Occupation, and Work Organization Characteristics in US Workers.

PURPOSE: To examine how the availability of and participation in workplace health promotion programs (WHPPs) vary as a function of sociodemographic, occupation, and work organization characteristics. DESIGN: Cross-sectional study. SETTING: 2015 National Health Interview Survey and Occupational Health Supplement. PARTICIPANTS: The study sample included 17 469 employed adults who completed the WHPP questions. MEASURES: The 2 dependent outcome measures were availability of WHPPs and participation in these programs when available. Independent variables included occupation and 8 work organization and employment characteristics: company size, hours worked, supervisory responsibility, hourly pay, paid sick leave, health insurance offered by employer, work schedule, and work arrangement. ANALYSIS: Poisson regression analyses were conducted with SUDAAN 11.0.1. RESULTS: Overall, 57.8% of 46.6% employees who have WHPPs available reported participating in these programs. This study found that adults who worked ≤20 h/wk, worked regular night shifts, were paid by the hour, or worked for temporary agencies were less likely to participate in WHPPs. Workers who supervised others were 13% more likely to participate than nonsupervisors. Borderline associations were seen for having access to employer-sponsored health insurance and working at a site with <10 employees. CONCLUSION: Despite the potential for improving physical and mental health, only 58% of US workers participated in WHPPs. Since barriers to WHPP participation (eg, time constraints, lack of awareness, and no perceived need) may vary across occupations and work organization characteristics, employers should tailor WHPPs based on their specific work organization characteristics to maximize participation.

Trust in the Work Environment and Cardiovascular Disease Risk: Findings from the Gallup-Sharecare Well-Being Index.

This study examined associations between trust, an important aspect of workplace social capital, with seven cardiovascular disease (CVD) risk factors (American Heart Association Life's Simple 7 (LS7)): smoking, obesity, low physical activity, poor diet, diabetes, high cholesterol, and high blood pressure. Data are from the U.S. Gallup-Sharecare Well-Being Index (2010⁻2012), a nationally representative telephone survey of U.S. workers (n = 412,884). The independent variable was the response to a work environment (WE) question as to whether their supervisor always creates an open and trusting environment. Regression models were adjusted for demographic characteristics with each of the LS7 CVD risk factors as dependent variables. Twenty-one percent of workers reported that their supervisor did not create an open and trusting environment. Trust was associated with increased adjusted odds of having many of the LS7 CVD risk factors. Among those workers whose supervisor created a mistrustful environment, the odds ratios were greatest (>20%) for having four or more of the LS7 CVD risk factors.

Integrating Childhood and Adult Blood Lead Surveillance to Improve Identification and Intervention Efforts.

The Centers for Disease Control and Prevention (CDC) collects information on blood lead levels (BLLs) in the United States through the Childhood Blood Lead Surveillance (CBLS) system (<16 years of age) and the Adult Blood Lead Epidemiology and Surveillance (ABLES) program (≥16 years of age). While both of these state-based national programs share the mutual goal of monitoring and reducing lead exposure in the US population, blood lead data for children and adults are maintained in separate data collection systems. This limits the ability to fully describe lead exposure in the US population across these 2 distinct population groups from sources such as take-home and maternal-child lead exposure. In addition, at the state level, having a unified system to collect, maintain, and analyze child and adult blood lead data provides a more efficient use of limited resources. Based on feedback from state partners, CDC is working to integrate CBLS and ABLES data collection systems at the national level. Several states have developed or are developing an integrated child and adult blood lead data collection system. We highlight efforts undertaken in Wisconsin, Minnesota, North Carolina, Iowa, and Oregon to investigate workplace and take-home lead exposure. Integrating blood lead surveillance data at the national level will enhance CDC's ability to monitor sources of lead exposure from both the home and work environments including paint, water, soil, dust, consumer products, and lead-related industries. Together, an integrated child and adult blood lead surveillance system will offer a coordinated, comprehensive, and systematic public health approach to the surveillance and monitoring of reported BLLs across the US population.

Lymphedema following breast cancer: The importance of surgical methods and obesity.

BACKGROUND: Breast cancer-related arm lymphedema is a serious complication that can adversely affect quality of life. Identifying risk factors that contribute to the development of lymphedema is vital for identifying avenues for prevention. The aim of this study was to examine the association between the development of arm lymphedema and both treatment and personal (e.g., obesity) risk factors. METHODS: Women diagnosed with breast cancer in Iowa during 2004 and followed through 2010, who met eligibility criteria, were asked to complete a short computer assisted telephone interview about chronic conditions, arm activities, demographics, and lymphedema status. Lymphedema was characterized by a reported physician-diagnosis, a difference between arms in the circumference (> 2cm), or the presence of multiple self-reported arm symptoms (at least two of five major arm symptoms, and at least four total arm symptoms). Relative risks (RR) were estimated using logistic regression. RESULTS: Arm lymphedema was identified in 102 of 522 participants (19.5%). Participants treated by both axillary dissection and radiation therapy were more likely to have arm lymphedema than treated by either alone. Women with advanced cancer stage, positive nodes, and larger tumors along with a body mass index > 40 were also more likely to develop lymphedema. Arm activity level was not associated with lymphedema. CONCLUSIONS: Surgical methods, cancer characteristics and obesity were found to contribute to the development of arm lymphedema. Vigorous arm activity post-surgery was not found to increase the risk of arm lymphedema.

Codability of industry and occupation information from cancer registry records: Differences by patient demographics, casefinding source, payor, and cancer type.

INTRODUCTION: Industry and occupation (I&O) information collected by cancer registries is useful for assessing associations among jobs and malignancies. However, systematic differences in I&O availability can bias findings. METHODS: Codability by patient demographics, payor, identifying (casefinding) source, and cancer site was assessed using I&O text from first primaries diagnosed 2011-2012 and reported to California Cancer Registry. I&O were coded to a U.S. Census code or classified as blank/inadequate/unknown, retired, or not working for pay. RESULTS: Industry was codable for 37% of cases; 50% had "unknown" and 9% "retired" instead of usual industry. Cases initially reported by hospitals, covered by preferred providers, or with known occupational etiology had highest codable industry; cases from private pathology laboratories, with Medicaid, or diagnosed in outpatient settings had least. Occupation results were similar. CONCLUSIONS: Recording usual I&O for retirees and improving linkages for reporting entities without patient access would improve I&O codability and research validity.

Restriction and modification of deoxyarchaeosine (dG+)-containing phage 9 g DNA.

E. coli phage 9 g contains the modified base deoxyarchaeosine (dG+) in its genome. The phage encodes its own primase, DNA ligase, DNA polymerase, and enzymes necessary to synthesize and incorporate dG+. Here we report phage 9 g DNA sensitivity to >200 Type II restriction endonucleases (REases). Among the REases tested approximately 29% generated complete or partial digestions, while the remaining 71% displayed resistance to restriction. Phage 9 g restriction fragments can be degraded by DNA exonucleases or ligated by T3 and T4 DNA ligases. In addition, we examined a number of cytosine and adenine methyltransferases to generate double base modifications. M.AluI, M.CviPI, M.HhaI, and M.EcoGII were able to introduce 5mC or N6mA into 9 g DNA as confirmed by partial resistance to restriction and by liquid chromatography-mass spectrometry. A number of wild-type E. coli bacteria restricted phage 9 g, indicating natural restriction barriers exist in some strains. A BlastP search of GenBank sequences revealed five glutamine amidotransferase-QueC homologs in Enterobacteria and Pseudomonas phage, and distant homologs in other phage and bacterial genomes, suggesting that dG+ is not a rare modification. We also mapped phage 9 g DNA packaging (pac) site containing two 21-bp direct repeats and a major terminase cleavage site in the phage genome.