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Article ; Online: Detecting tuberculosis in pregnant and postpartum women in Eswatini

Munyaradzi Pasipamire / Edward Broughton / Mandzisi Mkhontfo / Gugu Maphalala / Batsabile Simelane-Vilane / Samson Haumba

African Journal of Laboratory Medicine, Vol 9, Iss 1, Pp e1-e

2020 Volume 9

Abstract: Background: Tuberculosis diagnosis in pregnancy is complex because tuberculosis symptoms are often masked by physiological symptoms of pregnancy. Untreated tuberculosis in pregnant and postpartum women may lead to maternal morbidity and low birth weight. ...

Abstract	Background: Tuberculosis diagnosis in pregnancy is complex because tuberculosis symptoms are often masked by physiological symptoms of pregnancy. Untreated tuberculosis in pregnant and postpartum women may lead to maternal morbidity and low birth weight. Tuberculosis in HIV-positive pregnant women increases the risk of maternal and infant mortality. Objective: This study aimed to determine tuberculosis prevalence stratified by HIV status and identify screening algorithms that maximise detection of active tuberculosis among pregnant and postpartum women in Eswatini. Methods: Women were enrolled at antenatal and postnatal clinics in Eswatini for tuberculosis screening and diagnostic investigations from 01 April to 30 November 2015 in a cross-sectional study. Sputum samples were collected from all participants for tuberculosis diagnostic tests (smear microscopy, GeneXpert, MGIT culture). Blood and urine samples were collected from HIV-positive women for cluster-of-differentiation-4 cell count, interferon gamma release assay and tuberculosis lateral flow urine lipoarabinomannan tests. Results: We enrolled 990 women; 52% were pregnant and 47% were HIV-positive. The prevalence of tuberculosis among HIV-positive pregnant women was 5% (95% confidence interval [CI]: 2–7) and among postpartum women it was 1% (95%CI: -1–3). Tuberculosis prevalence was 2% (95%CI: 0–3) in HIV-negative pregnant women and 1% (95%CI: -1–2) in HIV-negative postpartum women. The national tuberculosis symptom screening tool failed to identify women who tested tuberculosis-culture positive. Conclusion: Routine tuberculosis symptom screening alone is insufficient to rule out tuberculosis in pregnant and postpartum women. Only sputum culture maximised the detection of tuberculosis, indicating a need to balance access and cost in developing countries.
Keywords	tuberculosis ; pregnant women ; postpartum women ; tuberculosis screening ; tuberculosis diagnosis ; hiv ; eswatini ; Public aspects of medicine ; RA1-1270 ; Medicine (General) ; R5-920
Language	English
Publishing date	2020-07-01T00:00:00Z
Publisher	AOSIS
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Enhanced Integration of TB Services in Reproductive Maternal Newborn and Child Health (RMNCH) Settings in Eswatini.

Kieran Hartsough / Chloe A Teasdale / Siphesihle Shongwe / Amanda Geller / Eduarda Pimentel De Gusmao / Phumzile Dlamini / Arnold Mafukidze / Munyaradzi Pasipamire / Trong Ao / Caroline Ryan / Surbhi Modi / Elaine J Abrams / Andrea A Howard

PLOS Global Public Health, Vol 2, Iss 4, p e

2022 Volume 0000217

Abstract: Tuberculosis (TB) primarily affects women during their reproductive years and contributes to maternal mortality and poor pregnancy outcomes. For pregnant women living with HIV (WLHIV), TB is the leading cause of non-obstetric maternal mortality, and ... ...

Abstract	Tuberculosis (TB) primarily affects women during their reproductive years and contributes to maternal mortality and poor pregnancy outcomes. For pregnant women living with HIV (WLHIV), TB is the leading cause of non-obstetric maternal mortality, and pregnant WLHIV with TB are at increased risk of transmitting both TB and HIV to their infants. TB diagnosis among pregnant women, particularly WLHIV, remains challenging, and TB preventive treatment (TPT) coverage among pregnant WLHIV is limited. This project aimed to strengthen integrated TB and reproductive, maternal, neonatal and child health (RMNCH) services in Eswatini to improve screening and treatment for TB disease, TPT uptake and completion among women receiving RMNCH services. The project was conducted from April-December 2017 at four health facilities in Eswatini and introduced enhanced monitoring tools and on-site technical support in RMNCH services. We present data on TB case finding among women, and TPT coverage and completion among eligible WLHIV. A questionnaire (S1 Appendix) measured healthcare provider perspectives on the project after three months of project implementation, including feasibility of scaling-up integrated TB and RMNCH services. A total of 5,724 women (HIV-negative or WLHIV) were screened for active TB disease while attending RMNCH services; 53 (0.9%) were identified with presumptive TB, of whom 37 (70%) were evaluated for TB disease and 6 (0.1% of those screened) were diagnosed with TB. Among 1,950 WLHIV who screened negative for TB, 848 (43%) initiated TPT and 462 (54%) completed. Forty-three healthcare providers completed the questionnaire, and overall were highly supportive of integrated TB and RMNCH services. Integration of TB/HIV services in RMNCH settings was feasible and ensured high TB screening coverage among women of reproductive age, however, symptom screening identified few TB cases, and further studies should explore various screening algorithms and diagnostics that optimize case finding in this population. Interventions ...
Keywords	Public aspects of medicine ; RA1-1270
Subject code	360
Language	English
Publishing date	2022-01-01T00:00:00Z
Publisher	Public Library of Science (PLoS)
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Prevalence of cryptococcal antigen (CrAg) among HIV-positive patients in Eswatini, 2014–2015

Samson M. Haumba / Mitsuru Toda / Rossana Jeffries / Peter Ehrenkranz / Munyaradzi Pasipamire / Trong Ao / Nomthandazo Lukhele / Sikhathele Mazibuko / Mandzisi Mkhontfo / Rachel M. Smith / Tom Chiller

African Journal of Laboratory Medicine, Vol 9, Iss 1, Pp e1-e

2020 Volume 7

Abstract: Background: Cryptococcal meningitis is a leading cause of death amongst people living with HIV. However, routine cryptococcal antigen (CrAg) screening was not in the national guidelines in Eswatini. Objectives: A cross-sectional study was conducted ... ...

Abstract	Background: Cryptococcal meningitis is a leading cause of death amongst people living with HIV. However, routine cryptococcal antigen (CrAg) screening was not in the national guidelines in Eswatini. Objectives: A cross-sectional study was conducted between August 2014 and March 2015 to examine CrAg prevalence at Mbabane Government Hospital in Eswatini. Methods: We collected urine and whole blood from antiretroviral-therapy-naïve patients with HIV and a cluster of differentiation 4 (CD4) counts 200 cells/mm3 for plasma and urine CrAg lateral flow assay (LFA) screening at the national HIV reference laboratory. Two CD4 cut-off points were used to estimate CrAg prevalence: CD4 100 and 200 cells/mm3. Sensitivity and specificity of urine CrAg LFA was compared to plasma CrAg LFA. Results: Plasma CrAg prevalence was 4% (8/182, 95% confidence interval [CI]: 2–8) amongst patients with CD4 counts of 200 cells/mm3, and 8% (8/102, 95% CI: 3–15) amongst patients with CD4 counts of 100 cells/mm3. Urine CrAg LFA had a sensitivity of 100% (95% CI: 59–100) and a specificity of 80% (95% CI: 72–86) compared with plasma CrAg LFA tests for patients with CD4 200 cells/mm3. Forty-three per cent of 99 patients with CD4 100 were at World Health Organization clinical stages I or II. Conclusion: The prevalence of CrAg in Eswatini was higher than the current global estimate of 6% amongst HIV-positive people with CD4 100 cell/mm3, indicating the importance of initiating a national screening programme. Mechanisms for CrAg testing, training, reporting, and drug and commodity supply issues are important considerations before national implementation.
Keywords	cryptococcal antigenaemia screening ; prevalence ; people living with hiv ; cryptococcal meningitis ; advanced hiv disease package ; eswatini ; Public aspects of medicine ; RA1-1270 ; Medicine (General) ; R5-920
Subject code	610
Language	English
Publishing date	2020-07-01T00:00:00Z
Publisher	AOSIS
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Identification of misdiagnosed HIV clients in an Early Access to ART for All implementation study in Swaziland

Shaukat Khan / Emma Mafara / Munyaradzi Pasipamire / Donna Spiegelman / Sikhathele Mazibuko / Nombuso Ntshalintshali / Anita Hettema / Charlotte Lejeune / Fiona Walsh / Velephi Okello

Journal of the International AIDS Society , Vol 20, Iss S6, Pp 28-

2017 Volume 34

Abstract: Introduction: Rapid diagnostic testing has made HIV diagnosis and subsequent treatment more accessible. However, multiple factors, including improper implementation of testing strategies and clerical errors, have been reported to lead to HIV misdiagnosis. ...

Abstract	Introduction: Rapid diagnostic testing has made HIV diagnosis and subsequent treatment more accessible. However, multiple factors, including improper implementation of testing strategies and clerical errors, have been reported to lead to HIV misdiagnosis. The World Health Organization has recommended HIV retesting prior to antiretroviral therapy (ART) initiation which has become pertinent with scaling up of Early Access to ART for All (EAAA). In this analysis, misdiagnosed clients are identified from a subgroup of clients enrolled in EAAA implementation study in Swaziland. Methods: The subgroup to assess misdiagnosis was identified from enrolled EAAA study clients, who had an undetectable viral load prior to ART initiation between September 1, 2014 and May 31, 2016. One hundred and five of 2533 (4%) clients had an undetectable viral load prior to initiation to ART (pre-ART). The HIV status of clients was confirmed using the Determine HIV 1/2 and Uni-Gold HIV 1/2 rapid tests performed serially as recommended by the national testing algorithm. The status of clients on ART was additionally confirmed by fourth-generation HIV Ag/Ab combo tests, Architect and Genscreen Ultra. Results: Fourteen of the 105 (13%) clients were false positive (HIV negative) on confirmation testing, of whom five (36%) were still in pre-ART care, while nine (64%) were in ART care. Overall, proportion of false positive was 0.6% (14/2533). The false-positive clients had a median CD4 of 791 cells/ml (interquartile range (IQR): 628, 967) compared to 549 cells/ml (IQR: 387, 791) for true positives (HIV positive) (p = 0.0081) and were nearly 20 years older (p = 0.0008). Conclusions: Overall 0.6% of all enrolled EAAA clients were misdiagnosed, and 64% of misdiagnosed clients were initiated on ART. With adoption of EAAA guidelines by national governments, ART initiation regardless of immunological criteria, strengthening of proficiency testing and adoption of retesting prior to ART initiation would allow identification of misdiagnosed clients and further reduce potential of initiating misdiagnosed clients on ART.
Keywords	Early Access to ART for All ; HIV misdiagnosis ; HIV false positive ; treatment for all ; Universal test and treat ; Swaziland ; HIV testing ; Medicine ; R ; Political science ; J ; Social Sciences ; H ; Immunologic diseases. Allergy ; RC581-607
Subject code	700
Language	English
Publishing date	2017-08-01T00:00:00Z
Publisher	Wiley
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: High uptake of antiretroviral therapy among HIV-positive TB patients receiving co-located services in Swaziland.

Ishani Pathmanathan / Munyaradzi Pasipamire / Sherri Pals / E Kainne Dokubo / Peter Preko / Trong Ao / Sikhathele Mazibuko / Janet Ongole / Themba Dhlamini / Samson Haumba

PLoS ONE, Vol 13, Iss 5, p e

2018 Volume 0196831

Abstract: Swaziland has the highest adult HIV prevalence and second highest rate of TB/HIV coinfection globally. Recently, the Ministry of Health and partners have increased integration and co-location of TB/HIV services, but the timing of antiretroviral therapy ( ... ...

Abstract	Swaziland has the highest adult HIV prevalence and second highest rate of TB/HIV coinfection globally. Recently, the Ministry of Health and partners have increased integration and co-location of TB/HIV services, but the timing of antiretroviral therapy (ART) relative to TB treatment-a marker of program quality and predictor of outcomes-is unknown.We conducted a retrospective analysis of programmatic data from 11 purposefully-sampled facilities to evaluate timely ART provision for HIV-positive TB patients enrolled on TB treatment between July-November 2014. Timely ART was defined as within two weeks of TB treatment initiation for patients with CD4<50/μL or missing, and within eight weeks otherwise. Descriptive statistics were estimated and logistic regression used to assess factors independently associated with timely ART.Of 466 HIV-positive TB patients, 51.5% were male, median age was 35 (interquartile range [IQR]: 29-42), and median CD4 was 137/μL (IQR: 58-268). 189 (40.6%) were on ART prior to, and five (1.8%) did not receive ART within six months of TB treatment initiation. Median time to ART after TB treatment initiation was 15 days (IQR: 14-28). Almost 90% started ART within eight weeks, and 45.5% of those with CD4<50/μL started within two weeks. Using thresholds for "timely ART" according to baseline CD4 count, 73.3% of patients overall received timely ART after TB treatment initiation. Patients with CD4 50-200/μL or ≥200/μL had significantly higher odds of timely ART than patients with CD4<50/μL, with adjusted odds ratios of 11.5 (95% confidence interval [CI]: 5.0-26.6) and 9.6 (95% CI: 4.6-19.9), respectively. TB cure or treatment completion was achieved by 71.1% of patients at six months, but this was not associated with timely ART.This study demonstrates the relative success of integrated and co-located TB/HIV services in Swaziland, and shows that timely ART uptake for HIV-positive TB patients can be achieved in resource-limited, but integrated settings. Gaps remain in getting patients with ...
Keywords	Medicine ; R ; Science ; Q
Subject code	700
Language	English
Publishing date	2018-01-01T00:00:00Z
Publisher	Public Library of Science (PLoS)
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Challenges and successes in the implementation of option B+ to prevent mother-to-child transmission of HIV in southern Swaziland

David Etoori / Bernhard Kerschberger / Nelly Staderini / Mpumelelo Ndlangamandla / Bonisile Nhlabatsi / Kiran Jobanputra / Simangele Mthethwa-Hleza / Lucy Anne Parker / Sifiso Sibanda / Edwin Mabhena / Munyaradzi Pasipamire / Serge Mathurin Kabore / Barbara Rusch / Christine Jamet / Iza Ciglenecki / Roger Teck

BMC Public Health, Vol 18, Iss 1, Pp 1-

2018 Volume 9

Abstract: Abstract Background Universal antiretroviral therapy (ART) for all pregnant/ breastfeeding women living with Human Immunodeficiency Virus (HIV), known as Prevention of mother-to child transmission of HIV (PMTCT) Option B+ (PMTCTB+), is being scaled up in ...

Abstract	Abstract Background Universal antiretroviral therapy (ART) for all pregnant/ breastfeeding women living with Human Immunodeficiency Virus (HIV), known as Prevention of mother-to child transmission of HIV (PMTCT) Option B+ (PMTCTB+), is being scaled up in most countries in Sub-Saharan Africa. In the transition to PMTCTB+, many countries face challenges with proper implementation of the HIV care cascade. We aimed to describe the feasibility of a PMTCTB+ approach in the public health sector in Swaziland. Methods Lifelong ART was offered to a cohort of HIV+ pregnant women aged ≥16 years at the first antenatal care (ANC1) visit in 9 public sector facilities, between 01/2013 and 06/2014. The study enrolment period was divided into 3 phases (early: 01–06/2013, mid: 07–12/2013 and late: 01–06/2014) to account for temporal trends. Kaplan-Meier estimates and Cox proportional-hazards regression models were applied for ART initiation and attrition analyses. Results Of 665 HIV+ pregnant women, 496 (74.6%) initiated ART. ART initiation increased in later study enrolment phases (mid: aHR: 1.41; later: aHR: 2.36), and decreased at CD4 ≥ 500 (aHR: 0.69). 52.9% were retained in care at 24 months. Attrition was associated with ANC1 in the third trimester (aHR: 2.37), attending a secondary care facility (aHR: 1.98) and ART initiation during later enrolment phases (mid aHR: 1.48; late aHR: 1.67). Of 373 women eligible, 67.3% received a first VL. 223/251 (88.8%) were virologically suppressed (< 1000 copies/mL). Of 670 infants, 53.6% received an EID test, 320/359 had a test result recorded and of whom 7 (2.2%) were HIV+. Conclusions PMTCTB+ was found to be feasible in this setting, with high rates of maternal viral suppression and low transmission to the infant. High treatment attrition, poor follow-up of mother-baby pairs and under-utilisation of VL and EID testing are important programmatic challenges.
Keywords	PMTCT ; HIV ; Retention ; ART initiation ; EID ; Public aspects of medicine ; RA1-1270
Subject code	360
Language	English
Publishing date	2018-03-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Screening in Maternity to Ascertain Tuberculosis Status (SMATS) study.

Broughton, Edward / Haumba, Samson / Calnan, Marianne / Ginindsa, Sandile / Jeffries, Rosanna / Maphalala, Gugu / Mazibuko, Sikhathele / Mirara, Munamato / Modi, Surbhi / Munyaradzi, Pasipamire / Preko, Peter / Simelane, Batsabile

BMC infectious diseases

2017 Volume 17, Issue 1, Page(s) 191

Abstract: Background: Diagnosis of tuberculosis is difficult among pregnant women because the signs and symptoms of the disease, such as fatigue, shortness of breath, sweating, cough, and mild fever are similar to some manifestations of pregnancy. It is ... ...

Abstract	Background: Diagnosis of tuberculosis is difficult among pregnant women because the signs and symptoms of the disease, such as fatigue, shortness of breath, sweating, cough, and mild fever are similar to some manifestations of pregnancy. It is particularly challenging among HIV-infected women as symptoms are often masked or atypical. Currently, WHO recommends a standard four-symptom screening tool for pregnant and lactating women. There is evidence from South Africa that this screening tool (which, despite complex symptomology in this population, recommends identification of patients with weight loss, fever, current cough and night sweats), may be missing true active TB cases. However there exist several laboratory and clinical procedures that have the potential to improve the sensitivity and specificity of this screening tool. Methods: This study will evaluate the sensitivity and specificity of the current TB screening tool for pregnant and lactating women, both HIV positive and negative. We will also assess several different enhanced screening algorithm using LAM, IGRA, TST and chest radiography and clinical/laboratory procedures and tests. The study will use a cross-sectional analytical study design involving pregnant and lactating women up to six months post-delivery attending antenatal or postnatal care, respectively in one of three selected public health units in Swaziland. Participants will be consecutively enrolled and will be in one of four groups of interest: HIV infected pregnant women, non-HIV infected pregnant women, HIV infected lactating women and non-HIV infected lactating women. Discussion: We expect in conducting all procedures on all participants regardless of result of the symptom screening we may experience a high refusal rate. However, this risk will be mitigated by the long data collection period of five or more months.
MeSH term(s)	Adolescent ; Adult ; Algorithms ; Clinical Protocols ; Coinfection/diagnosis ; Cross-Sectional Studies ; Female ; HIV Infections/complications ; Humans ; Lactation ; Postnatal Care/methods ; Pregnancy ; Pregnancy Complications, Infectious/diagnosis ; Prenatal Care/methods ; Sensitivity and Specificity ; Swaziland ; Tuberculosis/complications ; Tuberculosis/diagnosis ; Young Adult
Language	English
Publishing date	2017-03-06
Publishing country	England
Document type	Clinical Trial ; Journal Article ; Research Support, U.S. Gov't, Non-P.H.S.
ISSN	1471-2334
ISSN (online)	1471-2334
DOI	10.1186/s12879-017-2285-0
Database	MEDical Literature Analysis and Retrieval System OnLINE

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Article ; Online: Status of HIV Epidemic Control Among Adolescent Girls and Young Women Aged 15-24 Years - Seven African Countries, 2015-2017.

Brown, Kristin / Williams, Daniel B / Kinchen, Steve / Saito, Suzue / Radin, Elizabeth / Patel, Hetal / Low, Andrea / Delgado, Stephen / Mugurungi, Owen / Musuka, Godfrey / Tippett Barr, Beth A / Nwankwo-Igomu, E Amaka / Ruangtragool, Leala / Hakim, Avi J / Kalua, Thokozani / Nyirenda, Rose / Chipungu, Gertrude / Auld, Andrew / Kim, Evelyn /

Payne, Danielle / Wadonda-Kabondo, Nellie / West, Christine / Brennan, Elizabeth / Deutsch, Beth / Worku, Anteneh / Jonnalagadda, Sasi / Mulenga, Lloyd B / Dzekedzeke, Kumbutso / Barradas, Danielle T / Cai, Haotian / Gupta, Sundeep / Kamocha, Stanley / Riggs, Margaret A / Sachathep, Karampreet / Kirungi, Wilford / Musinguzi, Joshua / Opio, Alex / Biraro, Sam / Bancroft, Elizabeth / Galbraith, Jennifer / Kiyingi, Herbert / Farahani, Mansoor / Hladik, Wolfgang / Nyangoma, Edith / Ginindza, Choice / Masangane, Zandile / Mhlanga, Fortune / Mnisi, Zandile / Munyaradzi, Pasipamire / Zwane, Amos / Burke, Sean / Kayigamba, Felix B / Nuwagaba-Biribonwoha, Harriet / Sahabo, Ruben / Ao, Trong T / Draghi, Chiara / Ryan, Caroline / Philip, Neena M / Mosha, Fausta / Mulokozi, Aroldia / Ntigiti, Phausta / Ramadhani, Angela A / Somi, Geoffrey R / Makafu, Cecilia / Mugisha, Veronicah / Zelothe, Julius / Lavilla, Kayla / Lowrance, David W / Mdodo, Rennatus / Gummerson, Elizabeth / Stupp, Paul / Thin, Kyaw / Frederix, Koen / Davia, Stefania / Schwitters, Amee M / McCracken, Stephen D / Duong, Yen T / Hoos, David / Parekh, Bharat / Justman, Jessica E / Voetsch, Andrew C

MMWR. Morbidity and mortality weekly report

2018 Volume 67, Issue 1, Page(s) 29–32

Abstract: In 2016, an estimated 1.5 million females aged 15-24 years were living with human immunodeficiency virus (HIV) infection in Eastern and Southern Africa, where the prevalence of HIV infection among adolescent girls and young women (3.4%) is more than ... ...

Abstract	In 2016, an estimated 1.5 million females aged 15-24 years were living with human immunodeficiency virus (HIV) infection in Eastern and Southern Africa, where the prevalence of HIV infection among adolescent girls and young women (3.4%) is more than double that for males in the same age range (1.6%) (1). Progress was assessed toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 2020 targets for adolescent girls and young women in sub-Saharan Africa (90% of those with HIV infection aware of their status, 90% of HIV-infected persons aware of their status on antiretroviral treatment [ART], and 90% of those on treatment virally suppressed [HIV viral load <1,000 HIV RNA copies/mL]) (2) using data from recent Population-based HIV Impact Assessment (PHIA) surveys in seven countries. The national prevalence of HIV infection in adolescent girls and young women aged 15-24 years, the percentage who were aware of their status, and among those persons who were aware, the percentage who had achieved viral suppression were calculated. The target for viral suppression among all persons with HIV infection is 73% (the product of 90% x 90% x 90%). Among all seven countries, the prevalence of HIV infection among adolescent girls and young women was 3.6%; among those in this group, 46.3% reported being aware of their HIV-positive status, and 45.0% were virally suppressed. Sustained efforts by national HIV and public health programs to diagnose HIV infection in adolescent girls and young women as early as possible to ensure rapid initiation of ART should help achieve epidemic control among adolescent girls and young women.
MeSH term(s)	Adolescent ; Africa/epidemiology ; Anti-HIV Agents/therapeutic use ; Epidemics/prevention & control ; Female ; HIV Infections/epidemiology ; HIV Infections/prevention & control ; Health Knowledge, Attitudes, Practice ; Humans ; Prevalence ; Program Evaluation ; Viral Load/statistics & numerical data ; Young Adult
Chemical Substances	Anti-HIV Agents
Language	English
Publishing date	2018-01-12
Publishing country	United States
Document type	Journal Article
ZDB-ID	412775-4
ISSN	1545-861X ; 0149-2195
ISSN (online)	1545-861X
ISSN	0149-2195
DOI	10.15585/mmwr.mm6701a6
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