A fatal case of primary amebic meningoencephalitis (PAM), an infection caused by Naegleria fowleri, was diagnosed in Arkansas in a young child in September 2023. A public health investigation was completed, with epidemiologic, laboratory, and environmental data suggesting that a splash pad (an interactive water play venue that sprays or jets water on users and has little or no standing water) with inadequately disinfected water was the most likely site of the patient's N. fowleri exposure. This case is the third occurrence of splash pad-associated PAM reported in the United States; all three cases involved inadequately disinfected water. PAM should be considered in patients with acute meningoencephalitis and a history of recent possible exposure to fresh water, including treated recreational water (e.g., in splash pads or pools), via the nasal passages. Proper design, construction, operation, and management of splash pads can help prevent illnesses, including N. fowleri infections. Increased awareness, collaboration, and communication among clinicians, hospitals, laboratories, CDC, health departments, the aquatics sector, and the public can help support N. fowleri infection identification, treatment, prevention, and control efforts.

A case of locally acquired (autochthonous) mosquito-transmitted Plasmodium vivax malaria was diagnosed in Arkansas in September 2023. This represents the 10th autochthonous case identified nationally in 2023, after 20 years without recorded local mosquitoborne malaria transmission in the United States. The public health response included case investigation, active case surveillance, mosquito surveillance and control, assessment of medical countermeasures, and clinical and public outreach. Prompt diagnosis and appropriate treatment of malaria can improve clinical outcomes and, in addition to vector control, minimize risk for local transmission. Clinicians should consider malaria among patients who have traveled to countries where malaria is endemic, or with unexplained fever regardless of travel history. Although the risk for autochthonous malaria in the United States remains very low, its reemergence highlights the importance of vectorborne disease preparedness and response. Examples of such efforts include improving awareness among clinicians, access to diagnostics and antimalarial medications, and capacity for mosquito surveillance and control. Collaboration and communication among CDC, health departments, local jurisdictions, clinicians, hospitals, laboratories, and the public can support rapid malaria diagnosis, prevention, and control. Before traveling internationally to areas where malaria is endemic, travelers should consult with their health care provider regarding recommended malaria prevention measures, including chemoprophylaxis and precautions to avoid mosquito bites, to reduce both personal and community risk.

In the United States, injury is the leading cause of death for persons aged 1-44 years. In 2008, approximately 30 million injuries were serious enough to require the injured person to visit a hospital emergency department (ED); 5.4 million (18%) of these injured patients were transported by Emergency Medical Services (EMS). On arrival at the scene of an injury, the EMS provider must determine the severity of injury, initiate management of the patient's injuries, and decide the most appropriate destination hospital for the individual patient. These destination decisions are made through a process known as "field triage," which involves an assessment not only of the physiology and anatomy of injury but also of the mechanism of the injury and special patient and system considerations. Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process through its "Field Triage Decision Scheme." This guidance was updated with each version of the decision scheme (published in 1986, 1990, 1993, and 1999). In 2005, CDC, with financial support from the National Highway Traffic Safety Administration, collaborated with ACS-COT to convene the initial meetings of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme; the revised version was published in 2006 by ACS-COT (American College of Surgeons. Resources for the optimal care of the injured patient: 2006. Chicago, IL: American College of Surgeons; 2006). In 2009, CDC published a detailed description of the scientific rationale for revising the field triage criteria (CDC. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR 2009;58[No. RR-1]). In 2011, CDC reconvened the Panel to review the 2006 Guidelines in the context of recently published literature, assess the experiences of states and local communities working to implement the Guidelines, and recommend any needed changes or modifications to the Guidelines. This report describes the dissemination and impact of the 2006 Guidelines; outlines the methodology used by the Panel for its 2011 review; explains the revisions and modifications to the physiologic, anatomic, mechanism-of-injury, and special considerations criteria; updates the schematic of the 2006 Guidelines; and provides the rationale used by the Panel for these changes. This report is intended to help prehospital-care providers in their daily duties recognize individual injured patients who are most likely to benefit from specialized trauma center resources and is not intended as a mass casualty or disaster triage tool. The Panel anticipates a review of these Guidelines approximately every 5 years.

Tinea capitis (TC), a common childhood scalp and hair dermatophytosis, is associated with lower socioeconomic status,1 54 but national data on TC incidence and risk factors among children from lower income | 55 households are lacking to guide public health efforts and clinical care. We estimated incidence, assessed | 56 risk factors, and described clinical practices for TC among a large U.S. cohort of Medicaid-insured | 57 children. | In the MerativeTM MarketScan® Multi-State Medicaid Database* 58 , we identified TC cases among children | <18 years, underlying conditions, and TC-related diagnostic testing† 59 (Supplemental Table, available via | 60 Mendeley at https://data.mendeley.com/datasets/7wz5p6bxk3/1). We calculated one-year TC incidence | 61 overall and by race/ethnicity, age, and underlying health conditions. We used Poisson regression to | 62 assess associations between risk factors and TC incidence and compared TC diagnostic and treatment | 63 patterns by race/ethnicity using chi-square tests (α=0.05).

Tinea capitis (TC), a dermatophyte scalp and hair shaft infection, is an important public health concern. Confirmatory testing (eg, direct microscopy, fungal culture) before treatment is generally considered best practice because suspected TC has a broad differential diagnosis and treatment requires prolonged oral antifungal therapy.1,2 Since national data on TC epidemiology, testing, and treatment practices are lacking, our objectives were to calculate TC incidence and describe testing and treatment practices for a large cohort of commercially insured children in the United States.

OBJECTIVES: To describe COVID-19-related pediatric hospitalizations during a period of B.1.617.2 (Delta) variant predominance and to determine age-specific factors associated with severe illness. PATIENTS AND METHODS: We abstracted data from medical charts to conduct a cross-sectional study of patients aged <21 years hospitalized at 6 US children's hospitals during July-August 2021 for COVID-19 or with an incidental positive SARS-CoV-2 test. Among patients with COVID-19, we assessed factors associated with severe illness by calculating age-stratified prevalence ratios (PR). We defined severe illness as receiving high-flow nasal cannula, positive airway pressure, or invasive mechanical ventilation. RESULTS: Of 947 hospitalized patients, 759 (80.1%) had COVID-19, of whom 287 (37.8%) had severe illness. Factors associated with severe illness included coinfection with RSV (PR 3.64) and bacteria (PR 1.88) in infants; RSV coinfection in patients aged 1-4 years (PR 1.96); and obesity in patients aged 5-11 (PR 2.20) and 12-17 years (PR 2.48). Having ≥2 underlying medical conditions was associated with severe illness in patients aged <1 (PR 1.82), 5-11 (PR 3.72), and 12-17 years (PR 3.19). CONCLUSIONS: Among patients hospitalized for COVID-19, factors associated with severe illness included RSV coinfection in those aged <5 years, obesity in those aged 5-17 years, and other underlying conditions for all age groups <18 years. These findings can inform pediatric practice, risk communication, and prevention strategies, including vaccination against COVID-19.

During June 2021, the highly transmissible(†) B.1.617.2 (Delta) variant of SARS-CoV-2, the virus that causes COVID-19, became the predominant circulating strain in the United States. U.S. pediatric COVID-19-related hospitalizations increased during July-August 2021 following emergence of the Delta variant and peaked in September 2021.(§) As of May 12, 2021, CDC recommended COVID-19 vaccinations for persons aged ≥12 years,(¶) and on November 2, 2021, COVID-19 vaccinations were recommended for persons aged 5-11 years.** To date, clinical signs and symptoms, illness course, and factors contributing to hospitalizations during the period of Delta predominance have not been well described in pediatric patients. CDC partnered with six children's hospitals to review medical record data for patients aged <18 years with COVID-19-related hospitalizations during July-August 2021.(††) Among 915 patients identified, 713 (77.9%) were hospitalized for COVID-19 (acute COVID-19 as the primary or contributing reason for hospitalization), 177 (19.3%) had incidental positive SARS-CoV-2 test results (asymptomatic or mild infection unrelated to the reason for hospitalization), and 25 (2.7%) had multisystem inflammatory syndrome in children (MIS-C), a rare but serious inflammatory condition associated with COVID-19.(§§) Among the 713 patients hospitalized for COVID-19, 24.7% were aged <1 year, 17.1% were aged 1-4 years, 20.1% were aged 5-11 years, and 38.1% were aged 12-17 years. Approximately two thirds of patients (67.5%) had one or more underlying medical conditions, with obesity being the most common (32.4%); among patients aged 12-17 years, 61.4% had obesity. Among patients hospitalized for COVID-19, 15.8% had a viral coinfection(¶¶) (66.4% of whom had respiratory syncytial virus [RSV] infection). Approximately one third (33.9%) of patients aged <5 years hospitalized for COVID-19 had a viral coinfection. Among 272 vaccine-eligible (aged 12-17 years) patients hospitalized for COVID-19, one (0.4%) was fully vaccinated.*** Approximately one half (54.0%) of patients hospitalized for COVID-19 received oxygen support, 29.5% were admitted to the intensive care unit (ICU), and 1.5% died; of those requiring respiratory support, 14.5% required invasive mechanical ventilation (IMV). Among pediatric patients with COVID-19-related hospitalizations, many had severe illness and viral coinfections, and few vaccine-eligible patients hospitalized for COVID-19 were vaccinated, highlighting the importance of vaccination for those aged ≥5 years and other prevention strategies to protect children and adolescents from COVID-19, particularly those with underlying medical conditions.

During September 17–24, 2021, three clinicians independently notified the Arkansas Department of Health (ADH) of multiple patients with mucormycosis after a recent diagnosis of COVID-19. To provide data to guide clinical and public health practice, ADH coordinated a statewide call on October 11, 2021 to infection preventionists for COVID-19–associated mucormycosis cases.

The epidemiology of varicella is believed to differ between temperate and tropical countries. We conducted a varicella seroprevalence study in elementary and college students in the US territory of American Samoa before introduction of a routine varicella vaccination programme. Sera from 515 elementary and 208 college students were tested for the presence of varicella-zoster virus (VZV) IgG antibodies. VZV seroprevalence increased with age from 76.0% in the 4-6 years group to 97.7% in those aged 23 years. Reported history of varicella disease for elementary students was significantly associated with VZV seropositivity. The positive and negative predictive values of varicella disease history were 93.4% and 36.4%, respectively, in elementary students and 97.6% and 3.0%, respectively, in college students. VZV seroprevalence in this Pacific island appears to be similar to that in temperate countries and suggests endemic VZV circulation.

INTRODUCTION: In line with the global goals for measles elimination, countries in the West Pacific Region (WPR) have set a goal to eliminate measles by 2012. Due to its contagiousness, high population immunity is needed for achieving and documenting measles elimination. We assessed population immunity to measles, mumps and rubella among first grade children in American Samoa (AS) through a seroprevalance study. METHODS: Using commercial indirect enzyme-linked immunosorbant IgG assays (Wampole Laboratories, Cranbury, NJ) we determined IgG antibodies against the measles, mumps, and rubella (MMR) viruses in sera collected from first grade students in AS in April-May 2011. Vaccination status was retrieved from the immunization cards. Factors associated with seropositivity of measles, mumps, and rubella were analyzed separately. RESULT: Among 509 first grade students, measles, mumps, and rubella seroprevalence were 92%, 90%, and 93%, respectively. The proportions of first grade students with documented one or two doses of MMR vaccine were 93% and 84%, respectively. The vaccination status of 6% of the first graders was unknown and 1% was unvaccinated. Receiving two-doses of MMR vaccines was associated with high measles and mumps seropositivity (p<0.01). CONCLUSION: The high measles seroprevalence among children shows the progress by American Samoa towards measles elimination. Achieving and maintaining high two-dose MMR vaccine coverage in all age groups will aid in attaining the measles elimination status and prevent transmission of measles from potential imported measles cases from other countries.

Most persons who receive hepatitis B vaccine during infancy will have a level of antibody to hepatitis B surface antigen (anti-HBs) <10 IU/L if measured 10-15 years later; however, most will demonstrate immune memory by an anamnestic response to a vaccine challenge dose. To determine whether there was a difference in anamnestic response among college students vaccinated during infancy, we compared anti-HBs levels after a dose of Engerix-B 20 mcg between those with a residual anti-HBs level of 0 IU/L versus those with a level of 1-9 IU/L. Anti-HBs was measured before (baseline) and two weeks after a challenge dose; response was defined as a level ≥10 IU/L after the dose among those <10 IU/L at baseline. Among 153 students who completed the study, 130 (85%) had an anti-HBs level <10 IU/L at baseline; 72 had a level of 0 IU/L and 58 had a level ranging from 1 to 9 IU/L. Students with a level from 1-9 IU/L were more likely to respond to the challenge dose compared to those with a baseline anti-HBs level of 0 IU/L (83% versus 50%; p<0.001). The presence of any detectable anti-HBs among persons vaccinated in the remote past may indicate the persistence of immune memory.

OBJECTIVE: To describe factors associated with inpatient mortality in a field hospital established following the 2010 Haiti earthquake. DESIGN: Data were abstracted from medical records of patients admitted to the University of Miami Global Institute/Project Medishare hospital. Decedents were compared to survivors in terms of age, sex, length of stay, admission ward, diagnosis, and where relevant, injury mechanism and surgical procedure. Three multivariate logistic regression models were constructed to determine predictors of death among all patients, injured patients, and noninjured patients. RESULTS: During the study period, 1,339 patients were admitted to the hospital with 100 inpatient deaths (7.5 percent). The highest proportion of deaths occurred among patients aged < or = 15 years. Among all patients, adult intensive care unit (ICU) admission (adjusted odds ratio [AOR] = 7.6 and 95% confidence interval [CI] = 3.4-16.8), neonatal ICU/pediatric ICU (NICU/PICU) admission (AOR = 7.8 and 95% CI = 2.7-22.9), and cardiac/respiratory diagnoses (AOR = 8.5 and 95% CI = 4.9-14.8) were significantly associated with death. Among injured patients, adult ICU admission (AOR = 7.4 and 95% CI = 1.7-33.3) and penetrating injury (AOR = 3.3 and 95% CI = 1.004-11.1) were significantly associated with death. Among noninjured patients, adult ICU admission (AOR = 6.6 and 95% CI = 2.7-16.4), NICU/PICU admission (AOR = 8.2 and 95% CI = 2.1-31.8), and cardiac/ respiratory diagnoses (AOR = 6.5 and 95% CI = 3.6-12.0) were significantly associated with death. CONCLUSIONS: Following earthquakes in resource-limited settings, survivors may require care in field hospitals for injuries or exacerbation of chronic medical conditions. Planning for sustained post-earthquake response should address these needs and include pediatric-specific preparation and long-term critical care requirements.