Beginning in late 2023, Oropouche virus was identified as the cause of large outbreaks in Amazon regions with known endemic transmission and in new areas in South America and the Caribbean. The virus is spread to humans by infected biting midges and some mosquito species. Although infection typically causes a self-limited febrile illness, reports of two deaths in patients with Oropouche virus infection and vertical transmission associated with adverse pregnancy outcomes have raised concerns about the threat of this virus to human health. In addition to approximately 8,000 locally acquired cases in the Americas, travel-associated Oropouche virus disease cases have recently been identified in European travelers returning from Cuba and Brazil. As of August 16, 2024, a total of 21 Oropouche virus disease cases were identified among U.S. travelers returning from Cuba. Most patients initially experienced fever, myalgia, and headache, often with other symptoms including arthralgia, diarrhea, nausea or vomiting, and rash. At least three patients had recurrent symptoms after the initial illness, a common characteristic of Oropouche virus disease. Clinicians and public health jurisdictions should be aware of the occurrence of Oropouche virus disease in U.S. travelers and request testing for suspected cases. Travelers should prevent insect bites when traveling, and pregnant persons should consider deferring travel to areas experiencing outbreaks of Oropouche virus disease.

Eight cases of locally acquired, mosquito-transmitted (i.e., autochthonous) Plasmodium vivax malaria, which has not been reported in the United States since 2003, were reported to CDC from state health departments in Florida and Texas during May 18-July 17, 2023. As of August 4, 2023, case surveillance, mosquito surveillance and control activities, and public outreach and education activities continue in both states. U.S. clinicians need to consider a malaria diagnosis in patients with unexplained fever, especially in areas where autochthonous malaria has been recently reported, although the risk for autochthonous malaria in the United States remains very low. Prompt diagnosis and treatment of malaria can prevent severe disease or death and limit ongoing transmission to local Anopheles mosquitoes and other persons. Preventing mosquito bites and controlling mosquitoes at home can prevent mosquitoborne diseases, including malaria. Before traveling internationally to areas with endemic malaria, travelers should consult with a health care provider regarding recommended malaria prevention measures, including potentially taking malaria prophylaxis. Malaria is a nationally notifiable disease; continued reporting of malaria cases to jurisdictional health departments and CDC will also help ensure robust surveillance to detect and prevent autochthonous malaria in the United States.

Importance Reported cases of SARS-CoV-2 infection likely underestimate the prevalence of infection in affected communities. Large-scale seroprevalence studies provide better estimates of the proportion of the population previously infected.Objective To estimate prevalence of SARS-CoV-2 antibodies in convenience samples from several geographic sites in the United States.Design Serologic testing of convenience samples using residual sera obtained for routine clinical testing by two commercial laboratory companies.Setting Connecticut (CT), south Florida (FL), Missouri (MO), New York City metro region (NYC), Utah (UT), and Washington State’s (WA) Puget Sound region.Participants Persons of all ages with serum collected during intervals from March 23 through May 3, 2020.Exposure SARS-CoV-2 virus infection.Main outcomes and measures We estimated the presence of antibodies to SARS-CoV-2 spike protein using an ELISA assay. We standardized estimates to the site populations by age and sex. Estimates were adjusted for test performance characteristics (96.0% sensitivity and 99.3% specificity). We estimated the number of infections in each site by extrapolating seroprevalence to site populations. We compared estimated infections to number of reported COVID-19 cases as of last specimen collection date.Results We tested sera from 11,933 persons. Adjusted estimates of the proportion of persons seroreactive to the SARS-CoV-2 spike protein ranged from 1.13% (95% confidence interval [CI] 0.70-1.94) in WA to 6.93% (95% CI 5.02-8.92) in NYC (collected March 23-April 1). For sites with later collection dates, estimates ranged from 1.85% (95% CI 1.00-3.23, collected April 6-10) for FL to 4.94% (95% CI 3.61-6.52) for CT (April 26-May 3). The estimated number of infections ranged from 6 to 24 times the number of reported cases in each site.Conclusions and relevance Our seroprevalence estimates suggest that for five of six U.S. sites, from late March to early May 2020, >10 times more SARS-CoV-2 infections occurred than the number of reported cases. Seroprevalence and under-ascertainment varied by site and specimen collection period. Most specimens from each site had no evidence of antibody to SARS-CoV-2. Tracking population seroprevalence serially, in a variety of specific geographic sites, will inform models of transmission dynamics and guide future community-wide public health measures.Question What proportion of persons in six U.S. sites had detectable antibodies to SARS-CoV-2, March 23-May 3, 2020?Findings We tested 11,933 residual clinical specimens. We estimate that from 1.1% of persons in the Puget Sound to 6.9% in New York City (collected March 23-April 1) had detectable antibodies. Estimates ranged from 1.9% in south Florida to 4.9% in Connecticut with specimens collected during intervals from April 6-May 3. Six to 24 times more infections were estimated per site with seroprevalence than with case report data.Meaning For most sites, evidence suggests >10 times more SARS-CoV-2 infections occurred than reported cases. Most persons in each site likely had no detectable SARS-CoV-2 antibodies.Competing Interest StatementThe authors have declared no competing interest.Funding StatementThis study was funded by the Centers for Disease Control and Prevention.Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:This protocol underwent review by CDC human subjects research officials, who determined that the testing represented non-research activity in the setting of a public health response to the COVID-19 pandemic.All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any su h study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesA limited dataset will be made publicly available at a later time.

In August 2022, the Florida Department of Health notified CDC of a nurse who acquired monkeypox through an occupational exposure while providing care to a patient with monkeypox. To date, occupationally acquired Monkeypox virus (MPXV) infections in health care personnel (HCP) have been rarely reported during the 2022 multinational outbreak (1,2). This report describes the first reported U.S. case and recommends approaches for preventing occupationally acquired MPXV infections in HCP.

Disasters can adversely affect population health, resulting in increased need for health services. Hurricane Irma made landfall in the Florida Keys (Monroe County) as a Category 4 hurricane on September 10, 2017. The hurricane caused substantial damage to 65% of homes and resulted in 40 persons injured and 17 deaths from hurricane-related causes.* During 2018, the county suicide rate increased to 34.9 per 100,000 population from the 5-year (2013-2017) average of 25.2 per 100,000 population (1). In May 2019, 20 months after the hurricane, the Florida Department of Health (FDOH) conducted a modified Community Assessment for Public Health Emergency Response (CASPER) to assess the community's mental, physical, and economic health and develop public health interventions to decrease the suicide rate. A consenting adult member from 231 households was interviewed, and a weighted cluster analysis was conducted to estimate the number and percentage of households throughout the Florida Keys with a particular response, as well as the number and percentage of persons at risk for suicide. During the 20 months since Hurricane Irma, 17% of households reported a need for a mental health care provider; 37.9% of these did not receive those services. A modified CASPER was used to calculate population estimates of suicide risk in an area of high landfall for hurricanes; estimated population suicide risk was 7.3%. Respondents reported worsening of respiratory conditions (17.7%), anxiety (17.0%), and depression (11.3%). Emergency preparedness plans should consider strengthening mental health service delivery after a hurricane, particularly during the long-term recovery phase.

BACKGROUND: The SARS-CoV-2 virus responsible for severe respiratory infection associated with coronavirus disease 2019 (COVID-19) was first confirmed in Florida on March 1, 2020. Responding to the pandemic, multi-agency collaborative partnerships put in place actions integrating point-of-care antibody testing at established large-scale COVID-19 testing sites where the baseline seropositivity of COVID-19 in health care workers and first responders in Florida at the start of the pandemic was established. PURPOSE: Determine the seropositivity of healthcare workers and first responders at five drive thru testing sites using a rapid SARS-CoV-2 antibody test in Florida from May 6 through June 3, 2020. METHODS: The first drive-thru SARS-CoV-2 antibody test site was opened at Miami Hard Rock Stadium, May 6, 2020. Testing expanded to three additional sites on May 9, 2020: Jacksonville, Orlando, and Palm Beach. The fifth and final site, Miami Beach, began testing on May 21, 2020. Healthcare workers and first responder's self-seeking SARS-CoV-2 testing were designated for antibody testing and completed a laboratory collection form onsite for the point-of-care test. All testing was performed on whole blood specimens (obtained by venipuncture) using the Cellex Inc. qSARS-CoV-2 IgG/IgM Rapid Test. Seropositivity was assessed by univariate analysis and by logistic regression including the covariates age, sex, race/ethnicity, and testing location. RESULTS AND DISCUSSION: As of June 3, 2020, of 5,779 healthcare workers and first responders tested, 4.1% were seropositive (range 2.6-8.2%). SARS-COV-2 antibody tests had higher odds of being positive for persons testing at the Miami Hard Rock Stadium (aOR 2.24 [95% C.I. 1.48-3.39]), persons of Haitian/Creole ethnicity (aOR 3.28 [95% C.I. 1.23-8.72]), Hispanic/Latino(a) ethnicity (aOR 2.17 [95% C.I. 1.50-3.13], and Black non-Hispanic persons (aOR 1.63 [95% C.I. 1.08-2.46]). SARS-COV-2 antibody prevalence among first responders and healthcare workers in five sites in Florida varied by race and ethnicity and by testing location.

After detection of cases of COVID-19 in Florida in March 2020, the governor declared a state of emergency on March 9,* and all school districts in the state suspended in-person instruction by March 20. Most kindergarten through grade 12 (K-12) public and private schools in Florida reopened for in-person learning during August 2020, with varying options for remote learning offered by school districts. During August 10-December 21, 2020, a total of 63,654 COVID-19 cases were reported in school-aged children; an estimated 60% of these cases were not school-related. Fewer than 1% of registered students were identified as having school-related COVID-19 and <11% of K-12 schools reported outbreaks. District incidences among students correlated with the background disease incidence in the county; resumption of in-person education was not associated with a proportionate increase in COVID-19 among school-aged children. Higher rates among students were observed in smaller districts, districts without mandatory mask-use policies, and districts with a lower proportion of students participating in remote learning. These findings highlight the importance of implementing both community-level and school-based strategies to reduce the spread of COVID-19 and suggest that school reopening can be achieved without resulting in widespread illness among students in K-12 school settings.

On December 7, 2020, local public health officials in Florida county A were notified of a person with an antigen-positive SARS-CoV-2 test* result who had attended two high school wrestling tournaments held in the county on December 4 and 5. The tournaments included 10 participating high schools from three counties. The host school (school A in county A) participated in the tournaments on both days; five high school teams from two counties participated the first day only; four additional high school teams from the three counties participated the second day. A total of 130 wrestlers, coaches, and referees attended the tournaments (Table). During December 8-9, 13 wrestlers from school A received positive SARS-CoV-2 test results (Figure), including nine who were symptomatic, two who were asymptomatic, and two for whom symptom status at time of specimen collection was unknown. Local public health officials in the three counties initiated an investigation(†) and tested specimens from an additional 40 attendees from nine of the 10 participating schools. A total of 54 (41.5%) of the 130 tournament attendees received testing, and 38 cases of SARS-CoV-2 infection were identified; the minimum attack rate was 30.2% (38 of 126(§)), and 70.4% (38 of 54) of tests had a positive result. Among contacts of the 38 COVID-19 patients, 446 were determined by investigators to meet the CDC definition of a close contact,(¶) including 62 who were household contacts and 384 who were in-school contacts (classmates, teachers, noncompeting wrestling team members, and other school athletic team members). Among these 446 contacts, five had received a diagnosis of COVID-19 during June-November and were excluded from attack rate calculations. Among 95 (21.3%) contacts who received SARS-CoV-2 testing, 41 (43.2%) received a positive test result (minimum attack rate = 9.3% [41 of 441]); 21 (51.2%) persons with positive test results were symptomatic, eight (19.5%) were asymptomatic, and symptom status for 12 (29.3%) was unknown at the time of specimen collection. Among contacts, attack rates were highest among household members (30.0%) and wrestling team members who did not attend the tournament (20.3%), as were the percentages of positive test results (60.0% among household members and 54.2% among team members). Among all contacts, the odds of receiving a positive test result were highest among household contacts (odds ratio = 2.7; 95% confidence interval = 1.2-6.0). Local health authorities reported the death of one adult contact aged >50 years.

IMPORTANCE: Reported cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection likely underestimate the prevalence of infection in affected communities. Large-scale seroprevalence studies provide better estimates of the proportion of the population previously infected. OBJECTIVE: To estimate prevalence of SARS-CoV-2 antibodies in convenience samples from several geographic sites in the US. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study performed serologic testing on a convenience sample of residual sera obtained from persons of all ages. The serum was collected from March 23 through May 12, 2020, for routine clinical testing by 2 commercial laboratory companies. Sites of collection were San Francisco Bay area, California; Connecticut; south Florida; Louisiana; Minneapolis-St Paul-St Cloud metro area, Minnesota; Missouri; New York City metro area, New York; Philadelphia metro area, Pennsylvania; Utah; and western Washington State. EXPOSURES: Infection with SARS-CoV-2. MAIN OUTCOMES AND MEASURES: The presence of antibodies to SARS-CoV-2 spike protein was estimated using an enzyme-linked immunosorbent assay, and estimates were standardized to the site populations by age and sex. Estimates were adjusted for test performance characteristics (96.0% sensitivity and 99.3% specificity). The number of infections in each site was estimated by extrapolating seroprevalence to site populations; estimated infections were compared with the number of reported coronavirus disease 2019 (COVID-19) cases as of last specimen collection date. RESULTS: Serum samples were tested from 16 025 persons, 8853 (55.2%) of whom were women; 1205 (7.5%) were 18 years or younger and 5845 (36.2%) were 65 years or older. Most specimens from each site had no evidence of antibodies to SARS-CoV-2. Adjusted estimates of the proportion of persons seroreactive to the SARS-CoV-2 spike protein antibodies ranged from 1.0% in the San Francisco Bay area (collected April 23-27) to 6.9% of persons in New York City (collected March 23-April 1). The estimated number of infections ranged from 6 to 24 times the number of reported cases; for 7 sites (Connecticut, Florida, Louisiana, Missouri, New York City metro area, Utah, and western Washington State), an estimated greater than 10 times more SARS-CoV-2 infections occurred than the number of reported cases. CONCLUSIONS AND RELEVANCE: During March to early May 2020, most persons in 10 diverse geographic sites in the US had not been infected with SARS-CoV-2 virus. The estimated number of infections, however, was much greater than the number of reported cases in all sites. The findings may reflect the number of persons who had mild or no illness or who did not seek medical care or undergo testing but who still may have contributed to ongoing virus transmission in the population.

We assessed IgM detection in Zika patients from the 2016 outbreak in Miami-Dade County, Florida, USA. Of those with positive or equivocal IgM after 12-19 months, 87% (26/30) had IgM 6 months later. In a survival analysis, approximately 76% had IgM at 25 months. Zika virus IgM persists for years, complicating serologic diagnosis.

Prevention of HIV outbreaks among people who inject drugs remains a challenge to ending the HIV epidemic in the United States. The first legal syringe services program (SSP) in Florida implemented routine screening in 2018 leading to the identification of ten anonymous HIV seroconversions. The SSP collaborated with the Department of Health to conduct an epidemiologic investigation. All seven acute HIV seroconversions were linked to care (86% within 30 days) and achieved viral suppression (mean 70 days). Six of the seven individuals are epidemiologically and/or socially linked to at least two other seroconversions. Analysis of the HIV genotypes revealed that two individuals are connected molecularly at 0.5% genetic distance. We identified a risk network with complex transmission dynamics that could not be explained by epidemiological methods or molecular analyses alone. Providing wrap-around services through the SSP, including routine screening, intensive linkage and patient navigation, could be an effective model for achieving viral suppression for people who inject drugs.

Data on the duration of detectable Zika virus-specific IgM in infected persons are limited. Neutralizing antibody cross-reactivity occurs between Zika virus and related flaviviruses, but the degree to which this confounds diagnosis is uncertain. We tested serum specimens collected 12-19 months after illness onset from patients with confirmed Zika virus disease for Zika virus IgM and Zika virus and dengue virus neutralizing antibodies. Among 62 participants, 45 (73%) had detectable Zika virus IgM and 12 (19%) had an equivocal result. Although all patients tested had Zika virus neutralizing antibodies, 39 (63%) also had neutralizing antibodies against dengue virus; of those, 12 (19%) had <4-fold difference between Zika virus and dengue virus titers, and 5 (8%) had dengue virus titer >4-fold higher than Zika virus titer. Prolonged detection of IgM and neutralizing antibody cross-reactivity make it difficult to determine the timing of Zika virus infection and differentiate between related flaviviruses.

Three powerful and devastating hurricanes from the 2017 Atlantic hurricane season (Harvey [August 17-September 1], Irma [August 30-September 13], and Maria [September 16-October 2]) resulted in the deaths of hundreds of persons. Disaster-related mortality surveillance is critical to an emergency response because it provides government and public health officials with information about the scope of the disaster and topics for prevention messaging. CDC's Emergency Operations Center collaborated with state health departments in Florida, Georgia, and North Carolina to collect and analyze Hurricane Irma-related mortality data to understand the main circumstances of death. The most common circumstance-of-death categories were exacerbation of existing medical conditions and power outage. Further analysis revealed two unique subcategories of heat-related and oxygen-dependent deaths in which power outage contributed to exacerbation of an existing medical condition. Understanding the need for subcategorization of disaster-related circumstances of death and the possibility of overlapping categories can help public health practitioners derive more effective public health interventions to prevent deaths in future disasters.

In December 2014, the Food and Drug Administration granted the first-ever Clinical Laboratory Improvement Amendments waiver for a rapid treponemal syphilis screening test, Syphilis Health Check (SHC) (1). SHC is a new tool for public health programs to combat increasing syphilis rates, specifically among persons without a prior syphilis infection. SHC can be performed by nonlaboratorian health care personnel and results are available in 10 minutes. In 2015, a total of 7,094 noncongenital cases of syphilis (35.8 case per 100,000) were reported to the Florida Department of Health (2). The Florida Department of Health evaluated the performance of SHC in comparison with treponemal and nontreponemal tests routinely used in its sexually transmitted disease (STD) clinic in Escambia County. | For this evaluation, patients seeking STD testing at the Florida Department of Health STD clinic in Escambia County during March 11–April 21, 2016, were tested for syphilis using the SHC on blood specimens obtained by fingerstick; a venous blood specimen was drawn concurrently and submitted for treponemal (Trep-Sure), and nontreponemal (Arlington Scientific, Inc. [ASI] rapid plasma reagin [RPR] card test for syphilis) testing at the state public health laboratory. The state public health laboratory in Florida uses the CDC-recommended algorithm for syphilis testing (i.e., nontreponemal testing followed by treponemal testing for persons with a reactive nontreponemal test); however, for the purpose of this study, all collected specimens underwent treponemal testing regardless of the nontreponemal test result. The SHC result was compared with results of routine syphilis testing using the traditional testing algorithm at the state laboratory. Sensitivity, specificity, and overall laboratory test agreement were determined using the Trep-Sure qualitative enzyme immunoassay (EIA) reference treponemal test as the standard for “true” positive or negative treponemal test results.

During the first 6 months of 2016, large outbreaks of Zika virus disease caused by local mosquito-borne transmission occurred in Puerto Rico and other U.S. territories, but local mosquito-borne transmission was not identified in the continental United States. As of July 22, 2016, the Florida Department of Health had identified 321 Zika virus disease cases among Florida residents and visitors, all occurring in either travelers from other countries or territories with ongoing Zika virus transmission or sexual contacts of recent travelers.* During standard case investigation of persons with compatible illness and laboratory evidence of recent Zika virus infection (i.e., a specimen positive by real-time reverse transcription-polymerase chain reaction [rRT-PCR], or positive Zika immunoglobulin M [IgM] with supporting dengue serology [negative for dengue IgM antibodies and positive for dengue IgG antibodies], or confirmation of Zika virus neutralizing antibodies by plaque reduction neutralization testing [PRNT]), four persons were identified in Broward and Miami-Dade counties whose infections were attributed to likely local mosquito-borne transmission. Two of these persons worked within 120 meters (131 yards) of each other but had no other epidemiologic connections, suggesting the possibility of a local community-based outbreak. Further epidemiologic and laboratory investigations of the worksites and surrounding neighborhood identified a total of 29 persons with laboratory evidence of recent Zika virus infection and likely exposure during late June to early August, most within an approximate 6-block area. In response to limited impact on the population of Aedes aegypti mosquito vectors from initial ground-based mosquito control efforts, aerial ultralow volume spraying with the organophosphate insecticide naled was applied over a 10 square-mile area beginning in early August and alternated with aerial larviciding with Bacillus thuringiensis subspecies israelensis (Bti), a group biologic control agent, in a central 2 square-mile area. No additional cases were identified after implementation of this mosquito control strategy. No increases in emergency department (ED) patient visits associated with aerial spraying were reported, including visits for asthma, reactive airway disease, wheezing, shortness of breath, nausea, vomiting, or diarrhea. Local and state health departments serving communities where Ae. aegypti, the primary vector of Zika virus, is found should continue to actively monitor for local transmission of the virus.

BACKGROUND: During a routine human immunodeficiency virus (HIV) investigation, Florida Department of Health staff identified a house (house A) in which over 150 individuals had resided at least briefly. Further investigation revealed that house A is used by the producer of a small adult film production company to board his actors. This report describes sexually transmitted infection (STI) prevalence among male actors in gay adult films residing in a common Florida residence. METHODS: LexisNexis Accurint was used to identify house A residents since October 2002 when the producer arrived. Information on STIs and interview data were obtained from Florida's STI surveillance system. An infection was considered to be associated with residence in house A if the date of diagnosis occurred 6 months before an individual's residence start date through 6 months after his residence end date. RESULTS: Excluding the producer, 150 men resided in house A starting from September 2003 to July 2015. Forty-six individuals had a reported case of HIV, syphilis, gonorrhea, and/or chlamydia with 92 infections total. Forty-two (46%) infections among 24 men were considered associated with residence in house A. CONCLUSIONS: LexisNexis Accurint was a useful tool for identifying house A residents, a highly mobile and highly sexually active population. There is a high prevalence of STIs among residents, but it is unclear where transmission is occurring. Settings like house A are good candidates for HIV pre-exposure prophylaxis and active STI screenings and may be an opportunity for public health officials to intervene in high-risk groups to reduce STI rates in the community.

The National Ecological Observatory Network (NEON) intends to monitor mosquito populations across its broad geographical range of sites because of their prevalence in food webs, sensitivity to abiotic factors, and relevance for human health. We describe the design of mosquito population sampling in the context of NEON's long-term continental scale monitoring program, emphasizing the sampling design schedule, priorities, and collection methods. Freely available NEON data and associated field and laboratory samples, will increase our understanding of how mosquito abundance, demography, diversity, and phenology are responding to land use and climate change.

Parasites and pathogens are increasingly recognized as significant drivers of ecological and evolutionary change in natural ecosystems. Concurrently, transmission of infectious agents among human, livestock, and wildlife populations represents a growing threat to veterinary and human health. In light of these trends and the scarcity of long-term time series data on infection rates among vectors and reservoirs, the National Ecological Observatory Network (NEON) will collect measurements and samples of a suite of tick-, mosquito-, and rodent-borne parasites through a continental-scale surveillance program. Here, we describe the sampling designs for these efforts, highlighting sampling priorities, field and analytical methods, and the data as well as archived samples to be made available to the research community. Insights generated by this sampling will advance current understanding of and ability to predict changes in infection and disease dynamics in novel, interdisciplinary, and collaborative ways.

Neonatal abstinence syndrome (NAS) is a constellation of physiologic and neurobehavioral signs exhibited by newborns exposed to addictive prescription or illicit drugs taken by a mother during pregnancy. The number of hospital discharges of newborns diagnosed with NAS has increased more than 10-fold (from 0.4 to 4.4 discharges per 1,000 live births) in Florida since 1995, far exceeding the three-fold increase observed nationally. In February 2014, the Florida Department of Health requested the assistance of CDC to 1) assess the accuracy and validity of using Florida's hospital inpatient discharge data, linked to birth and infant death certificates, as a means of NAS surveillance and 2) describe the characteristics of infants with NAS and their mothers. This report focuses only on objective two, describing maternal and infant characteristics in the 242 confirmed NAS cases identified in three Florida hospitals during a 2-year period (2010-2011). Infants with NAS experienced serious medical complications, with 97.1% being admitted to an intensive care unit, and had prolonged hospital stays, with a mean duration of 26.1 days. The findings of this investigation underscore the important public health problem of NAS and add to current knowledge on the characteristics of these mothers and infants. Effective June 2014, NAS is now a mandatory reportable condition in Florida. Interventions are also needed to 1) increase the number and use of community resources available to drug-abusing and drug-dependent women of reproductive age, 2) improve drug addiction counseling and rehabilitation referral and documentation policies, and 3) link women to these resources before or earlier in pregnancy.

BACKGROUND: In 2009-2010, 93 cases of dengue were identified in Key West, Florida. This was the first outbreak of autochthonous transmission of dengue in Florida since 1934. In response to this outbreak, a multifaceted public education outreach campaign was launched. The aim of this study is to compare dengue prevention knowledge, attitudes, perceptions, and prevention practices among residents of subsidized public housing to the general population in Key West and to assess whether there were barriers preventing effective outreach from reaching specific vulnerable populations. METHODS: A randomized population-based evaluation of knowledge, attitudes, and behaviors toward dengue prevention consisting of 521 separate household interviews was undertaken in July of 2011. A subset analysis was performed on interviews collected from 28 public housing units within four subsidized public housing complexes. Analysis was performed to determine whether knowledge, attitudes, and behaviors exhibited by public housing residents differed from the non-public housing study population. RESULTS: Public housing residents recalled fewer outreach materials (p=0.01) and were 3.4 times (95% confidence interval [CI] 1.4-8.3) more likely not to recall any outreach materials. Public housing residents were less likely to correctly identify how dengue transmission occurs (61% vs. 89%), where mosquitoes lay their eggs (54% vs. 85%), or to identify any signs or symptoms related to dengue (36% vs. 64%). Public housing residents were less likely to perform dengue prevention practices such as removing standing water or always using air conditioning. CONCLUSIONS: Examination of public housing residents identified an at-risk population that recalled less exposure to outreach materials and had less knowledge about dengue infection and prevention than the randomized study population. This provides public health systems the opportunity to target or modify future health messages and interventions to this group. Differences identified in the demographics of this population suggest that alternative methods or non-English materials may be required to reach desired outcomes.

Since mid-March 2014, the frequency with which cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection have been reported has increased, with the majority of recent cases reported from Saudi Arabia and United Arab Emirates (UAE). In addition, the frequency with which travel-associated MERS cases have been reported and the number of countries that have reported them to the World Health Organization (WHO) have also increased. The first case of MERS in the United States, identified in a traveler recently returned from Saudi Arabia, was reported to CDC by the Indiana State Department of Health on May 1, 2014, and confirmed by CDC on May 2. A second imported case of MERS in the United States, identified in a traveler from Saudi Arabia having no connection with the first case, was reported to CDC by the Florida Department of Health on May 11, 2014. The purpose of this report is to alert clinicians, health officials, and others to increase awareness of the need to consider MERS-CoV infection in persons who have recently traveled from countries in or near the Arabian Peninsula. This report summarizes recent epidemiologic information, provides preliminary descriptions of the cases reported from Indiana and Florida, and updates CDC guidance about patient evaluation, home care and isolation, specimen collection, and travel as of May 13, 2014.

This article describes and contrasts the public health response to two human rabies cases: one organ recipient diagnosed within days of symptom onset and the transplant donor who was diagnosed 18 months post-symptom onset. In response to an organ-transplant-related rabies case diagnosed in 2013, organ donor and recipient investigations were conducted by multiple public health agencies. Persons with potential exposure to infectious patient materials were assessed for rabies virus exposure. An exposure investigation was conducted to determine the source of the organ donor's infection. Over 100 persons from more than 20 agencies spent over 2700 h conducting contact investigations in healthcare, military and community settings. The 564 persons assessed include 417 healthcare workers [5.8% recommended for post-exposure prophylaxis (PEP)], 96 community contacts (15.6% recommended for PEP), 30 autopsy personnel (50% recommended for PEP), and 21 other persons (4.8% recommended for PEP). Donor contacts represented 188 assessed with 20.2% recommended for PEP, compared with 5.6% of 306 recipient contacts recommended for PEP. Human rabies cases result in substantial use of public health and medical resources, especially when diagnosis is delayed. Although rare, clinicians should consider rabies in cases of encephalitis of unexplained aetiology, particularly for cases that may result in organ donation.

Inhalation anthrax occurred in a man who vacationed in 4 US states where anthrax is enzootic. Despite an extensive multi-agency investigation, the specific source was not detected, and no additional related human or animal cases were found. Although rare, inhalation anthrax can occur naturally in the United States.

This report augments guidelines published in 1990 for investigating clusters of health events (CDC. Guidelines for investigating clusters of health events. MMWR 1990;39[No. RR-11]). The 1990 Guidelines considered any noninfectious disease cluster, injuries, birth defects, and previously unrecognized syndromes or illnesses. These new guidelines focus on cancer clusters. State and local health departments can use these guidelines to develop a systematic approach to responding to community concerns regarding cancer clusters. The guidelines are intended to apply to situations in which a health department responds to an inquiry about a suspected cancer cluster in a residential or community setting only. Occupational or medical treatment-related clusters are not included in this report. Since 1990, many improvements have occurred in data resources, investigative techniques, and analytic/statistical methods, and much has been learned from both large- and small-scale cancer cluster investigations. These improvements and lessons have informed these updated guidelines. These guidelines utilize a four-step approach (initial response, assessment, major feasibility study, and etiologic investigation) as a tool for managing a reported cluster. Even if a cancer cluster is identified, there is no guarantee that a common cause or an environmental contaminant will be implicated. Identification of a common cause or an implicated contaminant might be an expected outcome for the concerned community. Therefore, during all parts of an inquiry, responders should be transparent, communicate clearly, and explain their decisions to the community.

BACKGROUND: In 2010, malaria caused approximately 216 million infections in people and 655,000 deaths. In the United States, imported malaria cases occur every year, primarily in returning travelers and immigrants from endemic countries. In 2010, five Plasmodium falciparum malaria cases occurred among crew members of one US commercial airline company (Airline A). This investigation aimed to assess the malaria prevention knowledge, attitudes, and practices (KAP) of Airline A crew members to provide information for potential interventions. METHODS: The web link to a self-administered on-line survey was distributed by internal company communications to Airline A pilots and flight attendants (FA) eligible for international travel. The survey collected demographic information as well as occupation, work history, and malaria prevention education. RESULTS: Of approximately 7,000 nonrandomly selected crew members, 220 FA and 217 pilots completed the survey (6%). Respondents correctly identified antimalarial medication (91% FA, 95% pilots) and insect repellents (96% FA, 96% pilots) as effective preventive measures. While in malaria-intense destinations, few FA and less than half of pilots always took antimalarial medication (4% FA, 40% pilots) yet many often spent greater than 30 minutes outdoors after sundown (71% FA, 66% pilots). Less than half in both groups always used insect repellents (46% FA, 47% pilots). Many respondents were unaware of how to get antimalarial medications (52% FA, 30% pilots) and were concerned about their side effects (61% FA, 31% pilots). CONCLUSION: Overall, FA and pilots demonstrated good knowledge of malaria prevention, but many performed risky activities while practicing only some recommended malaria preventive measures. Malaria prevention education should focus on advance notification if traveling to a malaria-endemic area, how to easily obtain antimalarial medications, and the importance of practicing all recommended preventive measures. (2012 International Society of Travel Medicine, 1195-1982.)

Public health surveillance and epidemiology are the foundations for disease prevention because they provide the factual basis from which agencies can set priorities, plan programs, and take actions to protect the public's health. Surveillance for noninfectious diseases associated with exposure to agents in the environment like lead and pesticides has been a function of state health departments for more than 3 decades, but many state programs do not have adequate funding or staff for this function. Following the efforts to identify core public health epidemiology functions in chronic diseases, injury, and occupational health and safety, a workgroup of public health environmental epidemiologists operating within the organizational structure of the Council of State and Territorial Epidemiologists has defined the essential core functions of noninfectious disease environmental epidemiology that should be present in every state health department and additional functions of a comprehensive program. These functions are described in terms of the "10 Essential Environmental Public Health Services" and their associated performance standards. Application of these consensus core and expanded functions should help state and large metropolitan health departments allocate resources and prioritize activities of their environmental epidemiologists, thus improving the delivery of environmental health services to the public.

After 3 dengue cases were acquired in Key West, Florida, we conducted a serosurvey to determine the scope of the outbreak. Thirteen residents showed recent infection (infection rate 5%; 90% CI 2%-8%), demonstrating the reemergence of dengue in Florida. Increased awareness of dengue among health care providers is needed.

Leptospirosis is caused by pathogenic spirochetes of the genus Leptospira and transmitted through direct contact of skin or mucous membranes with urine or tissues of Leptospira-infected animals or through indirect contact with contaminated freshwater or soil. Leptospirosis shares common clinical signs with influenza, including fever, headache, myalgia, and sometimes cough and gastrointestinal symptoms. During 2009, acute complicated influenza-like illness (ILI) and rapid progressive pneumonia were often attributed to pandemic (H1N1) 2009; however, alternative final diagnoses were reported to be common. We report 3 cases of severe leptospirosis in Florida and Missouri with clinical signs similar to those of pandemic (H1N1) 2009.

BACKGROUND: Current methods for measuring folates in clinical laboratories are competitive folate binding protein assays. These assays show a considerable lack of agreement that has implications for the comparability of data across studies as well as for long-term population studies. The development of isotope dilution-liquid chromatography-tandem mass spectrometry (ID-LC-MS/MS) reference methods permitted the evaluation of method accuracy and consistency over time. METHODS: We measured 3 pools of human serum by ID-LC-MS/MS, calculated values for total folate, and distributed the same pools to participants in a national External Quality Assessment scheme. We used linear regression to compare the all-laboratory and method data with reference method values. The exercise was repeated after 18 months to assess the stability of the all-laboratory and method data. RESULTS: The distributed serum pools had mass spectrometry values for folate species typical of those found in healthy individuals from populations not receiving dietary folic acid fortification. There was good agreement of the all-laboratory data set with the reference method (y =0.86x + 0.91 mcg/L) at both time points. Linear regression demonstrated that the Abbott Architect showed the closest agreement with the reference method. The Roche Elecsys method was nonlinear and showed a calibration offset of 2.6 mcg/L (4.57 nmol/L). CONCLUSIONS: Calibration of serum folate assays traceable to higher-order reference methods increases method accuracy and improves consistency. The all-laboratory consensus mean proved sufficiently accurate and stable to be used as the target for monitoring laboratory performance.

A roundtable to discuss the measurement of folate status biomarkers in NHANES took place in July 2010. NHANES has measured serum folate since 1974 and red blood cell (RBC) folate since 1978 with the use of several different measurement procedures. Data on serum 5-methyltetrahydrofolate (5MTHF) and folic acid (FA) concentrations in persons aged ≥60 y are available in NHANES 1999-2002. The roundtable reviewed data that showed that folate concentrations from the Bio-Rad Quantaphase II procedure (Bio-Rad Laboratories, Hercules, CA; used in NHANES 1991-1994 and NHANES 1999-2006) were, on average, 29% lower for serum and 45% lower for RBC than were those from the microbiological assay (MA), which was used in NHANES 2007-2010. Roundtable experts agreed that these differences required a data adjustment for time-trend analyses. The roundtable reviewed the possible use of an isotope-dilution liquid chromatography-tandem mass spectrometry (LC-MS/MS) measurement procedure for future NHANES and agreed that the close agreement between the MA and LC-MS/MS results for serum folate supported conversion to the LC-MS/MS procedure. However, for RBC folate, the MA gave 25% higher concentrations than did the LC-MS/MS procedure. The roundtable agreed that the use of the LC-MS/MS procedure to measure RBC folate is premature at this time. The roundtable reviewed the reference materials available or under development at the National Institute of Standards and Technology and recognized the challenges related to, and the scientific need for, these materials. They noted the need for a commutability study for the available reference materials for serum 5MTHF and FA.