Cryptosporidium parvum is a parasitic zoonotic pathogen responsible for diarrheal illness in humans and animals worldwide. We report an investigation of a cryptosporidiosis outbreak in raccoons and wildlife rehabilitation workers at a Virginia facility. Fifteen (31%) of 49 facility personnel experienced symptoms meeting the case definition, including four laboratory-confirmed cases. Seven juvenile raccoons were reported to have diarrhoea; six had laboratory-confirmed cryptosporidiosis. Cryptosporidium parvum of the same molecular subtype (IIaA16G3R2) was identified in two human cases and six raccoons. Raccoon illness preceded human illness by 11days, suggesting possible zoonotic transmission from raccoons to humans. This appears to be the first report of a human cryptosporidiosis outbreak associated with exposure to raccoons infected with C.parvum. Raccoons might be an under-recognized reservoir for human C.parvum infections. Further study is needed to explore the prevalence of cryptosporidial species in raccoons and their role as a wildlife reservoir.

In 2011, the Joint United Nations | Programme on HIV/AIDS (UNAIDS) | and the US Office of the Global AIDS | Coordinator—the office charged with implementing the President’s Emergency Plan for | AIDS Relief (PEPFAR), launched a 4-year | Global Plan Toward the Elimination of New | HIV Infections Among Children by 2015, and | Keeping their Mothers Alive (UNAIDS, 2011). | Focusing on the 22 countries with the highest number of HIV positive pregnant women | globally, this initiative promotes a range of | HIV and maternal, newborn, and child health | (MNCH) interventions aimed at decreasing | new HIV infections among children by 90% | and reducing HIV-related maternal mortality by 50%. The Global Plan emphasises | HIV prevention through timely initiation of | antiretroviral therapy (ART) for pregnant and | breastfeeding mothers, early diagnosis of HIV | exposed infants, and treatment for those who | become HIV infected. The overlap in the timing and frequency of these HIV services with | MNCH interventions, including immunisations, infant feeding support, and family planning, underscores the need for greater synergy | between these programmes.

Affordable and effective interventions have been identified that can prevent new infant HIV infections, maintain the health of mothers, and greatly reduce transmission between discordant partners. Yet, 330 000 HIV-infected infants were born in 2011 worldwide, in part due to operational challenges inherent in the design of current PMTCT programmes. Option B+, the provision of life-long antiretroviral treatment (ART) to all pregnant and breastfeeding women, was recently introduced as a progressive and innovative approach to simplify service delivery and improve maternal and infant outcomes. This emphasis on treatment as the cornerstone of PMTCT has catalysed a shift in thinking about the PMTCT paradigm. No longer can PMTCT viewed as a time-limited intervention around pregnancy and breastfeeding. It must be reconceived as multiple overlapping continua of care that address the health and family planning needs of HIV-positive women throughout their reproductive years. Optimising maternal ART and exposed infant follow-up will require a bridging of maternal, neonatal, and child health programmes with HIV treatment programmes to support alternative service delivery models, develop new health care worker competencies, and address infrastructural constraints. The engagement of nurses and midwives in this PMTCT transformation will be critical to meeting the global goal of an AIDS-free generation.

OBJECTIVES: We sought to describe the integration of syndromic surveillance data into daily surveillance practice at local health departments (LHDs) and make recommendations for the effective integration of syndromic and reportable disease data for public health use. METHODS: Structured interviews were conducted with local health directors and communicable disease nursing staff from a stratified random sample of LHDs from May through September 2009. Interviews captured information on direct access to the North Carolina syndromic surveillance system and on the use of syndromic surveillance information for outbreak management, program management, and the creation of reports. We analyzed syndromic surveillance system data to assess the number of signals resulting in a public health response. RESULTS: Syndromic surveillance data were used for outbreak investigation (19% of respondents) and program management and report writing (43% of respondents); a minority reported use of both syndromic and reportable disease data for these purposes (15% and 23%, respectively). Receiving data from frequent system users was associated with using data for these purposes (p50.016 and p50.033, respectively, for syndromic and reportable disease data). A small proportion of signals (<25%) resulted in a public health response. CONCLUSIONS: Use of syndromic surveillance data by North Carolina local public health authorities resulted in meaningful public health action, including both case investigation and program management. While useful, the syndromic surveillance data system was oriented toward sensitivity rather than efficiency. Successful incorporation of new surveillance data is likely to require systems that are oriented toward efficiency. (2012 Association of Schools of Public Health.)

BACKGROUND: In accordance with WHO guidelines, people with HIV infection in Botswana receive daily isoniazid preventive therapy against tuberculosis without obtaining a tuberculin skin test, but duration of prophylaxis is restricted to 6 months. We aimed to assess effectiveness of extended isoniazid therapy. METHODS: In our randomised, double-blind, placebo-controlled trial we enrolled adults infected with HIV aged 18 years or older at government HIV-care clinics in Botswana. Exclusion criteria included current illness such as cough and an abnormal chest radiograph without antecedent tuberculosis or pneumonia. Eligible individuals were randomly allocated (1:1) to receive 6 months' open-label isoniazid followed by 30 months' masked placebo (control group) or 6 months' open-label isoniazid followed by 30 months' masked isoniazid (continued isoniazid group) on the basis of a computer-generated randomisation list with permuted blocks of ten at each clinic. Antiretroviral therapy was provided if participants had CD4-positive lymphocyte counts of fewer than 200 cells per muL. We used Cox regression analysis and the log-rank test to compare incident tuberculosis in the groups. Cox regression models were used to estimate the effect of antiretroviral therapy. The trial is registered at ClinicalTrials.gov, number NCT00164281. FINDINGS: Between Nov 26, 2004, and July 3, 2009, we recorded 34 (3.4%) cases of incident tuberculosis in 989 participants allocated to the control group and 20 (2.0%) in 1006 allocated to the continued isoniazid group (incidence 1.26% per year vs 0.72%; hazard ratio 0.57, 95% CI 0.33-0.99, p=0.047). Tuberculosis incidence in those individuals receiving placebo escalated approximately 200 days after completion of open-label isoniazid. Participants who were tuberculin skin test positive (ie, ≥5 mm induration) at enrolment received a substantial benefit from continued isoniazid treatment (0.26, 0.09-0.80, p=0.02), whereas participants who were tuberculin skin test-negative received no significant benefit (0.75, 0.38-1.46, p=0.40). By study completion, 946 (47%) of 1995 participants had initiated antiretroviral therapy. Tuberculosis incidence was reduced by 50% in those receiving 360 days of antiretroviral therapy compared with participants receiving no antiretroviral therapy (adjusted hazard ratio 0.50, 95% CI 0.26-0.97). Severe adverse events and death were much the same in the control and continued isoniazid groups. INTERPRETATION: In a tuberculosis-endemic setting, 36 months' isoniazid prophylaxis was more effective for prevention of tuberculosis than was 6-month prophylaxis in individuals with HIV infection, and chiefly benefited those who were tuberculin skin test positive. FUNDING: US Centers for Disease Control and Prevention and US Agency for International Development.

BACKGROUND: In 2006, a pediatric diarrhea outbreak occurred in Botswana, coinciding with heavy rains. Surveillance recorded a 3 times increase in cases and a 25 fold increase in deaths between January and March. Botswana has high HIV prevalence among pregnant women (33.4% in 2005), and an estimated 35% of all infants under the age of 6 months are not breastfed. METHODS: We followed all children <5 years old with diarrhea in the country's second largest referral hospital at the peak of the outbreak by chart review, interviewed mothers, and conducted laboratory testing for HIV and enteric pathogens. RESULTS: Of 153 hospitalized children with diarrhea, 97% were <2 years old; 88% of these were not breastfeeding. HIV was diagnosed in 18% of children and 64% of mothers. Cryptosporidium and enteropathogenic Escherichia coli were common; many children had multiple pathogens. Severe acute malnutrition (kwashiorkor or marasmus) developed in 38 (25%) patients, and 33 (22%) died. Kwashiorkor increased risk for death (relative risk 2.0; P = 0.05); only one breastfeeding child died. Many children who died had been undersupplied with formula. CONCLUSIONS: Most of the severe morbidity and mortality in this outbreak occurred in children who were HIV negative and not breastfed. Feeding and nutritional factors were the most important determinants of severe illness and death. Breastfeeding is critical to infant survival in the developing world, and support for breastfeeding among HIV-negative women, and HIV-positive women who cannot formula feed safely, may prevent further high-mortality outbreaks.