Q fever is a disease caused by Coxiella burnetii, which can cause serious illness in humans and abortions in goats. A Q fever outbreak among an unvaccinated goat herd led to a 65% loss of the kid crop in spring 2018. To assess the impact of the outbreak on the herd and environment, longitudinal surveillance of the ranch was conducted across three samplings in September 2018, April 2019, and May 2022. Antibodies against C. burnetii were monitored by an indirect immunofluorescence assay. Shedding was monitored through analysis of vaginal/fecal swabs and milk. Environmental swabs and bulk soil were collected from various locations around the ranch. Animal and environmental samples were analyzed for C. burnetii DNA by PCR. Herd-level seroprevalence decreased from 89% in 2018 to 84.3% in 2019, and 64.5% in 2022. Overall herd shedding was 14.4% in 2018, 7.4% in 2019, and 6.7% in 2022. The percentage of C. burnetii-positive environmental samples was 83.7% in 2018, 51.7% in 2019, and 28.6% in 2022. Serological evidence suggests that new infections were occurring in the herd 4 years post-abortion storm. This study demonstrates the presence of C. burnetii shedding and environmental contamination in a goat operation at least four kidding seasons after an outbreak. A better understanding of management practices that can improve outcomes for infected herds, particularly in areas without access to vaccines against C. burnetii, is needed to better protect operators and the public.

Coxiella burnetii is a bacterial pathogen capable of causing serious disease in humans and abortions in goats. Infected goats can shed C. burnetii through urine, feces, and parturient byproducts, which can lead to infections in humans when the bacteria are inhaled. Goats are important C. burnetii reservoirs as evidenced by goat-related outbreaks across the world. To better understand the current landscape of C. burnetii infection in the domestic goat population, 4,121 vaginal swabs from 388 operations across the United States were analyzed for the presence of C. burnetii by IS1111 PCR as part of the United States Department of Agriculture, Animal Plant Health Inspection Service, Veterinary Services' National Animal Health Monitoring System Goats 2019 Study. In total, 1.5% (61/4121) of swabs representing 10.3% (40/388) (weighted estimate of 7.8, 95% CI 4.4-13.5) of operations were positive for C. burnetii DNA. The quantity of C. burnetii on positive swabs was low with an average Ct of 37.9. Factors associated with greater odds of testing positive included suspected Q fever in the herd in the previous 3 years, the presence of wild deer or elk on the operation, and the utilization of hormones for estrus synchronization. Factors associated with reduced odds of testing positive include the presence of kittens and treatment of herds with high tannin concentrate plants, diatomaceous earth, and tetrahydropyrimidines. In vitro analysis demonstrated an inhibitory effect of the tetrahydropyrimidine, pyrantel pamoate, on the growth of C. burnetii in axenic media as low as 1 μg per mL. The final multivariable logistic regression modeling identified the presence of wild predators on the operation or adjacent property (OR = 9.0, 95% CI 1.3-61.6, p value = 0.0248) as a risk factor for C. burnetii infection.

INTRODUCTION: the number of wild poliomyelitis cases, worldwide, dropped from 350,000 cases in 1988 to 33 in 2018. Acute flaccid paralysis (AFP) surveillance is a key strategy toward achieving global polio eradication. The 2014 Ebola virus disease (EVD) epidemic in West Africa infected over 28,000 people and had devastating effects on health systems in Guinea, Liberia, and Sierra Leone. We sought to assess the effects of the 2014 Ebola outbreak on AFP surveillance in Guinea and Liberia. METHODS: a retrospective cross-sectional analysis was performed for Guinea and Liberia to evaluate EVD´s impact on World Health Organization (WHO) AFP surveillance performance indicators during 2012-2015. RESULTS: both Guinea and Liberia met the WHO target non-polio AFP incidence rate nationally, and generally sub-nationally, prior to the EVD outbreak; rates decreased substantially during the outbreak in seven of eight regions in Guinea and 11 of 15 counties in Liberia. Throughout the study period, both Guinea and Liberia attained appropriate overall targets nationally for "notification" and "stool adequacy" indicators, but each country experienced periods of poor regional/county-specific indicator performance. CONCLUSION: these findings mirrored the negative effect of the Ebola outbreak on polio elimination activities in both countries and highlights the need to reinforce this surveillance system during times of crisis.

BACKGROUND: To assist clinicians with identifying children at risk of severe outcomes, we assessed the association between laboratory findings and severe outcomes among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children and determined if SARS-CoV-2 test result status modified the associations. METHODS: We conducted a cross-sectional analysis of participants tested for SARS-CoV-2 infection in 41 pediatric emergency departments in 10 countries. Participants were hospitalized, had laboratory testing performed, and completed 14-day follow-up. The primary objective was to assess the associations between laboratory findings and severe outcomes. The secondary objective was to determine if the SARS-CoV-2 test result modified the associations. RESULTS: We included 1817 participants; 522 (28.7%) SARS-CoV-2 test-positive and 1295 (71.3%) test-negative. Seventy-five (14.4%) test-positive and 174 (13.4%) test-negative children experienced severe outcomes. In regression analysis, we found that among SARS-CoV-2-positive children, procalcitonin ≥0.5 ng/mL (adjusted odds ratio [aOR], 9.14; 95% CI, 2.90-28.80), ferritin >500 ng/mL (aOR, 7.95; 95% CI, 1.89-33.44), D-dimer ≥1500 ng/mL (aOR, 4.57; 95% CI, 1.12-18.68), serum glucose ≥120 mg/dL (aOR, 2.01; 95% CI, 1.06-3.81), lymphocyte count <1.0 × 10(9)/L (aOR, 3.21; 95% CI, 1.34-7.69), and platelet count <150 × 10(9)/L (aOR, 2.82; 95% CI, 1.31-6.07) were associated with severe outcomes. Evaluation of the interaction term revealed that a positive SARS-CoV-2 result increased the associations with severe outcomes for elevated procalcitonin, C-reactive protein (CRP), D-dimer, and for reduced lymphocyte and platelet counts. CONCLUSIONS: Specific laboratory parameters are associated with severe outcomes in SARS-CoV-2-infected children, and elevated serum procalcitonin, CRP, and D-dimer and low absolute lymphocyte and platelet counts were more strongly associated with severe outcomes in children testing positive compared with those testing negative.

Rubella is a highly contagious viral infection that usually causes a mild disease in children and adults. However, infection during pregnancy can result in a fetal or newborn death or congenital rubella syndrome (CRS), a constellation of permanent birth defects including cataracts, heart defects, and sensorineural deafness. The live-attenuated rubella vaccine has been highly effective, with the Americas declared free of endemic rubella transmission in 2015. However, rubella remains a significant problem worldwide and the leading cause of vaccine-preventable birth defects globally. Thus, elimination of rubella and CRS is a goal of the World Health Organization. No specific therapeutics are approved for the rubella virus. Therefore, we set out to identify whether existing small molecules may be repurposed for use against rubella virus infection. Thus, we performed a high-throughput screen for small molecules active against rubella virus in human respiratory cells and identified two nucleoside analogs, NM107 and AT-527, with potent antiviral activity. Furthermore, we found that combining these nucleoside analogs with inhibitors of host nucleoside biosynthesis had synergistic antiviral activity. These studies open the door to new potential approaches to treat rubella infections.

Little filtered cigars are tobacco products with many cigarette-like characteristics. However, despite cigars falling under the U.S. Food and Drug Administration regulatory authority, characterizing flavors, which are still allowed in little filtered cigars, and filter design may influence how people use the products and the resulting exposure to harmful and potentially harmful constituents. We estimated nicotine mouth level intake (MLI) from analyses of little cigar filter butt solanesol levels, brand characteristics, carbon monoxide boost, and puff volume in 48 dual cigarette/cigar users during two repeat bouts of ad lib smoking of three little filtered cigar brands. Mean nicotine MLI for the three brands was significantly different with Swisher Sweets (0.1% ventilation) Cherry at 1.20 mg nicotine, Cheyenne Menthol (1.5%) at 0.63 mg, and Santa Fe unflavored (49%) at 0.94 mg. The association between nicotine MLI and puff volume was the same between Cheyenne Menthol and Santa Fe unflavored. However, these were different from Swisher Sweets Cherry. At least five main factors─flavor, ventilation, filter design, nicotine delivery related to tar, and user puff volume─may directly or indirectly impact MLI and its association with other measures. We found that users of little filtered cigars that have different filter ventilation and flavor draw dissimilar amounts of nicotine from the product, which may be accompanied by differences in exposure to other harmful smoke constituents.

BACKGROUND: Alpha-gal syndrome (AGS) is an IgE-mediated allergy to galactose-alpha-1,3-galactose. Clinical presentation ranges from hives to anaphylaxis; episodes typically occur 2-6 hours after exposure to alpha-gal-containing products. In the United States, lone star tick bites are associated with development of AGS. To characterize features of AGS, we evaluated a cohort of patients presenting for care at the University of North Carolina, focusing on symptoms, severity, and identifying features unique to specific alpha-gal-containing product exposures. METHODS: We performed a chart review and descriptive analysis of 100 randomly selected patients with AGS during 2010-2019. RESULTS: Median age at onset was 53years, 56% were female, 95% reported White race, 86% reported a history of tick bite, and 75% met criteria for anaphylaxis based on involvement of 2 organ systems. Those reporting dairy reactions were significantly less likely to report isolated mucocutaneous symptoms (3% vs 24%; ratio [95% CI]: 0.1 [0.1, 0.3]) than those who tolerated dairy, and were more likely to report gastrointestinal symptoms (79% vs 59%; ratio [95% CI]: 1.3 [0.7, 2.6]), although this difference was not statistically significant. Dairy-tolerant patients demonstrated higher alpha-gal sIgE titers (as a percentage of total IgE) than dairy-reactive patients (GM 4.1[95% CI: 2.7, 6.1] vs. GM 2.5 [95% CI: 1.3, 4.8], respectively; ratio - 1.6 [95% CI: -1.0, 3.9]). CONCLUSION: While tick exposure is common in the southern United States, nearly all AGS patients reported a tick bite. Gastrointestinal symptoms were prominent among those reporting reactions to dairy. Anaphylaxis was common, underscoring the severity and need to raise awareness of AGS among patients and providers.

IMPORTANCE: Little is known about the risk factors for, and the risk of, developing post-COVID-19 conditions (PCCs) among children. OBJECTIVES: To estimate the proportion of SARS-CoV-2-positive children with PCCs 90 days after a positive test result, to compare this proportion with SARS-CoV-2-negative children, and to assess factors associated with PCCs. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study, conducted in 36 emergency departments (EDs) in 8 countries between March 7, 2020, and January 20, 2021, included 1884 SARS-CoV-2-positive children who completed 90-day follow-up; 1686 of these children were frequency matched by hospitalization status, country, and recruitment date with 1701 SARS-CoV-2-negative controls. EXPOSURE: SARS-CoV-2 detected via nucleic acid testing. MAIN OUTCOMES AND MEASURES: Post-COVID-19 conditions, defined as any persistent, new, or recurrent health problems reported in the 90-day follow-up survey. RESULTS: Of 8642 enrolled children, 2368 (27.4%) were SARS-CoV-2 positive, among whom 2365 (99.9%) had index ED visit disposition data available; among the 1884 children (79.7%) who completed follow-up, the median age was 3 years (IQR, 0-10 years) and 994 (52.8%) were boys. A total of 110 SARS-CoV-2-positive children (5.8%; 95% CI, 4.8%-7.0%) reported PCCs, including 44 of 447 children (9.8%; 95% CI, 7.4%-13.0%) hospitalized during the acute illness and 66 of 1437 children (4.6%; 95% CI, 3.6%-5.8%) not hospitalized during the acute illness (difference, 5.3%; 95% CI, 2.5%-8.5%). Among SARS-CoV-2-positive children, the most common symptom was fatigue or weakness (21 [1.1%]). Characteristics associated with reporting at least 1 PCC at 90 days included being hospitalized 48 hours or more compared with no hospitalization (adjusted odds ratio [aOR], 2.67 [95% CI, 1.63-4.38]); having 4 or more symptoms reported at the index ED visit compared with 1 to 3 symptoms (4-6 symptoms: aOR, 2.35 [95% CI, 1.28-4.31]; ≥7 symptoms: aOR, 4.59 [95% CI, 2.50-8.44]); and being 14 years of age or older compared with younger than 1 year (aOR, 2.67 [95% CI, 1.43-4.99]). SARS-CoV-2-positive children were more likely to report PCCs at 90 days compared with those who tested negative, both among those who were not hospitalized (55 of 1295 [4.2%; 95% CI, 3.2%-5.5%] vs 35 of 1321 [2.7%; 95% CI, 1.9%-3.7%]; difference, 1.6% [95% CI, 0.2%-3.0%]) and those who were hospitalized (40 of 391 [10.2%; 95% CI, 7.4%-13.7%] vs 19 of 380 [5.0%; 95% CI, 3.0%-7.7%]; difference, 5.2% [95% CI, 1.5%-9.1%]). In addition, SARS-CoV-2 positivity was associated with reporting PCCs 90 days after the index ED visit (aOR, 1.63 [95% CI, 1.14-2.35]), specifically systemic health problems (eg, fatigue, weakness, fever; aOR, 2.44 [95% CI, 1.19-5.00]). CONCLUSIONS AND RELEVANCE: In this cohort study, SARS-CoV-2 infection was associated with reporting PCCs at 90 days in children. Guidance and follow-up are particularly necessary for hospitalized children who have numerous acute symptoms and are older.

The global emergence of many severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants jeopardizes the protective antiviral immunity induced following infection or vaccination. To address the public health threat caused by the increasing SARS-CoV-2 genomic diversity, the National Institute of Allergy and Infectious Diseases (NIAID) within the National Institutes of Health (NIH) established the SARS-CoV-2 Assessment of Viral Evolution (SAVE) program. This effort was designed to provide a real-time risk assessment of SARS-CoV-2 variants potentially impacting transmission, virulence, and resistance to convalescent and vaccine-induced immunity. The SAVE program serves as a critical data-generating component of the United States Government SARS-CoV-2 Interagency Group to assess implications of SARS-CoV-2 variants on diagnostics, vaccines, and therapeutics and for communicating public health risk. Here we describe the coordinated approach used to identify and curate data about emerging variants, their impact on immunity, and effects on vaccine protection using animal models. We report the development of reagents, methodologies, models, and pivotal findings facilitated by this collaborative approach and identify future challenges. This program serves as a template for the response against rapidly evolving pandemic pathogens by monitoring viral evolution in the human population to identify variants that could erode the effectiveness of countermeasures.

OBJECTIVE: To understand large animal veterinarians' knowledge of select zoonotic diseases that cause livestock abortions and identify barriers to using personal protective equipment (PPE). SAMPLE: A convenience sample of 469 veterinarians currently working with livestock. PROCEDURES: We sent an electronic survey invitation to large animal veterinarians through various veterinary organizations. Respondents answered questions addressing knowledge and prior experience with select abortion-associated zoonotic diseases, resources available for infection control, attitudes and barriers to PPE use, and demographics. RESULTS: Median participant age was 49 years (range, 22 to 82 years), and 54% (235/438) were male. Half of veterinarians (185/348) were contacted 5 or fewer times per year to consult on livestock abortions. No veterinarians surveyed answered all questions on zoonotic disease transmission correctly. Personal protective equipment access varied, from 99% (289/290) having access to gloves to 20% (59/290) having access to respirators. Concerns for spreading disease to other animals (136/289 [47%]) and to other humans (108/287 [38%]) ranked as the most common reported motivators for PPE use. Reported barriers to PPE use among survey participants were the inconvenience of taking PPE into the field (101/286 [35%]) and the inconvenience of wearing PPE (97/286 [34%]). Access to PPE was not correlated with PPE use. CLINICAL RELEVANCE: Surveyed veterinarians had limited knowledge of transmission of select abortion-associated zoonotic diseases. Incomplete understanding might lead to inappropriate PPE selection, preventable disease exposure, or missed opportunities for client education. Inconvenience was a primary reason PPE was not used.

IMPORTANCE: Severe outcomes among youths with SARS-CoV-2 infections are poorly characterized. OBJECTIVE: To estimate the proportion of children with severe outcomes within 14 days of testing positive for SARS-CoV-2 in an emergency department (ED). DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study with 14-day follow-up enrolled participants between March 2020 and June 2021. Participants were youths aged younger than 18 years who were tested for SARS-CoV-2 infection at one of 41 EDs across 10 countries including Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Statistical analysis was performed from September to October 2021. EXPOSURES: Acute SARS-CoV-2 infection was determined by nucleic acid (eg, polymerase chain reaction) testing. MAIN OUTCOMES AND MEASURES: Severe outcomes, a composite measure defined as intensive interventions during hospitalization (eg, inotropic support, positive pressure ventilation), diagnoses indicating severe organ impairment, or death. RESULTS: Among 3222 enrolled youths who tested positive for SARS-CoV-2 infection, 3221 (>99.9%) had index visit outcome data available, 2007 (62.3%) were from the United States, 1694 (52.6%) were male, and 484 (15.0%) had a self-reported chronic illness; the median (IQR) age was 3 (0-10) years. After 14 days of follow-up, 735 children (22.8% [95% CI, 21.4%-24.3%]) were hospitalized, 107 (3.3% [95% CI, 2.7%-4.0%]) had severe outcomes, and 4 children (0.12% [95% CI, 0.03%-0.32%]) died. Characteristics associated with severe outcomes included being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). Among a subgroup of 2510 participants discharged home from the ED after initial testing and who had complete follow-up, 50 (2.0%; 95% CI, 1.5%-2.6%) were eventually hospitalized and 12 (0.5%; 95% CI, 0.3%-0.8%) had severe outcomes. Compared with hospitalized SARS-CoV-2-negative youths, the risk of severe outcomes was higher among hospitalized SARS-CoV-2-positive youths (risk difference, 3.9%; 95% CI, 1.1%-6.9%). CONCLUSIONS AND RELEVANCE: In this study, approximately 3% of SARS-CoV-2-positive youths tested in EDs experienced severe outcomes within 2 weeks of their ED visit. Among children discharged home from the ED, the risk was much lower. Risk factors such as age, underlying chronic illness, and symptom duration may be useful to consider when making clinical care decisions.

The emergence of SARS-CoV-2 created a crucial need for serology assays to detect anti-SARS-CoV-2 antibodies, which led to many serology assays entering the market. A trans-government collaboration was created in April 2020 to independently evaluate the performance of commercial SARS-CoV-2 serology assays and help inform U.S. Food and Drug Administration (FDA) regulatory decisions. To assess assay performance, three evaluation panels with similar antibody titer distributions were assembled. Each panel consisted of 110 samples with positive (n = 30) serum samples with a wide range of anti-SARS-CoV-2 antibody titers and negative (n = 80) plasma and/or serum samples that were collected before the start of the COVID-19 pandemic. Each sample was characterized for anti-SARS-CoV-2 antibodies against the spike protein using enzyme-linked immunosorbent assays (ELISA). Samples were selected for the panel when there was agreement on seropositivity by laboratories at National Cancer Institute's Frederick National Laboratory for Cancer Research (NCI-FNLCR) and Centers for Disease Control and Prevention (CDC). The sensitivity and specificity of each assay were assessed to determine Emergency Use Authorization (EUA) suitability. As of January 8, 2021, results from 91 evaluations were made publicly available (https://open.fda.gov/apis/device/covid19serology/, and https://www.cdc.gov/coronavirus/2019-ncov/covid-data/serology-surveillance/serology-test-evaluation.html). Sensitivity ranged from 27% to 100% for IgG (n = 81), from 10% to 100% for IgM (n = 74), and from 73% to 100% for total or pan-immunoglobulins (n = 5). The combined specificity ranged from 58% to 100% (n = 91). Approximately one-third (n = 27) of the assays evaluated are now authorized by FDA for emergency use. This collaboration established a framework for assay performance evaluation that could be used for future outbreaks and could serve as a model for other technologies. IMPORTANCE The SARS-CoV-2 pandemic created a crucial need for accurate serology assays to evaluate seroprevalence and antiviral immune responses. The initial flood of serology assays entering the market with inadequate performance emphasized the need for independent evaluation of commercial SARS-CoV-2 antibody assays using performance evaluation panels to determine suitability for use under EUA. Through a government-wide collaborative network, 91 commercial SARS-CoV-2 serology assay evaluations were performed. Three evaluation panels with similar overall antibody titer distributions were assembled to evaluate performance. Nearly one-third of the assays evaluated met acceptable performance recommendations, and two assays had EUAs revoked and were removed from the U.S. market based on inadequate performance. Data for all serology assays evaluated are available at the FDA and CDC websites (https://open.fda.gov/apis/device/covid19serology/, and https://www.cdc.gov/coronavirus/2019-ncov/covid-data/serology-surveillance/serology-test-evaluation.html).

Ehrlichiosis and anaplasmosis are emerging tickborne diseases that can also be transmitted through blood transfusions or organ transplants. Since 2000, ehrlichiosis and anaplasmosis cases in the United States have increased substantially, resulting in potential risk to transplant and transfusion recipients. We reviewed ehrlichiosis and anaplasmosis cases among blood transfusion and solid organ transplant recipients in the United States from peer-reviewed literature and Centers for Disease Control and Prevention investigations. We identified 132 cases during 1997-2020, 12 transfusion-associated cases and 120 cases in transplant recipients; 8 cases were donor-derived, and in 13 cases illness occurred <1 year after transplant. Disease in the remaining 99 cases occurred ≥1 year after transplant, suggesting donor-derived disease was unlikely. Severe illness or death were reported among 15 transfusion and transplant recipients. Clinicians should be alert for these possible infections among transfusion and transplant recipients to prevent severe complications or death by quickly treating them.

Q fever is a zoonotic disease caused by the bacterium Coxiella burnetii and can manifest in an acute or chronic form. Many persons with acute Q fever are asymptomatic, but some develop a febrile illness, pneumonia or hepatitis. Chronic infections are rare and occur in less than 5% of persons exposed. Forms of chronic Q fever include endocarditis, infection of vascular grafts or aneurysms, osteomyelitis and osteoarthritis. Acute and chronic Q fever are nationally notifiable diseases, and presented here are the incidence, demographics and distribution of acute and chronic Q fever in the United States during 2008-2017. We summarized passive surveillance data from the Centers for Disease Control and Prevention's (CDC) National Notifiable Diseases Surveillance System (NNDSS) and supplemental case report forms (CRFs). Health departments reported 1,109 cases of acute Q fever and 272 chronic Q fever cases to NNDSS during this period. The 10-year average annual incidence for acute Q fever was 0.36 cases per million persons, and the average annual incidence for chronic Q fever was 0.09. Males accounted for nearly 75% of both acute and chronic Q fever cases. Average annual incidence was highest among persons aged 60-69 years for both acute and chronic Q fever (0.70 cases per million persons and 0.25, respectively). As reported through CRFs, many Q fever cases did not have a known exposure to C. burnetii; 60% (n = 380) of acute Q fever cases did not report exposure to animals in the 2 months before symptom onset. Almost 90% (n = 558) did not report exposure to unpasteurized milk. Only 40% (n = 247) of persons with reported Q fever were employed in high-risk occupations. Even though Q fever is a rare disease in the United States, incidence doubled from 2008 to 2017.

BACKGROUND: With limited SARS-CoV-2 testing capacity in the US at the start of the epidemic (January - March), testing was focused on symptomatic patients with a travel history throughout February, obscuring the picture of SARS-CoV-2 seeding and community transmission. We sought to identify individuals with SARS-CoV-2 antibodies in the early weeks of the US epidemic. METHODS: All of Us study participants in all 50 US states provided blood specimens during study visits from January 2 to March 18, 2020. A participant was considered seropositive if they tested positive for SARS-CoV-2 immunoglobulin G (IgG) antibodies on the Abbott Architect SARS-CoV-2 IgG ELISA and the EUROIMMUN SARS-CoV-2 ELISA in a sequential testing algorithm. Sensitivity and specificity of the Abbott and EUROIMMUNE ELISAs and the net sensitivity and specificity of the sequential testing algorithm were estimated with 95% confidence intervals. RESULTS: The estimated sensitivity of Abbott and EUROIMMUN was 100% (107/107 [96.6%, 100%]) and 90.7% (97/107 [83.5%, 95.4%]), respectively. The estimated specificity of Abbott and EUROIMMUN was 99.5% (995/1,000 [98.8%, 99.8%]) and 99.7% (997/1,000 [99.1%, 99.9%), respectively. The net sensitivity and specificity of our sequential testing algorithm was 90.7% (97/107 [83.5%, 95.4%]) and 100.0% (1,000/1,000 [99.6%, 100%]), respectively. Of the 24,079 study participants with blood specimens from January 2 to March 18, 2020, 9 were seropositive, 7 of whom were seropositive prior to the first confirmed case in the states of Illinois, Massachusetts, Wisconsin, Pennsylvania, and Mississippi. CONCLUSIONS: Our findings indicate SARS-CoV-2 infections weeks prior to the first recognized cases in 5 US states.

The commercial fishing industry in the United States is one of the most hazardous work settings. Operations are characterized by hazardous machinery and equipment, strenuous labor, long work hours, harsh weather, and moving decks. Risk varies by vessel and types of gear. During 2000–2016, the fishing industry suffered a fatality rate of 115 deaths per 100,000 workers, compared with an average of 4 deaths per 100,000 workers among all U.S. workers.1 During this same time, 755 commercial fishermen died, with nearly half of these fatalities (364, 48%) occurring after a vessel disaster, 30% (227) after a fall overboard, and 13% (97) from traumatic injuries sustained onboard.1 The remaining 67 (9%) fatalities occurred either while diving or from injuries that occurred onshore or on the dock.1 Risk factors and recommendations have been made to prevent these fatalities by fishery and by region of the country.2–6

Since their discovery in the United States in 1963, outbreaks of infection with equine influenza virus (H3N8) have been associated with serious respiratory disease in horses worldwide. Genomic analysis suggests that equine H3 viruses are of an avian lineage, likely originating in wild birds. Equine-like internal genes have been identified in avian influenza viruses isolated from wild birds in the Southern Cone of South America. However, an equine-like H3 hemagglutinin has not been identified. We isolated 6 distinct H3 viruses from wild birds in Chile that have hemagglutinin, nucleoprotein, nonstructural protein 1, and polymerase acidic genes with high nucleotide homology to the 1963 H3N8 equine influenza virus lineage. Despite the nucleotide similarity, viruses from Chile were antigenically more closely related to avian viruses and transmitted effectively in chickens, suggesting adaptation to the avian host. These studies provide the initial demonstration that equine-like H3 hemagglutinin continues to circulate in a wild bird reservoir.

Influenza virus isolation from clinical samples is critical for the identification and characterization of circulating and emerging viruses. Yet efficient isolation can be difficult. In these studies, we isolated primary swine nasal and tracheal respiratory epithelial cells and immortalized swine nasal epithelial cells (siNEC) and tracheal epithelial cells (siTEC) that retained the abilities to form tight junctions and cilia and to differentiate at the air-liquid interface like primary cells. Critically, both human and swine influenza viruses replicated in the immortalized cells, which generally yielded higher-titer viral isolates from human and swine nasal swabs, supported the replication of isolates that failed to grow in Madin-Darby canine kidney (MDCK) cells, and resulted in fewer dominating mutations during viral passaging than MDCK cells.IMPORTANCE Robust in vitro culture systems for influenza virus are critically needed. MDCK cells, the most widely used cell line for influenza isolation and propagation, do not adequately model the respiratory tract. Therefore, many clinical isolates, both animal and human, are unable to be isolated and characterized, limiting our understanding of currently circulating influenza viruses. We have developed immortalized swine respiratory epithelial cells that retain the ability to differentiate and can support influenza replication and isolation. These cell lines can be used as additional tools to enhance influenza research and vaccine development.

Mass gatherings have been implicated in higher rates of transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), and many sporting events have been restricted or canceled to limit disease spread (1). Based on current CDC COVID-19 mitigation recommendations related to events and gatherings (2), Major League Baseball (MLB) developed new health and safety protocols before the July 24 start of the 2020 season. In addition, MLB made the decision that games would be played without spectators. Before a three-game series between teams A and B, the Philadelphia Department of Public Health was notified of a team A player with laboratory-confirmed COVID-19; the player was isolated as recommended (2). During the series and the week after, laboratory-confirmed COVID-19 was diagnosed among 19 additional team A players and staff members and one team B staff member. Throughout their potentially infectious periods, some asymptomatic team A players and coaches, who subsequently received positive SARS-CoV-2 test results, engaged in on-field play with teams B and C. No on-field team B or team C players or staff members subsequently received a clinical diagnosis of COVID-19. Certain MLB health and safety protocols, which include frequent diagnostic testing for rapid case identification, isolation of persons with positive test results, quarantine for close contacts, mask wearing, and social distancing, might have limited COVID-19 transmission between teams.

OBJECTIVES: Adults with multiple chronic conditions (MCCs; >/=2 chronic conditions) account for a substantial number of visits to health care providers. The complexity of a patient's care, including the number of chronic conditions, may differ by physician specialty. The objectives of this study were to (1) examine differences in physician office visits among adults with MCCs by physician specialty and (2) identify the types of MCC dyads (combinations of 2 chronic conditions) most common among visits to office-based physicians. METHODS: We used data from the 2014-2015 National Ambulatory Medical Care Survey (unweighted analytic sample, n = 61 682), a nationally representative survey of physician office-based ambulatory visits, to examine differences in physician office visits among adults with MCCs by physician specialty. We also identified the most commonly observed MCC dyads among these visits. RESULTS: During 2014-2015, 40.0% of physician office visits were made by adults with MCCs. Compared with visits for all specialties combined (40.0%), a significantly higher percentage of physician office visits among adults with MCCs were to specialists in cardiovascular disease (74.7%) and internal medicine (57.6%). For all physician specialties except psychiatry, the MCC dyads of hyperlipidemia and hypertension and diabetes and hypertension were among the most commonly observed MCC dyads among visits made by adults with MCCs. CONCLUSIONS: Awareness of these findings may help specialists improve care for adults with MCCs. The recognition among physicians of common MCC dyads is relevant to the care management of persons with MCCs.

Purpose of Review: The non-specific presentation of acute Q fever makes it difficult to diagnose in children, but untreated Q fever can result in chronic infections that have severe complications. Recent Findings: Pediatric Q fever cases continue to be infrequently reported in the literature, and primarily document cases of persistent infections with Coxiella burnetii. Standardized treatment protocols for chronic Q fever in children still do not exist. Doxycycline and hydroxychloroquine are the treatment combination most utilized by healthcare providers to treat Q fever endocarditis or osteomyelitis in children, but a variety of other antibiotic combinations have been reported with varying results. The use of adjunctive therapies, such as such as interferon gamma, has produced mixed outcomes. Summary: The true impact of Coxiella burnetii on the health of children remains unknown; long-term longitudinal follow-up of children with acute or chronic Q fever has not been reported. Both the acute and chronic forms of Q fever are underreported and underdiagnosed. Healthcare providers should consider Q fever in pediatric patients with culture-negative endocarditis or osteomyelitis.

Typhus group rickettsioses (TGRs) are vector-borne diseases that include murine typhus (Rickettsia typhi) and epidemic typhus (R. prowazekii). Twentieth-century public health interventions led to dramatic decreases in incidence; little is known about the contemporary TGR prevalence because neither disease is nationally notifiable. We summarized administrative claims data in a commercially insured population to examine trends in TGR medical encounters. We analysed data from 2003 to 2016 IBM(R) MarketScan(R) Commercial Databases to identify persons with inpatient or outpatient visits with an International Classification of Diseases, Ninth or Tenth Revision, Clinical Modification TGR-specific code. We summarized epidemiologic characteristics associated with incident diagnosis. We identified 1,799 patients diagnosed with a TGR. Patients resided in 46 states, and most were female (n = 1,019/1,799; 56.6%); the median age was 42 years (range: 0-64 years). Epidemic typhus (n = 931/1,799; 51.8%) was the most common TGRs, followed by murine typhus (n = 722/1,799; 40.1%). The majority of TGR patients were diagnosed in an outpatient setting (n = 1,725/1,799; 95.9%); among hospitalized patients, the majority received a murine typhus diagnosis (n = 67/74; 90.5%). TGRs are rarely diagnosed diseases. More patients were diagnosed with epidemic than murine typhus, even though R. prowazekii transmission requires body louse or flying squirrel exposure. Patients from all geographic regions were diagnosed with murine and epidemic typhus, despite historically recognized ranges for these diseases. The epidemiologic misalignment of insurance claims data versus historic TGRs data highlights the challenges of finding appropriate alternative data sources to serve as a proxy when national surveillance data do not exist.

What is already known about this topic? Eschars are a clinical sign used to differentiate less severe rickettsioses from potentially deadly Rocky Mountain spotted fever. What is added by this report? Eschars are infrequently reported in tickborne rickettsial disease (TBRD) surveillance data and represent an underutilized resource to aid in distinguishing the various spotted fever group Rickettsia. Although 1% of total TBRD case reports during 2010-2016 documented the presence of an eschar, 81% of cases lacked information on eschars altogether. What are the implications for public health practice? Systematic reporting of the presence or absence of eschars on the TBRD case report form can improve the quality of surveillance data and enhance understanding of the impact of spotted fever rickettsioses in the United States. © 2020 Department of Health and Human Services. All rights reserved.

We estimated the availability of the injectable antimicrobial drugs recommended for point-of-care treatment of gonorrhea and syphilis among US physicians who evaluated patients with sexually transmitted infections in 2016. Most physicians did not have these drugs available on-site. Further research is needed to determine the reasons for the unavailability of these drugs.

ABSTRACTObjective:In January 2017, Washington, DC, hosted the 58th United States presidential inauguration. The DC Department of Health leveraged multiple health surveillance approaches, including syndromic surveillance (human and animal) and medical aid station-based patient tracking, to detect disease and injury associated with this mass gathering. METHODS: Patient data were collected from a regional syndromic surveillance system, medical aid stations, and an internet-based emergency department reporting system. Animal health data were collected from DC veterinary facilities. RESULTS: Of 174 703 chief complaints from human syndromic data, there were 6 inauguration-related alerts. Inauguration attendees who visited aid stations (n = 162) and emergency departments (n = 180) most commonly reported feeling faint/dizzy (n = 29; 17.9%) and pain/cramps (n = 34;18.9%). In animals, of 533 clinical signs reported, most were gastrointestinal (n = 237; 44.5%) and occurred in canines (n = 374; 70.2%). Ten animals that presented dead on arrival were investigated; no significant threats were identified. CONCLUSION: Use of multiple surveillance systems allowed for near-real-time detection and monitoring of disease and injury syndromes in humans and domestic animals potentially associated with inaugural events and in local health care systems.

Objectives: The Centers for Disease Control and Prevention launched the Temporary Epidemiology Field Assignee (TEFA) Program to help state and local jurisdictions respond to the risk of Ebola virus importation during the 2014-2016 Ebola Outbreak in West Africa. We describe steps taken to launch the 2-year program, its outcomes and lessons learned. Methods: State and local health departments submitted proposals for a TEFA to strengthen local capacity in four key public health preparedness areas: 1) epidemiology and surveillance, 2) health systems preparedness, 3) health communications, and 4) incident management. TEFAs and jurisdictions were selected through a competitive process. Descriptions of TEFA activities in their quarterly reports were reviewed to select illustrative examples for each preparedness area. Results: Eleven TEFAs began in the fall of 2015, assigned to 7 states, 2 cities, 1 county and the District of Columbia. TEFAs strengthened epidemiologic capacity, investigating routine and major outbreaks in addition to implementing event-based and syndromic surveillance systems. They supported improvements in health communications, strengthened healthcare coalitions, and enhanced collaboration between local epidemiology and emergency preparedness units. Several TEFAs deployed to United States territories for the 2016 Zika Outbreak response. Conclusion: TEFAs made important contributions to their jurisdictions' preparedness. We believe the TEFA model can be a significant component of a national strategy for surging state and local capacity in future high-consequence events.

Introduction: Tularemia is a zoonotic infection caused by the highly infectious bacterium Francisella tularensis. Persons having outdoor professions are more likely than others to be exposed to F. tularensis through increased contact with arthropods, infected animals, and contaminated aerosols. Materials and Methods: After a tularemia epizootic during July and August 2015 at Devils Tower National Monument and an associated tularemia infection in a park employee, we assessed seroprevalence of F. tularensis antibodies, risk factors for F. tularensis seropositivity, and use of protective measures among park employees. Results: Seroprevalence among participating employees was 13% (3/23). Seropositive employees reported multiple risk factors for F. tularensis exposure through both job-related and recreational activities. Activities reported by more seropositive than seronegative employees included using a power blower (67% vs. 5%, p = 0.03), collecting animal carcasses (100% vs. 30%, p = 0.047), and hunting prairie dogs recreationally (67% vs. 5%, p = 0.03). Seropositive employees reported exposure to more ticks (median 30, range 25-35) than seronegative employees (median 6, range 0-25, p = 0.001). Most employees used protective measures (e.g., insect repellent) inconsistently but increased use after receiving educational materials. Conclusions: Educating and enabling at-risk employees to use protective measures consistently, both at work and during recreational activities, can reduce exposure during epizootics.

From 2016 through 2017, unprecedented increases in all nationally notifiable tickborne diseases were reported to the Centers for Disease Control and Prevention (CDC). The largest percentage increase was seen in reported cases of spotted fever rickettsiosis (SFR): a 46% increase from 4269 cases to a record 6248.1 Increases were reported in both new areas and in known endemic states. Although the New England, East North Central, and Middle Atlantic regions typically report only a handful of cases each year, in 2017, these areas experienced, a 215%, 78%, and 65% increase in reported cases, respectively. Among tickborne diseases, only anaplasmosis, with a 39% increase during this time, approached the rise seen with SFR. Although this increase raises concerns for elevated disease risk, additional factors are likely contributing to the high number of reports.

Tularemia is a bacterial zoonosis caused by Francisella tularensis. We conducted a serosurvey of black-tailed prairie dogs ( Cynomys ludovicianus) in Devils Tower National Monument, Wyoming, following an epizootic in voles ( Microtus spp.) due to F. tularensis. Only 1 of 44 (2%) sampled prairie dogs was seropositive for F. tularensis, providing evidence of survival and potentially limited spread among free-ranging prairie dogs.

OBJECTIVES: Nationally, animal-motor vehicle crashes (AVCs) account for 4.4% of all types of motor vehicle crashes (MVCs). AVCs are a safety risk for drivers and animals and many National Park Service (NPS) units (e.g., national park, national monument, or national parkway) have known AVC risk factors, including rural locations and substantial animal densities. We sought to describe conditions and circumstances involving AVCs to guide traffic and wildlife management for prevention of AVCs in select NPS units. METHODS: We conducted an analysis using NPS law enforcement MVC data. An MVC is a collision involving an in-transit motor vehicle that occurred or began on a public roadway. An AVC is characterized as a collision between a motor vehicle and an animal. A non-AVC is a crash between a motor vehicle and any object other than an animal or noncollision event (e.g., rollover crash). The final data for analysis included 54,068 records from 51 NPS units during 1990-2013. Counts and proportions were calculated for categorical variables and medians and ranges were calculated for continuous variables. We used Pearson's chi-square to compare circumstances of AVCs and non-AVCs. Data were compiled at the park regional level; NPS parks are assigned to 1 of 7 regions based on the park's location. RESULTS: AVCs accounted for 10.4% (5,643 of 54,068) of all MVCs from 51 NPS units. The Northeast (2,021 of 5,643; 35.8%) and Intermountain (1,180 of 5,643; 20.9%) regions had the largest percentage of the total AVC burden. November was the peak month for AVCs across all regions (881 of 5,643; 15.6%); however, seasonality varied by park geographic regions. The highest counts of AVCs were reported during fall for the National Capital, Northeast/Southeast, and Northeast regions; winter for the Southeast region; and summer for Intermountain and Pacific West regions. CONCLUSIONS: AVCs represent a public health and wildlife safety concern for NPS units. AVCs in select NPS units were approximately 2-fold higher than the national percentage for AVCs. The peak season for AVCs varied by NPS region. Knowledge of region-specific seasonality patterns for AVCs can help NPS staff develop mitigation strategies for use primarily during peak AVC months. Improving AVC data collection might provide NPS with a more complete understanding of risk factors and seasonal trends for specific NPS units. By collecting information concerning the animal species hit, park managers can better understand the impacts of AVC to wildlife population health.