Persons who work in close contact with dairy cattle and poultry that are infected with highly pathogenic avian influenza (HPAI) A(H5N1) virus are at increased risk for infection. In July 2024, the Colorado Department of Public Health & Environment responded to two poultry facilities with HPAI A(H5N1) virus detections in poultry. Across the two facilities, 663 workers assisting with poultry depopulation (i.e., euthanasia) received screening for illness; 109 (16.4%) reported symptoms and consented to testing. Among those who received testing, nine (8.3%) received a positive influenza A(H5) virus test result, and 19 (17.4%) received a positive SARS-CoV-2 test result. All nine workers who received positive influenza A(H5) test results had conjunctivitis, experienced mild illness, and received oseltamivir. This poultry exposure-associated cluster of human cases of influenza A(H5) is the first reported in the United States. The identification of these cases highlights the ongoing risk to persons who work in close contact with infected animals. Early response to each facility using multidisciplinary, multilingual teams facilitated case-finding, worker screening, and treatment. As the prevalence of HPAI A(H5N1) virus clade 2.3.4.4b genotype B3.13 increases, U.S. public health agencies should prepare to rapidly investigate and respond to illness in agricultural workers, including workers with limited access to health care.

Shiga toxin-producing Escherichia coli (STEC) causes acute diarrheal illness. To determine risk factors for non-O157 STEC infection, we enrolled 939 patients and 2,464 healthy controls in a case-control study conducted in 10 US sites. The highest population-attributable fractions for domestically acquired infections were for eating lettuce (39%), tomatoes (21%), or at a fast-food restaurant (23%). Exposures with 10%-19% population attributable fractions included eating at a table service restaurant, eating watermelon, eating chicken, pork, beef, or iceberg lettuce prepared in a restaurant, eating exotic fruit, taking acid-reducing medication, and living or working on or visiting a farm. Significant exposures with high individual-level risk (odds ratio >10) among those >1 year of age who did not travel internationally were all from farm animal environments. To markedly decrease the number of STEC-related illnesses, prevention measures should focus on decreasing contamination of produce and improving the safety of foods prepared in restaurants.

Treatment of Shiga toxin-producing Escherichia coli O157 (O157) diarrhea with antimicrobials might alter the risk of hemolytic uremic syndrome (HUS). However, full characterization of which antimicrobials might affect risk is lacking, particularly among adults. To inform clinical management, we conducted a case-control study of residents of the FoodNet surveillance areas with O157 diarrhea during a 4-year period to assess antimicrobial class-specific associations with HUS among persons with O157 diarrhea. We collected data from medical records and patient interviews. We measured associations between treatment with agents in specific antimicrobial classes during the first week of diarrhea and development of HUS, adjusting for age and illness severity. We enrolled 1308 patients; 102 (7.8%) developed confirmed HUS. Antimicrobial treatment varied by age: <5 years (12.6%), 5-14 (11.5%), 15-39 (45.4%), ≥40 (53.4%). Persons treated with a β-lactam had higher odds of developing HUS (OR 2.80, CI 1.14-6.89). None of the few persons treated with a macrolide developed HUS, but the protective association was not statistically significant. Exposure to "any antimicrobial" was not associated with increased odds of HUS. Our findings confirm the risk of β-lactams among children with O157 diarrhea and extends it to adults. We observed a high frequency of inappropriate antimicrobial treatment among adults. Our data suggest that antimicrobial classes differ in the magnitude of risk for persons with O157 diarrhea.

In the 64 years since preventive therapy for latent tuberculosis (TB) was first pioneered by Comstock and colleagues in Alaska, impressive treatment shortening has been achieved with two simple drug classes: isoniazid and rifamycins. In the last decade, the duration of therapy for latent TB infection (LTBI) has progressively decreased, going from 9 months to 3 to 4 months, and perhaps to 1 month. To guide these advances and design phase 3 prevention trials, investigators have designed and tested regimens of antimicrobial treatment in the chronic low-dose mouse model. Inconveniently, mice do not develop latent TB. Thus, to estimate drug/regimen efficacy, researchers have assessed rates of bacterial burden decline in mice as a surrogate for LTBI efficacy, coupled to a leap of faith.

Sports and recreation-related (SRR) activities are common in the United States. Beyond the benefits to health, SRR activities can create new friendships, give people a sense of belonging, foster teamwork and other leadership skills, and develop sportsmanship and a respect for rules that govern play. Public awareness about the risk of concussion has grown as the long-term consequences of traumatic brain injury (TBI) have become better known, and likely explains the increasing concussion incidence rates. Currently, surveillance systems capture SRR concussions among high school and college athletes participating in sanctioned sports. National estimates of SRR TBI presenting to an emergency department also exist. Persons under the age of 19 sustain a majority of SRR concussions. Concussion risk is greatest for boys in contact/collision sports like football, ice hockey, and lacrosse, and is more likely to occur in competition versus practice settings. Girls have elevated concussion rates in gender-comparable sports. Despite better data, concussions are still underreported, undermanaged, and often not properly identified. This is especially true for concussions occurring outside organized sports, in nonsport recreational activities, and for concussions either not seen or evaluated in nonemergency department settings. A new surveillance system proposed by the Centers for Disease Control and Prevention aims to fill the gap.

OBJECTIVES: To describe concussion rates in high school athletes and involvement of healthcare professionals in concussion diagnosis, management and compliance with return to play (RTP) guidelines. METHODS: Data were analysed from injury reports in the National High School Sports-Related Injury Surveillance System between 2009/2010 and 2012/2013 to identify student athletes with concussion and determine compliance with RTP guidelines. Compliance with RTP guidelines was examined using logistic regression, adjusting for sport and injury-related variables. RESULTS: There were 5611 concussions recorded during 15 712 475 athlete exposures (AEs), a rate of 3.6 concussions per 10 000 AEs. Rates were higher during competition and among girls compared to boys in gender equitable sports. Healthcare professionals were less likely to be present at the time of concussion for girls' sports, lower competition levels and practices. Compliance with RTP guidelines was higher for athletes with recurrent concussions, those sustained in collision sports, for athletes reporting more symptoms and when a physician made the RTP decision. CONCLUSIONS: Presence of healthcare professionals and compliance with RTP guidelines varied by sport, gender, level of play and exposure type. High school athletes with concussion are best served by assessment teams with athletic trainers and physicians working together to manage concussions and contribute to RTP decisions.

Background: Post-diarrheal hemolytic-uremic syndrome (D+HUS) following Shiga toxin-producing Escherichia coli (STEC) infection is a serious condition lacking specific treatment. Host immune dysregulation and genetic susceptibility to complement hyperactivation are implicated in non-STEC-related HUS. However, genetic susceptibility to D+HUS remains largely uncharacterized. Methods: Patients with culture-confirmed STEC diarrhea, identified through the CDC FoodNet surveillance system (2007-2012), were serotyped and classified by laboratory and/or clinical criteria as suspected, probable, or confirmed D+HUS, or as controls and genotyped at 200 loci linked to non-diarrheal HUS or similar pathologies. Genetic associations with D+HUS were explored by multivariable regression, adjusting for known risk factors. Results: Of 641 enrollees with STEC O157:H7, 80 had suspected D+HUS (41 probable and 32 confirmed D+HUS). Twelve genes related to cytokine signaling, complement pathways, platelet function, pathogen recognition, iron transport, and endothelial function were associated with D+HUS in multivariable-adjusted analyses (p≤0.05). Of 12 significant SNPs, 5 were associated with all levels of D+HUS (intergenic SNP rs10874639, TFRC rs3804141, EDN1 rs5370, GP1BA rs121908064, and B2M rs16966334), and 7 SNPs (6 non-complement-related) were associated with confirmed D+HUS (all p<0.05). Conclusions: Polymorphisms in many non-complement-related genes may contribute to D+HUS susceptibility. These results require replication, but they suggest novel therapeutic targets in D+HUS.

We describe the investigation of two temporally coincident illness clusters involving salmonella and Staphylococcus aureus in two states. Cases were defined as gastrointestinal illness following two meal events. Investigators interviewed ill persons. Stool, food and environmental samples underwent pathogen testing. Alabama: Eighty cases were identified. Median time from meal to illness was 5.8 h. Salmonella Heidelberg was identified from 27 of 28 stool specimens tested, and coagulase-positive S. aureus was isolated from three of 16 ill persons. Environmental investigation indicated that food handling deficiencies occurred. Colorado: Seven cases were identified. Median time from meal to illness was 4.5 h. Five persons were hospitalised, four of whom were admitted to the intensive care unit. Salmonella Heidelberg was identified in six of seven stool specimens and coagulase-positive S. aureus in three of six tested. No single food item was implicated in either outbreak. These two outbreaks were linked to infection with Salmonella Heidelberg, but additional factors, such as dual aetiology that included S. aureus or the dose of salmonella ingested may have contributed to the short incubation periods and high illness severity. The outbreaks underscore the importance of measures to prevent foodborne illness through appropriate washing, handling, preparation and storage of food.

The purposes of this study were to use the National Health and Nutrition Examination Study (NHANES 2011-12) data to determine nationally representative combined-hand grip strength ranges and percentile information by sex and age group, examine trends in strength across age by sex, and to determine the relative proportion of children and adults falling into established Health Benefit Zones (HBZ). Results indicate that mean strength was greater among males than females, increased linearly for children and in a quadratic fashion among adults for both sexes. Grip strength peaked in the 30 -39 year age group for both men (216.4lbs) and women (136.5lbs) with subsequent age groups showing gradual decline, ps < .0001. Relative and absolute increase in grip strength was greater for males than for females, but relative decrease from peak strength was less among women than men. Although absolute strength was greater among men than women, HBZ data indicated that a higher percentage of males than females overall and at each age group fell into the Needs Improvement zone, with differences particularly pronounced during adolescence and older adulthood. These data provide the first nationally representative population estimates of combined-hand grip strength and percentile information from childhood through senescence, and suggest consideration of HBZ information in conjunction with grip strength to improve surveillance data interpretation and intervention planning.

Unsafe practices are an underestimated contributor to the disease burden of bloodborne viruses. Outbreaks associated with failures in basic infection prevention have been identified in nonhospital settings with increased frequency in the United States during the past 15 years, representing an alarming trend and indicating that the challenge of providing consistently safe care is not always met. As has been the case with most medical specialties, there have been public health investigations by state and local health departments, and the Centers for Disease Control and Prevention have identified some instances of unsafe practices that have placed podiatric medical patients at risk for viral, bacterial, and fungal infections. All health-care providers, including podiatric physicians, must make infection prevention a priority in any setting in which care is delivered.

BACKGROUND: Data limited to emergency department and inpatient visits undoubtedly underestimate the medical charges associated with traumatic brain injury. The objective of this study was to estimate the direct medical charges of pediatric traumatic brain injuries across all clinical settings in one large, pediatric hospital in the United States. METHODS: Traumatic brain injuries sustained by children ≤20 years of age treated across all clinical settings at one large pediatric hospital from August 1, 2010-July 31, 2011 were identified using ICD-9-CM codes 310.2, 800-801.9, 803-804.9, 850-854.16, and 959.01. RESULTS: 3,971 individuals ≤20 years of age were seen during 5,429 traumatic brain injury-related visits. Total medical charges for pediatric traumatic brain injury-related visits were $13,131,547. Inpatient (68.7%) and emergency department (16.1%) visits accounted for the highest proportion of TBI-related charges; however, >15% of all charges were associated with visits to clinic outpatient, urgent care, and diagnostic/therapy outpatient settings. Fracture of the vault or base of the skull (37.1%) and brain injury with contusion, laceration, or hemorrhage (27.1%) accounted for the largest proportion of total charges. Although unspecified head injuries made up almost half of all TBI-related visits (47.4%), they accounted for only 12.6% of total charges. Mild traumatic brain injuries accounted for 92.0% of all traumatic brain injury-related visits but only 44.7% of all traumatic brain injury-related charges. Mild traumatic brain injuries treated in the emergency department had a higher median total charge than those treated in urgent care (p < 0.0001) or clinic outpatient setting (p < 0.001). CONCLUSIONS: This study, the first to evaluate the direct medical charges of pediatric traumatic brain injury across all clinical settings at one large pediatric hospital, found that pediatric traumatic brain injuries present to a wide variety of clinical settings, and differences exist in total charges by diagnosis, severity of the injury, and clinical site/setting. Investigating traumatic brain injuries across the full spectrum of clinical care is needed for a better understanding of the true medical cost and public health burden of pediatric traumatic brain injury.

INTRODUCTION: In January 2010, the Virginia Department of Health received reports of 2 hepatitis B virus (HBV) infections (1 acute, 1 chronic) among residents of a single assisted living facility (ALF). Both infected residents had diabetes and received assisted monitoring of blood glucose (AMBG) at the facility. An investigation was initiated in response. OBJECTIVE: To determine the extent and mechanism of HBV transmission among ALF residents. DESIGN: Retrospective cohort study. SETTING: An ALF that primarily housed residents with neuropsychiatric disorders in 2 adjacent buildings in Virginia. PARTICIPANTS: Residents of the facility as of March 2010. MEASUREMENTS: HBV serologic testing, relevant medical history, and HBV genome sequences. Risk ratios (RR) and 95% confidence intervals (CIs) were used to identify risk factors for HBV infection. RESULTS: HBV serologic status was determined for 126 (91%) of 139 residents. Among 88 susceptible residents, 14 became acutely infected (attack rate, 16%), and 74 remained uninfected. Acute HBV infection developed among 12 (92%) of 13 residents who received AMBG, compared with 2 (3%) of 75 residents who did not (RR = 35; 95% CI, 8.7, 137). Identified infection control breaches during AMBG included shared use of fingerstick devices for multiple residents. HBV genome sequencing demonstrated 2 building-specific phylogenetic infection clusters, each having 99.8-100% sequence identity. LIMITATIONS: Transfer of residents out of the facility prior to our investigation might have contributed to an underestimate of cases. Resident interviews provided insufficient information to fully assess behavioral risk factors for HBV infection. CONCLUSIONS: Failure to adhere to safe practices during AMBG resulted in a large HBV outbreak. Protection of a growing and vulnerable ALF population requires improved training of staff and routine facility licensing inspections that scrutinize infection control practices.

In 2009, after resident calls regarding an odor, the Vermont Department of Health and state partners responded to 2 scenarios of private drinking water contamination from utility poles treated with pentachlorophenol (PCP), an organochlorine wood preservative used in the United States. Public health professionals should consider PCP contamination of private water if they receive calls about a chemical or gasoline-like odor with concurrent history of nearby utility pole replacement. (Am J Public Health. Published online ahead of print December 13, 2012: e1-e2. doi:10.2105/AJPH.2012.300910).

BACKGROUND: Outbreaks of human salmonella infections are increasingly associated with contact with live poultry, but effective control measures are elusive. In 2005, a cluster of human salmonella Montevideo infections with a rare pattern on pulsed-field gel electrophoresis (the outbreak strain) was identified by PulseNet, a national subtyping network. METHODS: In cooperation with public health and animal health agencies, we conducted multistate investigations involving patient interviews, trace-back investigations, and environmental testing at a mail-order hatchery linked to the outbreak in order to identify the source of infections and prevent additional illnesses. A case was defined as an infection with the outbreak strain between 2004 and 2011. RESULTS: From 2004 through 2011, we identified 316 cases in 43 states. The median age of the patient was 4 years. Interviews were completed with 156 patients (or their caretakers) (49%), and 36 of these patients (23%) were hospitalized. Among the 145 patients for whom information was available, 80 (55%) had bloody diarrhea. Information on contact with live young poultry was available for 159 patients, and 122 of these patients (77%) reported having such contact. A mail-order hatchery in the western United States was identified in 81% of the trace-back investigations, and the outbreak strain was isolated from samples collected at the hatchery. After interventions at the hatchery, the number of human infections declined, but transmission continued. CONCLUSIONS: We identified a prolonged multistate outbreak of salmonellosis, predominantly affecting young children and associated with contact with live young poultry from a mail-order hatchery. Interventions performed at the hatchery reduced, but did not eliminate, associated human infections, demonstrating the difficulty of eliminating salmonella transmission from live poultry.

BACKGROUND: Postdiarrheal hemolytic uremic syndrome (HUS) is the most common cause of acute kidney failure among US children. The Foodborne Diseases Active Surveillance Network (FoodNet) conducts population-based surveillance of pediatric HUS to measure the incidence of disease and to validate surveillance trends in associated Shiga toxin-producing Escherichia coli (STEC) O157 infection. METHODS: We report the incidence of pediatric HUS, which is defined as HUS in children <18 years. We compare the results from provider-based surveillance and hospital discharge data review and examine the impact of different case definitions on the findings of the surveillance system. RESULTS: During 2000-2007, 627 pediatric HUS cases were reported. Fifty-two percent of cases were classified as confirmed (diarrhea, anemia, microangiopathic changes, low platelet count, and acute renal impairment). The average annual crude incidence rate for all reported cases of pediatric HUS was 0.78 per 100,000 children <18 years. Regardless of the case definition used, the year-to-year pattern of incidence appeared similar. More cases were captured by provider-based surveillance (76%) than by hospital discharge data review (68%); only 49% were identified by both methods. CONCLUSIONS: The overall incidence of pediatric HUS was affected by key characteristics of the surveillance system, including the method of ascertainment and the case definitions. However, year-to-year patterns were similar for all methods examined, suggesting that several approaches to HUS surveillance can be used to track trends.

INTRODUCTION: Heat illness is a leading cause of death and disability among U.S. high school athletes. METHODS: To examine the incidence and characteristics of heat illness among high school athletes, CDC analyzed data from the National High School Sports-Related Injury Surveillance Study for the period 2005-2009. RESULTS: During 2005-2009, the 100 schools sampled reported a total of 118 heat illnesses among high school athletes resulting in ≥1day of time lost from athletic activity, a rate of 1.6 per 100,000 athlete-exposures, and an average of 29.5 time-loss heat illnesses per school year. The average corresponds to a weighted average annual estimate of 9,237 illnesses nationwide. The highest rate of time-loss heat illness was among football players, 4.5 per 100,000 athlete-exposures, a rate 10 times higher than the average rate (0.4) for the eight other sports. Time-loss heat illnesses occurred most frequently during August (66.3%) and while practicing or playing football (70.7%). No deaths were reported. CONCLUSIONS: Consistent with guidelines from the National Athletic Trainers' Association, to reduce the risk for heat illness, high school athletic programs should implement heat-acclimatization guidelines (e.g., set limits on summer practice duration and intensity). All athletes, coaches, athletic trainers, and parents/guardians should be aware of the risk factors for heat illness, follow recommended strategies, and be prepared to respond quickly to symptoms of illness. Coaches also should continue to stress to their athletes the importance of maintaining proper hydration before, during, and after sports activities. IMPACT OF INDUSTRY: By implementing preventive recommendations and quickly recognizing and responding to heat illness, coaches, athletic trainers, and the sporting community can prevent future deaths.

CONTEXT: High school athletes sustain more than 1.4 million injuries annually. National high school sports injury surveillance forms the foundation for developing and evaluating preventive interventions to reduce injury rates. For national surveillance, individuals must report consistently and accurately with little one-on-one interaction with study staff. OBJECTIVE: To examine the feasibility of relying on high school coaches as data reporters in a national, Internet-based sports injury surveillance study, using the same methods that have already proven successful in the National High School Sports-Related Injury Surveillance Study, which calls on certified athletic trainers (ATs) as reporters. DESIGN: Prospective injury surveillance study. SETTING: Eighteen United States high schools PARTICIPANTS: Athletic trainers and varsity coaches for football, boys' and girls' soccer, and boys' and girls' basketball. MAIN OUTCOME MEASURE(S): Quantity and quality of exposure and injury reports. RESULTS: All enrolled ATs participated, compared with only 43.0% of enrolled coaches. Participating ATs submitted 96.7% of expected exposure reports, whereas participating coaches submitted only 36.5%. All ATs reported athlete exposures correctly, compared with only 2 in 3 coaches. Participating ATs submitted 338 injury reports; participating coaches submitted only 55 (16.3% of the 338 submitted by ATs). Injury patterns differed between AT-submitted and coach-submitted injury reports, with ATs reporting a higher proportion of ankle injuries and coaches reporting a higher proportion of knee injuries. The reports submitted by ATs and coaches for the same injury had low agreement for diagnosis and time loss, with only 63.2% and 55.3% of pairs, respectively, providing the same response. The ATs lacked more responses for demographic questions, whereas coaches lacked more responses regarding the need for surgery. CONCLUSIONS: Whenever possible, ATs should be the primary data reporters in large, national studies. In high schools without access to an AT, researchers must be willing to devote significant time and resources to achieving high participation and compliance from other reporters.