Results of Hepatitis C Birth-Cohort Testing and Linkage to Care in Selected U.S. Sites,

Transcription

1 Reserch Results of Heptitis C Birth-Cohort Testing nd Linkge to Cre in Selected U.S. Sites, Rjiv C. Ptel, MPH Cludi Vellozzi, MD, MPH Bryce D. Smith, PhD, MSSW,c ABSTRACT Ojective. Following its recommendtion for one-time heptitis C virus (HCV) testing of people orn etween 1945 nd 1965, CDC implemented the Heptitis Testing nd Linkge to Cre (HepTLC) inititive to conduct irthcohort heptitis testing in U.S. helth-cre settings. We descrie demogrphic chrcteristics, HCV infection prevlence, nd HCV-relted risk fctors mong people orn etween 1945 nd 1965 who were tested s prt of the progrm, which rn from 2012 to Methods. As prt of the HepTLC inititive, 14 grntees supporting 104 helth-cre sites in 21 U.S. municiplities tested prticipnts orn etween 1945 nd 1965 for HCV ntiody (nti-hcv). Demogrphic chrcteristics nd HCV risk fctors were reported for people tested for nti-hcv nd who were nti-hcv or HCV RNA positive. We evluted outcomes long the HCV testing-to-cre continuum using the following indictors: nti-hcv positive, HCV RNA test offered, HCV RNA positive, referred to cre, nd ttended first medicl ppointment. Results. Among 24,966 people tested for HCV infection, 2,900 (11.6%) were nti-hcv positive. Anti-HCV positivity ws highest mong those who selfidentified s non-hispnic lck (n51,701 of 12,202, 13.9%), men (n52,073 of 12,130, 17.1%), nd people orn etween 1951 nd 1955 (n5795 of 5,768, 13.8%). Of the 2,900 people testing nti-hcv positive, 2,108 (72.7%) received n HCV RNA test, 1,497 (51.6%) were HCV RNA positive, 1,201 (41.4%) were referred to cre, nd 938 (32.3%) ttended their first ppointment. Conclusion. Testing for HCV infection mong those orn etween 1945 nd 1965 without soliciting HCV risk fctors ws successful. Providers implementing irth-cohort testing should develop nd evlute strtegies to improve outcomes long the testing-to-cre continuum. Ok Ridge Institute for Science nd Eduction, Ok Ridge, TN Centers for Disese Control nd Prevention, Division of Virl Heptitis, Atlnt, GA c Current ffilition: Centers for Disese Control nd Prevention, Division of Dietes Trnsltion, Trnsltion, Helth Eduction, nd Evlution Brnch, Atlnt, GA Address correspondence to: Bryce D. Smith, PhD, MSSW, Centers for Disese Control nd Prevention, Division of Dietes Trnsltion, Trnsltion, Helth Eduction, nd Evlution Brnch, 1600 Clifton Rd. NE, MS G-37, Atlnt, GA 30333; tel ; e-mil <smith6@cdc.gov>. 12 Pulic Helth Reports / 2016 Supplement 2 / Volume 131

2 Birth-Cohort Heptitis C Testing nd Linkge to Cre 13 Approximtely 2.7 million noninstitutionlized people, nd n dditionl 375,000 to 750,000 homeless nd incrcerted people, re currently infected with the heptitis C virus (HCV) in the United Sttes. 1,2 Infections re often symptomtic, nd more thn 50% of people re estimted to e unwre of their chronic HCV infection. 3 6 Chronic HCV infections hve contriuted to n incresing incidence of chronic liver disese, heptocellulr crcinom, nd premture mortlity Asent interventions to increse wreness of chronic HCV infection nd link people to cre, HCV-ssocited moridity nd mortlity will continue to rise. 13 Since 1998, the Centers for Disese Control nd Prevention (CDC) hs recommended routine HCV ntiody (nti-hcv) testing of people with exposures ssocited with HCV infection, including pst or present injection drug use (IDU) nd people with humn immunodeficiency virus (HIV) infection. 14 However, the high proportion of people who were unwre of their HCV infection sttus, coupled with rising HCVssocited moridity nd mortlity, prompted CDC to expnd these recommendtions in 2012 to include one-time HCV test for ll people orn etween 1945 nd The U.S. Preventive Services Tsk Force issued similr recommendtion in ,15 It is criticl to ssess how recommendtions trnslte into prctice to ensure guidelines re followed nd to identify gps to inform future policy development. For exmple, evlutions of HIV testing recommendtions hve identified gps long the HIV cre continuum to improve the proportion of HIV-infected individuls who re dignosed, ccessing nd retined in medicl cre, otining ntiretrovirl therpy, nd chieving virl suppression Evluting irth-cohort testing recommendtions over time is lso expected to identify gps long the HCV testing-to-cre continuum. Addressing these chllenges my help to improve identifiction of HCV-infected people nd link those infected to highly effective nd tolerle HCV ntivirl tretments to vert HCV-ssocited moridity nd mortlity. CDC s Heptitis Testing nd Linkge to Cre (Hep- TLC) inititive provided n opportunity to ssess the implementtion of irth-cohort testing recommendtions. This inititive explored methods for identifying people infected with HCV, including irth-cohort testing, nd wys to link chroniclly infected people to cre. For this rticle, we report HCV irth-cohort testing nd linkge-to-cre results, including demogrphic chrcteristics, risk-fctor prevlence, nd nti-hcv nd HCV rionucleic cid (RNA) positivity. We lso discuss the proportion of people who completed ech step of the HCV testing-to-cre continuum, including the proportion of nti-hcv-positive people who were tested for HCV RNA nd the proportion of chroniclly infected people who were linked to cre. Finlly, we exmine how the use of HCV RNA sme-dy testing nd ssisted linkge-to-cre strtegies ffects the testingto-cre continuum. METHODS Study popultion CDC funded 14 grntees supporting 104 testing sites in 21 U.S. municiplities to implement irth-cohort testing for HepTLC. Grntees were sked to recruit previously undignosed people orn etween 1945 nd 1965 for nti-hcv testing in different clinicl settings, including emergency deprtments, federlly qulified helth centers, community helth clinics, sexully trnsmitted disese (STD) clinics, nd stte helth deprtments. Sites were locted in Sn Diego, Cliforni; Denver, Colordo; Atlnt, Georgi; Bronx, Ellenville, Rochester, nd Queens, New York; Durhm, North Crolin; Phildelphi, Pennsylvni; Agus Buens, Cgus, Sn Jun, nd Yuco, Puerto Rico; Bmerg, Cherw, Firfx, Florence, Mullens, nd Orngeurg, South Crolin; Sn Antonio, Texs; nd Wshington, D.C. Ech grntee trgeted people in the irth cohort ut lso followed CDC recommendtions to test people who reported HCV risk fctors, such s IDU. For the current study, we included ll people orn etween 1945 nd 1965 who were tested for nti-hcv or HCV RNA t ech testing site. Grntees de-duplicted the dt to exclude people with multiple testing sessions t different sites within the sme grntee project. Dt sources HCV testing occurred from Octoer 1, 2012, to June 28, Dt were extrcted from the dt collection nd mngement system, EvlutionWe, 19 on Septemer 26, 2014, to llow 90 dys of follow-up dt for prticipnts who received results, were referred to cre, or strted tretment fter June 28, Prticipnts self-reported irth yer, sex, rce/ethnicity, helth insurnce sttus nd type, nd risk-fctor informtion, nd site stff memers entered these dt into EvlutionWe. Age ws clculted sed on reported irth yer nd dte of HCV testing nd grouped into four ctegories: (ged yers), (ged yers), (ged yers), nd (ged yers). Rce/ethnicity ws ctegorized s non-hispnic lck, non-hispnic white, Hispnic or Ltino, nd other (i.e., non-hispnic Asin, Ntive Hwiin or other Pcific Islnder, nd Americn Indin or Alsk Ntive). Helth insurnce Pulic Helth Reports / 2016 Supplement 2 / Volume 131

3 14 Reserch ws ctegorized s pulic, privte, or no insurnce. Risk fctors included lifetime IDU (i.e., ever injected drugs), IDU in the pst 12 months, nd HIV infection. Project stff memers t ech testing site otined nti-hcv test dte nd results, HCV RNA test dte nd results, referrl to cre, nd ttendnce of first medicl ppointment, nd entered these dt into EvlutionWe. Those with positive HCV RNA test result were considered to hve chronic HCV infection. Anlysis We summed counts nd clculted percentges for three groups (i.e., those who were nti-hcv positive, those who were tested for HCV RNA, nd those who were HCV RNA positive) y demogrphic chrcteristic nd risk fctor. Percentges of those testing nti-hcv positive, tested for HCV RNA, nd testing HCV RNA positive were clculted y dividing the totl sums y the numer of study prticipnts, the numer tht tested nti-hcv positive, nd the numer tht were tested for HCV RNA, respectively, for ech demogrphic or risk-fctor group. We constructed testing-to-cre continuum to opertionlize the steps required to confirm chronic HCV infection nd link infected people to cre. We defined steps long the testing-to-cre continuum s nti-hcv-positive test result, HCV RNA test, HCV RNApositive test result, referred to cre, nd ttended first ppointment. People were required to hve completed ech step in the continuum to e counted in successive steps. Discrepncies etween the overll HCV RNA test nd HCV RNA-positive counts nd the counts reported long the testing-to-cre continuum resulted from this inclusion requirement for the testing-to-cre continuum nd ecuse some sites tested for HCV RNA first s prt of their testing lgorithm. We exmined the testing-to-cre continuum using two different pproches. In the first pproch, we clculted the proportion of nti-hcv-positive people who completed ech step of the testing-to-cre continuum; we divided the totl numer of people who completed ech step of the continuum (numertor) y the initil numer of those who tested nti-hcv positive (denomintor). In the second pproch, we clculted the proportion of people who completed ech successive step in the testing-to-cre continuum; we divided the totl numer of people who completed ech step in the continuum (numertor) y the totl numer of people who completed the previous step (denomintor). Additionlly, we evluted the success of improving confirmtory testing (i.e., HCV RNA testing) y compring the proportion of people who tested nti-hcv positive who received sme-dy HCV RNA testing with the proportion of people who tested nti-hcv positive nd received n HCV RNA test one or more dys fter the positive nti-hcv test. We lso compred ssisted-linkge strtegies with pssive-linkge strtegies to ensure HCV-infected people were linked to medicl cre. We ctegorized scheduling dte for follow-up medicl ppointment with specilist or primry cre physicin s n ssisted-linkge method, nd we ctegorized only providing referrl to specilist, primry cre physicin, or medicl fcility s pssive-linkge method. We evluted pssive- nd ssisted-linkge methods y compring the proportion of chroniclly infected people (i.e., HCV RNA positive) who ttended first medicl ppointment. We conducted nlyses using SAS version RESULTS A totl of 24,966 people orn etween 1945 nd 1965 were tested for nti-hcv during the HepTLC project. Of the 24,966 people who were tested, testing frequency ws highest mong people orn etween 1961 nd 1965 (n57,665, 30.7%), those who self-identified s non-hispnic lck (n512,202, 48.9%), nd women (n512,827, 51.4%). Furthermore, 11,652 (46.7%) ptients were pulicly insured nd 891 (3.6%) reported ever injecting drugs (Tle). Of the 24,966 people who received n nti-hcv test, 2,900 (11.6%) were nti-hcv positive. Anti-HCV positivity ws highest mong those who self-identified s non-hispnic lck (n51,701 of 12,202, 13.9%), men (n52,073 of 12,130, 17.1%), nd people orn etween 1951 nd 1955 (n5795 of 5,768, 13.8%). Anti-HCV prevlence ws lowest mong people orn in 1945 (2.4%), peked mong people orn etween 1954 nd 1958 (rnge 13.4% 15.1%), nd rnged from 9.7% to 11.9% for people orn fter 1958 (Figure 1). Demogrphic nd risk chrcteristics mong the 1,501 people who tested HCV RNA positive were similr to those who were nti-hcv positive. Of the 2,900 people who tested nti-hcv positive, 1,497 (51.6%) were confirmed with chronic infection y positive HCV RNA test, nd 938 (32.3%) ttended first medicl ppointment (Figure 2). Of the 2,900 people who tested nti-hcv positive, 2,108 (72.7%) received n HCV RNA test. Of the 1,497 people with chronic infection, 1,201 (80.2%) were referred to cre. All 1,088 nti-hcv-positive people who received sme-dy HCV RNA testing were tested for HCV RNA, nd 822 (75.6%) were identified s chroniclly infected (Figure 3). Of the 1,805 nti-hcv-positive Pulic Helth Reports / 2016 Supplement 2 / Volume 131

4 Birth-Cohort Heptitis C Testing nd Linkge to Cre 15 Tle. Chrcteristics nd HCV test results of people orn etween 1945 nd 1965 in the Heptitis Testing nd Linkge to Cre (HepTLC) inititive, 21 U.S. municiplities, Chrcteristic Numer of study prticipnts Numer of prticipnts testing nti-hcv positive (percent) Numer of prticipnts tested for HCV RNA (percent of those testing nti-hcv positive) Numer of prticipnts testing HCV RNA positive (percent of those tested for HCV RNA) Totl 24,966 2,900 2,205 1,501 Medin ge, in yers (IQR) 57 (53 62) 57 (53 61) 57 (53 61) 57 (53 60) Birth yer (ge rnge, in yers) (64 69) 4, (8.1) 249 (71.6) 170 (68.3) (59 63) 5, (13.8) 572 (71.9) 393 (68.7) (54 58) 7, (12.9) 707 (75.5) 483 (68.3) (49 53) 7, (10.7) 677 (82.6) 455 (67.2) Sex Mle 12,130 2,073 (17.1) 1,509 (72.8) 1,082 (71.7) Femle 12, (6.4) 696 (84.3) 419 (60.2) Not reported 9 1 (11.1) 0 (0.0) 0 (0.0) Rce/ethnicity Non-Hispnic white 4, (10.9) 404 (89.4) 244 (60.4) Non-Hispnic lck 12,202 1,701 (13.9) 1135 (66.7) 830 (73.1) Hispnic or Ltino 6, (8.0) 519 (93.1) 322 (62.0) Other c 1, (11.1) 147 (77.4) 105 (71.4) Helth insurnce None 8, (9.6) 725 (89.5) 491 (67.7) Pulic 11,652 1,869 (16.0) 1,295 (69.3) 898 (69.3) Privte 4, (3.5) 133 (89.9) 69 (51.9) Risk fctors Ever used injection drugs (72.4) 580 (89.9) 448 (77.2) Injection drug use in pst 12 months (72.4) 149 (90.3) 110 (73.8) HIV-positive (25.6) 94 (88.7) 57 (60.6) The HepTLC inititive promoted virl heptitis B nd heptitis C screening, posttest counseling, nd linkge to cre t 34 U.S. sites. Heptitis C testing sites were locted in Sn Diego, Cliforni; Denver, Colordo; Atlnt, Georgi; Bronx, Ellenville, Rochester, nd Queens, New York; Durhm, North Crolin; Phildelphi, Pennsylvni; Agus Buens, Cgus, Sn Jun, nd Yuco, Puerto Rico; Bmerg, Cherw, Firfx, Florence, Mullens, nd Orngeurg, South Crolin; Sn Antonio, Texs; nd Wshington, D.C. Percentges re row percentges. c Includes non-hispnic Asin, Ntive Hwiin or Pcific Islnder, nd Americn Indin or Alsk Ntive HCV 5 heptitis C virus nti-hcv 5 heptitis C virus ntiody RNA 5 rionucleic cid IQR 5 interqurtile rnge HIV 5 humn immunodeficiency virus people who did not receive sme-dy testing, 1,020 (56.5%) received n HCV RNA test nd 675 (37.4%) were identified s chroniclly infected. Among the 818 chroniclly infected people who received ssisted linkge to cre, 696 (85.1%) successfully ttended their first ppointment. Among the 383 chroniclly infected people who were pssively linked to cre, 235 (61.4%) successfully ttended their first medicl ppointment. DISCUSSION HCV testing nd follow-up This project demonstrted tht irth-cohort testing cn e successfully implemented in vriety of helth-cre settings. CDC s 1998 HCV testing recommendtions hve een less successful in identifying people living with HCV infection; in qulittive ssessment of these recommendtions, providers reported tht the complexity of multiple risk fctors nd discomfort in sking questions out socilly undesirle ehviors were rriers to effective risk-sed screening implementtion. 14,21 An importnt strength of irth-cohort testing is identifying infected people who re reluctnt to disclose history of IDU or other risky ehviors, or providers who re uncomfortle discussing these ehviors with their ptients. Those who self-identified s non-hispnic lck, men, nd people reporting pst or present IDU were Pulic Helth Reports / 2016 Supplement 2 / Volume 131

5 16 Reserch Figure 1. Anti-HCV prevlence per 100 study prticipnts, y irth yer, mong people orn etween 1945 nd 1965 who were tested for HCV in the Heptitis Testing nd Linkge to Cre (HepTLC) inititive, 21 U.S. municiplities, Anti-HCV prevlence per 100 study prticipnts Of 24,966 prticipnts who were tested, 2,900 were nti-hcv positive. The HepTLC inititive promoted virl heptitis B nd heptitis C screening, posttest counseling, nd linkge to cre t 34 U.S. sites. Heptitis C testing sites were locted in Sn Diego, Cliforni; Denver, Colordo; Atlnt, Georgi; Bronx, Ellenville, Rochester, nd Queens, New York; Durhm, North Crolin; Phildelphi, Pennsylvni; Agus Buens, Cgus, Sn Jun, nd Yuco, Puerto Rico; Bmerg, Cherw, Firfx, Florence, Mullens, nd Orngeurg, South Crolin; Sn Antonio, Texs; nd Wshington, D.C. nti-hcv 5 heptitis C virus ntiody HCV 5 heptitis C virus Birth yer Figure 2. Percent of people orn etween 1945 nd 1965 testing nti-hcv positive (n=2,900) who completed steps in the testing-to-cre continuum, Heptitis Testing nd Linkge to Cre (HepTLC) inititive, 21 U.S. municiplities, c Percent The HepTLC inititive promoted virl heptitis B nd heptitis C screening, posttest counseling, nd linkge to cre t 34 U.S. sites. Heptitis C testing sites were locted in Sn Diego, Cliforni; Denver, Colordo; Atlnt, Georgi; Bronx, Ellenville, Rochester, nd Queens, New York; Durhm, North Crolin; Phildelphi, Pennsylvni; Agus Buens, Cgus, nd Sn Jun, Yuco, Puerto Rico; Bmerg, Cherw, Firfx, Florence, Mullens, Orngeurg, South Crolin; Sn Antonio, Texs; nd Wshington, D.C. Line grph represents the percentge of ll nti-hcv-positive people who completed ech step of the testing-to-cre continuum. c Br grph represents the percentge of people who completed ech successive step of the testing-to-cre continuum. d Approximtely 20% 30% of HCV-infected individuls will cler the virus spontneously. nti-hcv 5 heptitis C virus ntiody HCV 5 heptitis C virus RNA 5 rionucleic cid Pulic Helth Reports / 2016 Supplement 2 / Volume 131

6 Birth-Cohort Heptitis C Testing nd Linkge to Cre 17 Figure 3. Proportion of nti-hcv-positive people who were tested for HCV RNA nd tested HCV RNA positive, y type of HCV RNA testing (n=2,893), in the Heptitis Testing nd Linkge to Cre (HepTLC) inititive, 21 U.S. municiplities, d Percent of nti-hcv-positive people who completed steps in the testing-to-cre continuum The HepTLC inititive promoted virl heptitis B nd heptitis C screening, posttest counseling, nd linkge to cre t 34 U.S. sites. Heptitis C testing sites were locted in Sn Diego, Cliforni; Denver, Colordo; Atlnt, Georgi; Bronx, Ellenville, Rochester, nd Queens, New York; Durhm, North Crolin; Phildelphi, Pennsylvni; Agus Buens, Cgus, nd Sn Jun, Yuco, Puerto Rico; Bmerg, Cherw, Firfx, Florence, Mullens, Orngeurg, South Crolin; Sn Antonio, Texs; nd Wshington, D.C. Seven people without vlid ntiody test dte were excluded. c Antiody positive for sme-dy testing included 1,088 prticipnts. d Antiody positive for non-sme-dy testing included 1,805 prticipnts. nti-hcv 5 heptitis C virus ntiody HCV 5 heptitis C virus RNA 5 rionucleic cid more likely to test nti-hcv positive findings similr to previous HCV irth-cohort studies. 1,22,23 However, nti-hcv prevlence ws higher in the current nlysis thn in ntionl irth-cohort studies, 22,23 likely ecuse of the higher level of risk for HCV infection mong the popultions served y the testing sites tht prticipted in this project (i.e., federlly qulified helth centers, STD clinics, community helth centers, nd helth deprtment clinics). 5,24 26 Providers seeking to implement irth-cohort testing should consider the clinic popultion eing served nd ensure tht resources will e ville to provide cre to newly dignosed ptients. Although nti-hcv testing ws successfully implemented in helth-cre settings, grntees hd difficulty otining follow-up HCV RNA tests for nti-hcv- positive ptients. These results re consistent with previous reserch reporting tht people orn etween 1945 nd 1965 re less likely thn other irth cohorts to hve follow-up HCV RNA test within six months of positive nti-hcv test, nd n estimted 63% 77% of people who test nti-hcv positive receive some followup virl heptitis cre, such s HCV RNA testing. 27,28 On the other hnd, sme-dy HCV RNA testing compred with testing nti-hcv-positive ptients on different dy following the ntiody test enled the identifiction of greter proportion of people with chronic HCV infection. Providers implementing irth-cohort testing in the clinicl setting should strive to provide ll nti-hcv-positive people with n HCV RNA test in single medicl visit through sme-dy HCV RNA testing Pulic Helth Reports / 2016 Supplement 2 / Volume 131

7 18 Reserch or HCV RNA reflex testing. Reflex testing enles providers to use the sme lood smple tht ws used for HCV-ntiody testing for HCV RNA testing, without the need for ptients to return to the testing site for nother lood drw. 29 Linkge to cre Aout three-qurters of ll HCV RNA-positive people who were referred to cre ttended n initil medicl ppointment. However, ssisted-linkge strtegies were more effective thn pssive-linkge strtegies in enling people with chronic HCV infection to ttend first medicl ppointment (85.1% vs. 61.4%). Providers implementing irth-cohort testing should consider using ssisted-linkge strtegies or other effective linkge-to-cre models to ensure tht ll HCV-infected people re successfully linked to cre. Fctors tht were eyond the scope of this project for which we did not collect dt, ut which my hve negtively ffected the testing-to-cre continuum, included eing underinsured, the perception tht tretments re long nd hve undesirle side effects, geogrphic rriers to cre, or shortge of skilled HCV clinicl providers. 3,30 Higher coverge of qulity helth insurnce, the promise of shorter durtion nd highly effective ll-orl tretment regimens, sme-dy testing, enhnced provider workforce, nd utiliztion of ssisted-linkge strtegies my help to increse the numer of people dignosed, entered, nd retined in cre. Limittions This study ws suject to severl limittions. First, people with positive nti-hcv result my hve received HCV RNA testing nd follow-up outside of the HepTLC grntee network. As such, the 71% of nti-hcv-positive people who received follow-up HCV RNA test should e interpreted s the minimum percentge who received follow-up HCV RNA test. Second, ll demogrphic nd risk-fctor dt from ptients were self-reported. Disclosure of pst or current IDU, mjor risk fctor for HCV infection, is often underreported. Third, lthough grntees were instructed to trget undignosed people in the irth cohort for nti-hcv testing, dt on previous HCV testing nd dignosis were not collected. It is possile tht some prticipnts my hve known their nti-hcv sttus prior to this project. However, people with previous dignosis represent smll minority of the study popultion nd most nti-hcv testing results represent newly dignosed people. Fourth, we were unle to include nlyses y clinicl setting ecuse of multiple limittions, such s lck of stndrdiztion or dt collected on prticipnt recruitment, testing procedures, nd linkge-to-cre interventions cross clinicl settings. These limittions my is results y clinicl setting or produce results tht cnnot e explined. CONCLUSION This study highlights successful implementtion of irth-cohort HCV testing in vriety of helth-cre settings cross 21 U.S. municiplities. Adoption of CDC recommendtions for one-time HCV testing of people orn etween 1945 nd 1965 should e supported, nd efforts should prioritize reching the popultions t gretest risk for HCV infection. However, chllenges remin to improve outcomes long the testing-to-cre continuum. Adherence to CDC guidelines, use of smedy HCV RNA testing, ensuring vilility of trined providers, nd ssisted-linkge strtegies my help to improve the testing-to-cre continuum. Continued irth-cohort HCV testing nd identifiction of people with chronic HCV infection, nd improved linkge to cre in comintion with new, effective ll-orl HCV tretments, will help to decrese HCV-ssocited moridity nd mortlity. The findings nd conclusions in this rticle re those of the uthors nd do not necessrily represent the officil position of the Centers for Disese Control nd Prevention (CDC). 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