Defense Center for Public Health - Aberdeen

The rat has been used extensively as a model for evaluating chemical toxicities and for understanding drug mechanisms. However, its transcriptome across multiple organs, or developmental stages, has not yet been reported. Here we show, as part of the SEQC consortium efforts, a comprehensive rat transcriptomic BodyMap created by performing RNA-Seq on 320 samples from 11 organs of both sexes of juvenile, adolescent, adult and aged Fischer 344 rats. We catalogue the expression profiles of 40,064 genes, 65,167 transcripts, 31,909 alternatively spliced transcript variants and 2,367 non-coding genes/non-coding RNAs (ncRNAs) annotated in AceView. We find that organ-enriched, differentially expressed genes reflect the known organ-specific biological activities. A large number of transcripts show organ-specific, age-dependent or sex-specific differential expression patterns. We create a web-based, open-access rat BodyMap database of expression profiles with crosslinks to other widely used databases, anticipating that it will serve as a primary resource for biomedical research using the rat model. Gene expression is highly variable between tissues, and changes during development and with age. Here, the authors provide a comprehensive RNA-Seq analysis of the rat transcriptome, spanning eleven organs, four developmental stages and both sexes.

IMPORTANCE: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent study designed to generate actionable recommendations to reduce Army suicides and increase knowledge of risk and resilience factors for suicidality. OBJECTIVES: To present data on prevalence, trends, and basic sociodemographic and Army experience correlates of suicides and accident deaths among active duty Regular Army soldiers between January 1, 2004, and December 31, 2009, and thereby establish a foundation for future Army STARRS investigations. DESIGN, SETTING, AND PARTICIPANTS: Analysis of trends and predictors of suicide and accident deaths using Army and Department of Defense administrative data systems. Participants were all members of the US Regular Army serving at any time between 2004 and 2009. MAIN OUTCOMES AND MEASURES: Death by suicide or accident during active Army service. RESULTS: The suicide rate rose between 2004 and 2009 among never deployed and currently and previously deployed Regular Army soldiers. The accident death rate fell sharply among currently deployed soldiers, remained constant among the previously deployed, and trended upward among the never deployed. Increased suicide risk was associated with being a man (or a woman during deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current or previous deployment. Sociodemographic and Army experience predictors were generally similar for suicides and accident deaths. Time trends in these predictors and in the Army's increased use of accession waivers (which relaxed some qualifications for new soldiers) do not explain the rise in Army suicides. CONCLUSIONS AND RELEVANCE: Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. The existence of a time trend in suicide risk among never-deployed soldiers argues indirectly against the view that exposure to combat-related trauma is the exclusive cause of the increase in Army suicides.

Long-term effectiveness of biochar for heavy metal stabilization depends upon biochar's sorptive property and recalcitrance in soil. To understand the role of carboxyl functional groups on heavy metal stabilization, cottonseed hull biochar and flax shive steam-activated biochar having a low O/C ratio (0.04-0.06) and high fixed carbon content (~80% dry weight basis) were oxidized using concentrated H(2)SO(4)/HNO(3) and 30% HNO(3). Oxidized and unoxidized biochars were characterized for O/C ratio, total acidity, pH, moisture, ash, volatile matter, and fixed carbon contents, Brunauer-Emmett-Teller surface area, and attenuated total reflectance Fourier transform infrared spectral features. Characterized biochars were amended (2%, 5%, 10%, and 20% in grams of biochar per gram of soil) on a sandy, slightly acidic (pH 6.27) heavy metal contaminated small arms range soil fraction (<250 μm) having low total organic carbon (0.518%) and low cation exchange capacity (0.95 cmol(c) kg(-1)). Oxidized biochars rich in carboxyl functional groups exhibited significantly greater Pb, Cu, and Zn stabilization ability compared to unoxidized biochars, especially in pH 4.9 acetate buffer (standard solution for the toxicity characteristic leaching procedure). Oppositely, only oxidized biochars caused desorption of Sb, indicating a counteracting impact of carboxyl functional groups on the solubility of anions and cations. The results suggested that appropriate selection of biochar oxidant will produce recalcitrant biochars rich in carboxyl functional groups for a long-term heavy metal stabilization strategy in contaminated soils.

INTRODUCTION: Noncombat injuries ("injuries") greatly impact soldier health and United States (U.S.) Army readiness; they are the leading cause of outpatient medical encounters (more than two million annually) among active component (AC) soldiers. Noncombat musculoskeletal injuries ("MSKIs") may account for nearly 60% of soldiers' limited duty days and 65% of soldiers who cannot deploy for medical reasons. Injuries primarily affect readiness through increased limited duty days, decreased deployability rates, and increased medical separation rates. MSKIs are also responsible for exorbitant medical costs to the U.S. government, including service-connected disability compensation. A significant subset of soldiers develops chronic pain or long-term disability after injury; this may increase their risk for chronic disease or secondary health deficits potentially associated with MSKIs. The authors will review trends in U.S. Army MSKI rates, summarize MSKI readiness-related impacts, and highlight the importance of standardizing surveillance approaches, including injury definitions used in injury surveillance. MATERIALS/METHODS: This review summarizes current reports and U.S. Department of Defense internal policy documents. MSKIs are defined as musculoskeletal disorders resulting from mechanical energy transfer, including traumatic and overuse injuries, which may cause pain and/or limit function. This review focuses on various U.S. Army populations, based on setting, sex, and age; the review excludes combat or battle injuries. RESULTS: More than half of all AC soldiers sustained at least one injury (MSKI or non-MSKI) in 2017. Overuse injuries comprise at least 70% of all injuries among AC soldiers. Female soldiers are at greater risk for MSKI than men. Female soldiers' aerobic and muscular fitness performances are typically lower than men's performances, which could account for their higher injury rates. Older soldiers are at greater injury risk than younger soldiers. Soldiers in noncombat arms units tend to have higher incidences of reported MSKIs, more limited duty days, and higher rates of limited duty days for chronic MSKIs than soldiers in combat arms units. MSKIs account for 65% of medically nondeployable AC soldiers. At any time, 4% of AC soldiers cannot deploy because of MSKIs. Once deployed, nonbattle injuries accounted for approximately 30% of all medical evacuations, and were the largest category of soldier evacuations from both recent major combat theaters (Iraq and Afghanistan). More than 85% of service members medically evacuated for MSKIs failed to return to the theater. MSKIs factored into (1) nearly 70% of medical disability discharges across the Army from 2011 through 2016 and (2) more than 90% of disability discharges within enlisted soldiers' first year of service from 2010 to 2015. MSKI-related, service-connected (SC) disabilities account for 44% of all SC disabilities (more than any other body system) among compensated U.S. Global War on Terrorism veterans. CONCLUSIONS: MSKIs significantly impact soldier health and U.S. Army readiness. MSKIs also figure prominently in medical disability discharges and long-term, service-connected disability costs. MSKI patterns and trends vary between trainees and soldiers in operational units and among military occupations and types of operational units. Coordinated injury surveillance efforts are needed to provide standardized metrics and accurately measure temporal changes in injury rates.

Since its emergence in the north-eastern and upper mid-western United States in the 1970s, Lyme disease, caused by Borrelia burgdorferi, has captured the public's attention as the nation's most prevalent vector-borne zoonotic disease. In contrast, recent publications on tick-pathogen systems in the eastern United States, and findings from Department of Defense investigations of ticks found biting military personnel, indicate that residents of the south-eastern United States are primarily at risk from emerging diseases caused by tick-borne pathogens other than B. burgdorferi. The risk of contracting these diseases varies greatly among states as a consequence of regional variation in the abundance of the key vector tick species. Moreover, this risk is changing, because tick distributions are in flux. To improve health outcomes, health providers need better information and awareness regarding which tick species bite humans in each state and which zoonotic pathogens are prevalent in these ticks. Effective diagnosis, treatment, control and reporting of tick-borne disease in the south-eastern United States require that health providers think 'beyond Lyme' and consider the marked regional differences in the tick species that bite humans and in the pathogens that these ticks carry.

Prevalence and risk factors associated with soldiers' suicides 2001–2009 (N = 874) were examined. Army suicide rates increased from 9 per 100,000 in 2001 to 22 per 100,000 in 2009. Soldier suicides were lower than civilians from 2001 to 2007, but higher than civilians after 2007. Army suicides were disproportionately higher for men, deployment experience, and a history of a mental health diagnosis/treatment; and lower for African Americans. Many involved planning (38%), communication (21%), alcohol (19%), or drugs (8%). Many had legal problems (31%), high stress loads (90%), a history of self-injury (10%), and other contributing factors prior to entry into the Army (31%). Implications for understanding suicide among military personnel are discussed.

Phosphorus-rich manure biochar has a potential for stabilizing Pb and other heavy metal contaminants, as well as serving as a sterile fertilizer. In this study, broiler litter biochars produced at 350 and 650 °C were employed to understand how biochar's elemental composition (P, K, Ca, Mg, Na, Cu, Pb, Sb, and Zn) affects the extent of heavy metal stabilization. Soil incubation experiments were conducted using a sandy, slightly acidic (pH 6.11) Pb-contaminated (19906 mg kg(-1) total Pb primarily as PbCO(3)) small arms range (SAR) soil fraction (<250 μm) amended with 2-20 wt % biochar. The Pb stabilization in pH 4.9 acetate buffer reached maximum at lower (2-10 wt %) biochar amendment rate, and 350 °C biochar containing more soluble P was better able to stabilize Pb than the 650 °C biochar. The 350 °C biochar consistently released greater amounts of P, K, Mg, Na, and Ca than 650 °C biochar in both unbuffered (pH 4.5 sulfuric acid) and buffered (pH 4.9 acetate) systems, despite 1.9-4.5-fold greater total content of the 650 °C biochar. Biochars, however, did not influence the total extractable Pb over three consecutive equilibration periods consisting of (1) 1 week in pH 4.5 sulfuric acid (simulated leaching by rainfall), (2) 1 week in pH 4.9 acetate buffer (standard solution for toxicity characteristic leaching procedure), and (3) 1 h in pH 1.5 glycine at 37 °C (in vitro bioaccessibility procedure). Overall, lower pyrolysis temperature was favorable for stabilizing Pb (major risk driver of SAR soils) and releasing P, K, Ca, and other plant nutrients in a sandy acidic soil.

During the past few decades, the science of toxicology has been undergoing a transformation from observational to predictive science. New approach methodologies (NAMs), including in vitro assays, in silico models, read-across, and in vitro to in vivo extrapolation (IVIVE), are being developed to reduce, refine, or replace whole animal testing, encouraging the judicious use of time and resources. Some of these methods have advanced past the exploratory research stage and are beginning to gain acceptance for the risk assessment of chemicals. A review of the recent literature reveals a burst of IVIVE publications over the past decade. In this review, we propose operational definitions for IVIVE, present literature examples for several common toxicity endpoints, and highlight their implications in decision-making processes across various federal agencies, as well as international organizations, including those in the European Union (EU). The current challenges and future needs are also summarized for IVIVE. In addition to refining and reducing the number of animals in traditional toxicity testing protocols and being used for prioritizing chemical testing, the goal to use IVIVE to facilitate the replacement of animal models can be achieved through their continued evolution and development, including a strategic plan to qualify IVIVE methods for regulatory acceptance.

Arthorpod-borne viruses (arboviruses) cause wide-spread morbidity in sub-Saharan Africa, but little research has documented the burden and distribution of these pathogens. Using a population-based, cross-sectional study design, we administered a detailed questionnaire and used ELISA to test the blood of 1,141 healthy Kenyan adults from three districts for the presence of anti-viral Immunoglobulin G (IgG) antibodies to the following viruses: dengue (DENV), West Nile (WNV), yellow fever (YFV), Chikungunya (CHIKV), and Rift Valley fever (RVFV). Of these, 14.4% were positive for DENV, 9.5% were WNV positive, 9.2% were YFV positive, 34.0% were positive for CHIKV and 0.7% were RVFV positive. In total, 46.6% had antibodies to at least one of these arboviruses. For all arboviruses, district of residence was strongly associated with seropositivity. Seroprevalence to YFV, DENV and WNV increased with age, while there was no correlation between age and seropositivity for CHIKV, suggesting that much of the seropositivity to CHIKV is due to sporadic epidemics. Paradoxically, literacy was associated with increased seropositivity of CHIKV and DENV.

OBJECTIVES: To provide an overall perspective on musculoskeletal injury (MSI) epidemiology, risk factors, and preventive strategies in military personnel. DESIGN: Narrative review. METHODS: The thematic session on MSIs in military personnel at the 5th International Congress on Soldiers' Physical Performance (ICSPP) included eight presentations on the descriptive epidemiology, risk factor identification, and prevention of MSIs in military personnel. Additional topics presented were bone anabolism, machine learning analysis, and the effects of non-steroidal anti-inflammatory drugs (NSAIDs) on MSIs. This narrative review focuses on the thematic session topics and includes identification of gaps in existing literature, as well as areas for future study. RESULTS: MSIs cause significant morbidity among military personnel. Physical training and occupational tasks are leading causes of MSI limited duty days (LDDs) for the U.S. Army. Recent studies have shown that MSIs are associated with the use of NSAIDs. Bone MSIs are very common in training; new imaging technology such as high resolution peripheral quantitative computed tomography allows visualization of bone microarchitecture and has been used to assess new bone formation during military training. Physical activity monitoring and machine learning have important applications in monitoring and informing evidence-based solutions to prevent MSIs. CONCLUSIONS: Despite many years of research, MSIs continue to have a high incidence among military personnel. Areas for future research include quantifying exposure when determining MSI risk; understanding associations between health-related components of physical fitness and MSI occurrence; and application of innovative imaging, physical activity monitoring and data analysis techniques for MSI prevention and return to duty.

The National Strength and Conditioning Association's tactical strength and conditioning program sponsored the second Blue Ribbon Panel on military physical readiness: military physical performance testing, April 18-19, 2013, Norfolk, VA. This meeting brought together a total of 20 subject matter experts (SMEs) from the U.S. Air Force, Army, Marine Corps, Navy, and academia representing practitioners, operators, researchers, and policy advisors to discuss the current state of physical performance testing across the Armed Services. The SME panel initially rated 9 common military tasks (jumping over obstacles, moving with agility, carrying heavy loads, dragging heavy loads, running long distances, moving quickly over short distances, climbing over obstacles, lifting heavy objects, loading equipment) by the degree to which health-related fitness components (e.g., aerobic fitness, muscular strength, muscular endurance, flexibility, and body composition) and skill-related fitness components (e.g., muscular power, agility, balance, coordination, speed, and reaction time) were required to accomplish these tasks. A scale from 1 to 10 (10 being highest) was used. Muscular strength, power, and endurance received the highest rating scores. Panel consensus concluded that (a) selected fitness components (particularly for skill-related fitness components) are currently not being assessed by the military; (b) field-expedient options to measure both health-based and skill-based fitness components are currently available; and

New approaches are needed to assess the effects of inhaled substances on human health. These approaches will be based on mechanisms of toxicity, an understanding of dosimetry, and the use of in silico modeling and in vitro test methods. In order to accelerate wider implementation of such approaches, development of adverse outcome pathways (AOPs) can help identify and address gaps in our understanding of relevant parameters for model input and mechanisms, and optimize non-animal approaches that can be used to investigate key events of toxicity. This paper describes the AOPs and the toolbox of in vitro and in silico models that can be used to assess the key events leading to toxicity following inhalation exposure. Because the optimal testing strategy will vary depending on the substance of interest, here we present a decision tree approach to identify an appropriate non-animal integrated testing strategy that incorporates consideration of a substance's physicochemical properties, relevant mechanisms of toxicity, and available in silico models and in vitro test methods. This decision tree can facilitate standardization of the testing approaches. Case study examples are presented to provide a basis for proof-of-concept testing to illustrate the utility of non-animal approaches to inform hazard identification and risk assessment of humans exposed to inhaled substances.

Physical fitness training of military recruits is an enduring focus of armies. This is important for safe and effective performance of general tasks that anyone may have to perform in a military setting as well as preparation for more specialized training in specific job specialties. Decades of studies on occupationally specific physical requirements have characterized the dual aerobic and strength demands of typical military tasks; however, scientifically founded strategies to prepare recruits with a good mix of these 2 physiologically opposing capabilities have not been well established. High levels of aerobic training can compromise resistance training gains and increase injury rates. Resistance training requires a greater commitment of time and resources as well as a greater understanding of the science to produce true strength gains that may be beneficial to military performance. These are critical issues for modern armies with increased demands for well-prepared soldiers and fewer injury losses. The actual physical requirements tied to metrics of success in military jobs are also under renewed examination as women are increasingly integrated into military jobs previously performed only by men. At the third International Congress on Soldiers' Physical Performance, a roundtable of 10 physiologists with military expertise presented comparative perspectives on aerobic and strength training. These topics included the physiological basis of training benefits, how to train effectively, how to measure training effectiveness, considerations for the integration of women, and the big perspective. Key discussion points centered on (a) the significance of findings from research on integrated training, (b) strategies for effective strength development, and

BACKGROUND: The importance of infectious disease epidemic forecasting and prediction research is underscored by decades of communicable disease outbreaks, including COVID-19. Unlike other fields of medical research, such as clinical trials and systematic reviews, no reporting guidelines exist for reporting epidemic forecasting and prediction research despite their utility. We therefore developed the EPIFORGE checklist, a guideline for standardized reporting of epidemic forecasting research. METHODS AND FINDINGS: We developed this checklist using a best-practice process for development of reporting guidelines, involving a Delphi process and broad consultation with an international panel of infectious disease modelers and model end users. The objectives of these guidelines are to improve the consistency, reproducibility, comparability, and quality of epidemic forecasting reporting. The guidelines are not designed to advise scientists on how to perform epidemic forecasting and prediction research, but rather to serve as a standard for reporting critical methodological details of such studies. CONCLUSIONS: These guidelines have been submitted to the EQUATOR network, in addition to hosting by other dedicated webpages to facilitate feedback and journal endorsement.

Prevention of musculoskeletal injuries (MSKI) is critical in both civilian and military populations to enhance physical performance, optimize health, and minimize health care expenses. Developing a more unified approach through addressing identified movement impairments could result in improved dynamic balance, trunk stability, and functional movement quality while potentially minimizing the risk of incurring such injuries. Although the evidence supporting the utility of injury prediction and return-to-activity readiness screening tools is encouraging, considerable additional research is needed regarding improving sensitivity, specificity, and outcomes, and especially the implementation challenges and barriers in a military setting. If selected current functional movement assessments can be administered in an efficient and cost-effective manner, utilization of the existing tools may be a beneficial first step in decreasing the burden of MSKI, with a subsequent focus on secondary and tertiary prevention via further assessments on those with prior injury history.

Decreased balance and impaired functional movement have been linked with increased injury risk. The purpose of our study was to determine the association between specific measures of power, strength, flexibility, balance, and endurance compared with more global measures of dynamic balance, using the Y-Balance Test (YBT), and functional movement, using the functional movement screen (FMS), in healthy soldiers. Our participants (n = 64; 53 men, 11 women) were healthy active duty service members (25.2 ± 3.8 years, 25.1 ± 3.1 kg·m(-2)). Seventeen tests with 38 associated measures of strength, power, flexibility, endurance, balance, and functional measures were assessed. A significant Pearson product moment correlation (r > 0.2 and p < 0.01) was used to narrow the number of variables of interest. Two hierarchical stepwise regression analyses were performed to determine the most parsimonious set of variables associated with the YBT and FMS performance scores. Our results included a 4 variable model (F = 13.4, p < 0.001) that was associated with YBT scores (R = 0.72, R2 = 0.51). Superior performance on the YBT was associated with better performance on the FMS lunge and upper trunk mobility tests, decreased number of hops during a 6-m hop test, and greater gastrocnemius flexibility. A second 4 variable model (F = 11.813, p < 0.001) was associated with FMS scores (R = 0.70, R2 = 0.50). Superior performance on the FMS was associated with greater anterior reach on the YBT, greater distance on the crossover hop test, increased hamstring flexibility, and higher levels of self-reported function through the lower-extremity functional scale. Physical fitness leaders and clinicians could use these models to inform decision making when developing and assessing the outcomes of a personalized intervention program for those with low FMS and YBT scores.

The emergence of nanoinformatics as a key component of nanotechnology and nanosafety assessment for the prediction of engineered nanomaterials (NMs) properties, interactions, and hazards, and for grouping and read-across to reduce reliance on animal testing, has put the spotlight firmly on the need for access to high-quality, curated datasets. To date, the focus has been around what constitutes data quality and completeness, on the development of minimum reporting standards, and on the FAIR (findable, accessible, interoperable, and reusable) data principles. However, moving from the theoretical realm to practical implementation requires human intervention, which will be facilitated by the definition of clear roles and responsibilities across the complete data lifecycle and a deeper appreciation of what metadata is, and how to capture and index it. Here, we demonstrate, using specific worked case studies, how to organise the nano-community efforts to define metadata schemas, by organising the data management cycle as a joint effort of all players (data creators, analysts, curators, managers, and customers) supervised by the newly defined role of data shepherd. We propose that once researchers understand their tasks and responsibilities, they will naturally apply the available tools. Two case studies are presented (modelling of particle agglomeration for dose metrics, and consensus for NM dissolution), along with a survey of the currently implemented metadata schema in existing nanosafety databases. We conclude by offering recommendations on the steps forward and the needed workflows for metadata capture to ensure FAIR nanosafety data.

BACKGROUND: The rickettsial bacterium Ehrlichia ruminantium is the causative agent of heartwater, a potential zoonotic disease of ruminants transmitted by ticks of the genus Amblyomma. The disease is distributed in nearly all of sub-Saharan Africa and some islands of the Caribbean, from where it threatens the American mainland. This report describes the development of two different loop-mediated isothermal amplification (LAMP) assays for sensitive and specific detection of E. ruminantium. RESULTS: Two sets of LAMP primers were designed from the pCS20 and sodB genes. The detection limits for each assay were 10 copies for pCS20 and 5 copies for sodB, which is at least 10 times higher than that of the conventional pCS20 PCR assay. DNA amplification was completed within 60 min. The assays detected 16 different isolates of E. ruminantium from geographically distinct countries as well as two attenuated vaccine isolates. No cross-reaction was observed with genetically related Rickettsiales, including zoonotic Ehrlichia species from the USA. LAMP detected more positive samples than conventional PCR but less than real-time PCR, when tested with field samples collected in sub-Saharan countries. CONCLUSIONS: Due to its simplicity and specificity, LAMP has the potential for use in resource-poor settings and also for active screening of E. ruminantium in both heartwater-endemic areas and regions that are at risk of contracting the disease.

Despite the prevalence of concussion in soldiers deployed to Iraq and Afghanistan, neuropsychological tests used to assist in concussion management have not been validated on the battlefield. This study evaluated the validity of the Automated Neuropsychological Assessment Metrics (ANAM) in the combat environment. Cases meeting criteria for concussion, healthy controls, and injured controls were assessed. Soldiers were administered the ANAM, traditional neuropsychological tests, and a background questionnaire. Cases were enrolled within 72 h of concussion. Cases exhibited poorer performance than controls on all ANAM subtests, with significant differences on simple reaction time (SRT), procedural reaction time (PRT), code substitution, and matching to sample (p<.001). Discriminant ability of scores on SRT and PRT subtests was 71%, which improved to 76% when pre-deployment baseline scores were available. An exploratory clinical decision tool incorporating ANAM scores and symptoms improved discriminant ability to 81%. Results provide initial validation of the ANAM for detecting acute effects of battlefield concussion.

PURPOSE: To evaluate noise-induced hearing injury (NIHI) and blast-related comorbidities among U.S. Army soldiers in an effort to understand the morbidity burden and future health service requirements for wounded war fighters returning from the Central Command Area of Responsibility, predominantly from Iraq and Afghanistan deployments. METHOD: Inpatient and outpatient records with diagnosed NIHI or blast-related comorbidities (e.g., significant threshold shift [STS], noise-induced hearing loss, tinnitus, sensorineural hearing loss, eardrum perforations, mild traumatic brain injury, and posttraumatic stress disorder) were extracted for active duty soldiers returning from combat deployments. Records were limited to those within 6 months of the soldier's return date from April 2003 through June 2009. To account for changes in STS coding practice, STS rates observed after October 1, 2006, were used to extrapolate prior probable postdeployment STS. RESULTS: Statistically significant increases were observed for tinnitus, dizziness, eardrum perforations, and speech-language disorders. The combination of observed and extrapolated STS yielded a conservative estimate of 27,427 cases. CONCLUSIONS: Estimates can be used to forecast resource requirements for hearing services among veterans. This article could serve as a guide for resourcing and innovating prevention measures and treatment in this population. Data provided may also serve as a baseline for evaluating prevention measures.