In response to notable increases in tick-associated illnesses in the United States, recent public health policies encouraged multi-sector collaborative approaches to preventing vector-borne diseases. Primary prevention strategies focus on educating the public about risks for tick-borne diseases and encouraging adoption of personal protection strategies. Accurate descriptions of when and where people are at risk for tick-borne diseases aid in the optimization of prevention messaging. Tick and tick-borne pathogen data can be used to fill gaps in epidemiological surveillance. However, the utility of acarological data is limited by their completeness. National maps showing the distribution of medically important tick species and the pathogens they carry are often incomplete or non-existent. Recent policies encourage accelerated efforts to monitor changes in the distribution and abundance of medically important ticks and the presence and prevalence of human pathogens that they carry, and to provide actionable, evidence-based information to the public, health care providers and public health policy makers. In 2018, the Centers for Disease Control and Prevention initiated a national tick surveillance program focused on Ixodes ticks. The national program coordinated and expanded upon existing efforts led by public health departments and academic institutions. Here, we describe experiences of state public health departments engaged in Ixodes tick surveillance, including information on why they initiated Ixodes surveillance programs, programmatic objectives, and strategies for maintaining tick surveillance programs. We share experiences and challenges in interpreting or communicating tick surveillance data to stakeholders and explore how the acarological data are used to complement epidemiological data.

INTRODUCTION: Disease and non-battle injuries (DNBIs) cause substantial losses among military personnel. NATO has monitored DNBIs among its personnel since 1996 using multiple versions of a tool now called EpiNATO-2, but the surveillance system has never been systematically evaluated. Following a request from NATO to the CDC, the objective of this study was to assess surveillance system attributes of EpiNATO-2 using CDC's updated guidelines for evaluating public health surveillance systems. MATERIALS AND METHODS: Between June and October 2022, a literature review and key informant interviews were conducted to assess the following attributes: usefulness, simplicity, flexibility, data quality, acceptability, sensitivity, positive predictive value, representativeness, timeliness, stability, informatics system quality, informatics service quality, and informatics interoperability. Key informant interviews were conducted in Kosovo, Germany, and remotely with EpiNATO-2 users spanning three levels: clinical and data entry personnel (tactical level); regional medical and public health officers (operational level); and senior commanders and other governmental entities (strategic level). RESULTS: Fourteen EpiNATO-2 users participated in interviews, representing 3 of the 5 major NATO missions, 3 partner entities, and 7 nationalities. All users (100%) reported that the system did not meet their needs, with most users noting the following challenges: lack of clearly defined system objectives; poor data quality due to ambiguous case definitions and frequently unsubmitted reports (37% missing during January to June 2022); long delay between the occurrence of health events and the availability of corresponding data (≥2 weeks); and an antiquated and inflexible data management system. Overall, performance was deemed unsatisfactory on 11 of the 13 attributes. CONCLUSIONS: This multinational sample of EpiNATO-2 users at all military levels reported that the system is currently not useful with respect to its stated objectives. Opportunities exist to improve the performance and usefulness of EpiNATO-2: improve case definitions, modernize data infrastructure, and regularly evaluate the surveillance system.

Legionella pneumophila serogroup 1 sequence types (ST) 213 and 222, a single-locus variant of ST213, were first detected in the early 1990s in the Midwest United States (U.S.) and the late 1990s in the Northeast U.S. and Canada. Since 1992, these STs have increasingly been implicated in community-acquired sporadic and outbreak-associated Legionnaires' disease (LD) cases. We were interested in understanding the change in LD frequency due to these STs and identifying genetic features that differentiate these STs from one another. For the geographic area examined here (Mountain West to Northeast) and over the study period (1992-2020), ST213/222-associated LD cases identified by the Centers for Disease Control and Prevention increased by 0.15 cases per year, with ST213/222-associated LD cases concentrated in four states: Michigan (26%), New York (18%), Minnesota (16%), and Ohio (10%). Additionally, between 2002 and 2021, ST222 caused at least five LD outbreaks in the U.S.; no known outbreaks due to ST213 occurred in the U.S. during this time. We compared the genomes of 230 ST213/222 isolates and found that the mean of the average nucleotide identity (ANI) within each ST was high (99.92% for ST222 and 99.92% for ST213), with a minimum between ST ANI of 99.50% and a maximum of 99.87%, indicating low genetic diversity within and between these STs. While genomic features were identified (e.g., plasmids and CRISPR-Cas systems), no association explained the increasing geographic distribution and prevalence of ST213 and ST222. Yet, we provide evidence of the expanded geographical distribution of ST213 and ST222 in the U.S.IMPORTANCESince the 1990s, cases of Legionnaires' disease (LD) attributed to a pair of closely related Legionella pneumophila variants, ST213 and ST222, have increased in the U.S. Furthermore, between 2002 and 2021, ST222 caused at least five outbreaks of LD in the U.S., while ST213 has not been linked to any U.S. outbreak. We wanted to understand how the rate of LD cases attributed to these variants has changed over time and compare the genetic features of the two variants. Between 1992 and 2020, we determined an increase of 0.15 LD cases ascribed to ST213/222 per year in the geographic region studied. Our research shows that these STs are spreading within the U.S., yet most of the cases occurred in four states: Michigan, New York, Minnesota, and Ohio. Additionally, we found little genetic diversity within and between these STs nor could specific genetic features explain their geographic spread.

Four Chlamydia psittaci isolates were recovered from clinical specimens from ill workers during a multistate outbreak at two chicken processing plants. Whole genome sequencing analyses revealed high similarity to C. psittaci genotype D. The isolates differed from each other by only two single nucleotide polymorphisms, indicating a common source.

As SARS-CoV-2 continues to spread and evolve, detecting emerging variants early is critical for public health interventions. Inferring lineage prevalence by clinical testing is infeasible at scale, especially in areas with limited resources, participation, or testing/sequencing capacity, which can also introduce biases. SARS-CoV-2 RNA concentration in wastewater successfully tracks regional infection dynamics and provides less biased abundance estimates than clinical testing. Tracking virus genomic sequences in wastewater would improve community prevalence estimates and detect emerging variants. However, two factors limit wastewater-based genomic surveillance: low-quality sequence data and inability to estimate relative lineage abundance in mixed samples. Here, we resolve these critical issues to perform a high-resolution, 295-day wastewater and clinical sequencing effort, in the controlled environment of a large university campus and the broader context of the surrounding county. We develop and deploy improved virus concentration protocols and deconvolution software that fully resolve multiple virus strains from wastewater. We detect emerging variants of concern up to 14 days earlier in wastewater samples, and identify multiple instances of virus spread not captured by clinical genomic surveillance. Our study provides a scalable solution for wastewater genomic surveillance that allows early detection of SARS-CoV-2 variants and identification of cryptic transmission.

Heartland virus (HRTV) disease is an emerging tickborne illness in the midwestern and southern United States. We describe a reported fatal case of HRTV infection in the Maryland and Virginia region, states not widely recognized to have human HRTV disease cases. The range of HRTV could be expanding in the United States.

We developed and assessed the performance of a new multiplex real-time PCR assay for the detection of all Chlamydia species and simultaneous differentiation of Chlamydia psittaci and Chlamydia pneumoniae-two important human respiratory pathogens-in human clinical specimens. Next-generation sequencing was used to identify unique targets to design real-time PCR assays targeting all Chlamydia species, C. psittaci, and C. pneumoniae. To validate the assay, we used a panel of 49 culture isolates comprising seven C. psittaci genotypes, eight C. pneumoniae isolates, seven other Chlamydia species, and 22 near-neighbor bacterial and viral isolates, along with 22 specimens from external quality assessment (EQA) panels and 34 nasopharyngeal and oropharyngeal swabs and cerebrospinal fluid, stool, and sputum specimens previously identified as positive or negative for C. psittaci or C. pneumoniae. The assays were 100% specific, with limits of detection of 7.64- 9.02 fg/μL. The assay results matched with historical assay results for all specimens, except for one owing to the increased sensitivity of the new C. psittaci assay; the results of the EQA specimens were 100% accurate. This assay may improve the timely and accurate clinical diagnosis of Chlamydia infections and provide a greater understanding of the burden of disease caused by these agents.

As SARS-CoV-2 continues to spread and evolve, detecting emerging variants early is critical for public health interventions. Inferring lineage prevalence by clinical testing is infeasible at scale, especially in areas with limited resources, participation, or testing/sequencing capacity, which can also introduce biases(1-3). SARS-CoV-2 RNA concentration in wastewater successfully tracks regional infection dynamics and provides less biased abundance estimates than clinical testing(4,5). Tracking virus genomic sequences in wastewater would improve community prevalence estimates and detect emerging variants. However, two factors limit wastewater-based genomic surveillance: low-quality sequence data and inability to estimate relative lineage abundance in mixed samples. Here, we resolve these critical issues to perform a high-resolution, 295-day wastewater and clinical sequencing effort, in the controlled environment of a large university campus and the broader context of the surrounding county. We develop and deploy improved virus concentration protocols and deconvolution software that fully resolve multiple virus strains from wastewater. We detect emerging variants of concern up to 14 days earlier in wastewater samples, and identify multiple instances of virus spread not captured by clinical genomic surveillance. Our study provides a scalable solution for wastewater genomic surveillance that allows early detection of SARS-CoV-2 variants and identification of cryptic transmission.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) are environmental contaminants that have received significant public attention. PFAS are a large group of human-made chemicals that have been used in industry and consumer products worldwide since the 1950s. Human exposure to PFAS is a growing public health concern. Studies suggest that exposure to PFAS may increase the risk of some cancers and have negative health impacts on the endocrine, metabolic, and immune systems. Federal and state health partners are investigating the exposure to and possible health effects associated with PFAS. Government agencies can observe social media discourse on PFAS to better understand public concerns and develop targeted communication and outreach efforts. OBJECTIVE: The primary objective of this study is to understand how social media is used to share, disseminate, and engage in public discussions of PFAS-related information in the United States. METHODS: We investigated PFAS-related content across 2 social media platforms between May 1, 2017, and April 30, 2019, to identify how social media is used in the United States to seek and disseminate PFAS-related information. Our key variable of interest was posts that mentioned "PFAS," "PFOA," "PFOS," and their hashtag variations across social media platforms. Additional variables included post type, time, PFAS event, and geographic location. We examined term use and post type differences across platforms. We used descriptive statistics and regression analysis to assess the incidence of PFAS discussions and to identify the date, event, and geographic patterns. We qualitatively analyzed social media content to determine the most prevalent themes discussed on social media platforms. RESULTS: Our analysis revealed that Twitter had a significantly greater volume of PFAS-related posts compared with Reddit (98,264 vs 3126 posts). PFAS-related social media posts increased by 670% over 2 years, indicating a marked increase in social media users' interest in and awareness of PFAS. Active engagement varied across platforms, with Reddit posts demonstrating more in-depth discussions compared with passive likes and reposts among Twitter users. Spikes in PFAS discussions were evident and connected to the discovery of contamination events, media coverage, and scientific publications. Thematic analysis revealed that social media users see PFAS as a significant public health concern and seek a trusted source of information about PFAS-related public health efforts. CONCLUSIONS: The analysis identified a prevalent theme-on social media, PFAS are perceived as an immediate public health concern, which demonstrates a growing sense of urgency to understand this emerging contaminant and its potential health impacts. Government agencies can continue using social media research to better understand the changing community sentiment on PFAS and disseminate targeted information and then use social media as a forum for dispelling misinformation, communicating scientific findings, and providing resources for relevant public health services.

Tick-borne rickettsial infections are serious, common, and difficult to diagnose. Among the most important factors leading to failure to diagnose and treat tick-borne rickettsioses effectively is a lack of consideration of the potential diagnosis by primary caregivers and emergency department physicians in patients presenting with undifferentiated acute febrile illness during tick season. This situation exists because of insufficient primary and continuing medical education of medical students, primary care and emergency medicine residents, and practicing physicians regarding tick-borne rickettsioses specific to the region where they practice. Delayed initiation of treatment with an appropriate antibiotic is associated with adverse outcomes including increased rates of hospitalization, admission to an intensive care unit, and mortality. The earliest symptoms are nonspecific, consisting of fever, headache, myalgias, and nausea and/or vomiting. Laboratory abnormalities are typically absent at this time when the therapeutic response to an appropriate antibiotic would be optimal. There is a mistaken idea among a substantial portion of physicians that the best antibiotic available, doxycycline, should not be administered to children 8 years of age or younger or during pregnancy. For all of the above reasons, there is unnecessary morbidity and mortality caused by tick-borne rickettsioses. This report proposes measures to address these critical issues regarding tick-borne rickettsioses.

BACKGROUND: Tick-borne encephalitis (TBE) is an arboviral disease that is focally endemic in parts of Europe and Asia. TBE cases among US travellers are rare, with previous reports of only six cases among civilian travellers through 2009 and nine military-related cases through 2020. A TBE vaccine was licenced in the USA in August 2021. Understanding TBE epidemiology and risks among US travellers can help with the counselling of travellers going to TBE-endemic areas. METHODS: Diagnostic testing for TBE in the USA is typically performed at the Centers for Disease Control and Prevention (CDC) because no commercial testing is available. Diagnostic testing for TBE at CDC since 2010 was reviewed. For individuals with evidence of TBE virus infection, information was gathered on demographics, clinical presentations and risk factors for infection. RESULTS: From 2010-20, six patients with TBE were identified. Cases occurred among both paediatric and adult travellers and all were male. Patients were diagnosed with meningitis (n = 2) or encephalitis (n = 4); none died. Cases had travelled to various countries in Europe or Russia. Three cases reported visiting friends or relatives. Activities reported included hiking, camping, trail running, or working outdoors, and two cases had a recognized tick bite. CONCLUSIONS: TBE cases among US travellers are uncommon, with these six cases being the only known TBE cases among civilian travellers during this 11-year period. Nonetheless, given potential disease severity, pre-travel counselling for travellers to TBE-endemic areas should include information on measures to reduce the risk for TBE and other tick-borne diseases, including possible TBE vaccine use if a traveller's itinerary puts them at higher risk for infection. Clinicians should consider the diagnosis of TBE in a patient with a neurologic or febrile illness recently returned from a TBE-endemic country, particularly if a tick bite or possible tick exposure is reported.

BACKGROUND: In response to the opioid crisis, over the last 10 years substantial strides have been made to increase the availability of evidence-based treatments for opioid use disorder, in particular buprenorphine maintenance, in the United States. Despite these worthwhile efforts, uptake rates of evidence-based treatment remain relatively low. As part of a broader study of opioid misuse, we examined proximity to evidence-based treatment as a potential barrier to treatment access. METHODS: In 2017-2018, we surveyed 218 individuals misusing prescription opioids or using street opioids in three Southern Californian counties. The study calculated driving distance from place of residence to the closest treatment provider offering buprenorphine or methadone treatment for opioid use disorders. RESULTS: Median distance to providers was 3.8 km (2.4 miles). Seventy one (33%) participants had received some form of treatment in the last 3 months; however, only 26 (40%) of these had received buprenorphine or methadone maintenance treatment. Participants receiving treatment at the time of their interview were traveling an average 16.8 km (10.4 miles) to reach treatment, indicating that as a group this population was both willing and able to seek and engage with treatment. CONCLUSIONS: In the suburban and exurban communities in which our study was based, our findings suggest that simple physical proximity to providers of evidence-based treatment for opioid use disorder is no longer a critical barrier. Other barriers to uptake of buprenorphine or methadone maintenance treatment clearly remain and need to be addressed. DISCLAIMER: Findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

OBJECTIVE: To describe medical tourism among a subset of US residents; identify possible indicators for medical tourism. METHODS: The US Centers for Disease Control and Prevention collaborated with 11 states and territories to ask 6 questions about medical tourism, using the Behavioral Risk Factor Surveillance System. Data collected from January 1, 2016, through December 31, 2016, included whether respondents traveled internationally for preplanned care, travel reasons and destinations, procedures received, and occurrence and treatment of complications. A descriptive analysis of demographics, socioeconomic status and health access variables was performed, and a regression model with a log-link function and Poisson distribution was used to estimate prevalence ratios (PR) for medical tourism. RESULTS: Of 93,492 respondents, 517 (0.55%) traveled internationally during the previous year for care. Mexico was the most common destination (41% of trips). Dentistry accounted for 55% of treatments. Complications from care received abroad were reported by 5% of medical tourists; 67% sought care upon returning to the United States. The prevalence of medical tourism was 1.32% (95% CI, 1.00-1.64). The prevalence of medical tourism was higher in Hispanics and non-whites (PR, 3.97; 95% CI, 2.48-6.32) and higher among those without current health insurance (PR, 2.70; 95% CI, 1.69-4.34). CONCLUSIONS: This is the largest collection of population-based surveillance data describing medical tourism among US residents from multiple states and territories. Understanding the demographic and socioeconomic factors associated with medical tourism can inform evidence-based recommendations for travelers and clinicians who may advise or care for these individuals before, during, or after travel.

In 2019, President Trump announced a new initiative, Ending the HIV Epidemic: A Plan for America (EHE). EHE will use 3 key strategies-diagnose, treat, and prevent-to reduce new HIV infections at least 90% by 2030, as well as new laboratory methods and epidemiological techniques to respond quickly to potential outbreaks. Partnerships are an important component in the initiative's success. Pharmacists and pharmacies can play important roles in EHE, including dispensing antiretroviral therapy and providing HIV screening, adherence counseling, medication therapy management, preexposure prophylaxis, and nonprescription syringe sales. The objective of this report is to discuss potential roles that pharmacists and pharmacies can play under the key strategies of EHE.

Mental health (MH) disorders are associated with HIV-related risk and health outcomes. Primary care providers (PCPs) conducting MH screenings can link persons living with HIV (PWH) to appropriate services, particularly in HIV burden areas of Southeastern States (the South). Little data exist on PCPs' MH screening practices. Depression, MH history, and substance use screenings among PCPs were examined in the South. Rao-Scott chi-square (chi(2)[df]) statistics (p </= 0.05) analyzed MH screening between PCPs with and without PWH patients. Compared with PCPs without PWH patients, PCPs with PWH patients routinely screened for substance use more frequently (50.6% vs. 43.2%; chi(2)[1] = 20.3; p < 0.0001). Compared with PCPs without PWH patients, PCPs with PWH patients routinely screened for depression less frequently (36.2% vs. 50.9%; chi(2)[1] = 32.0; p < 0.0001). Providers increasing MH screenings will improve HIV-related outcomes in the South.

INTRODUCTION: Research identifying pathways to heroin use has typically been conducted among urban populations. This study examined heroin initiation following pharmaceutical opioid use in three suburban/exurban Southern California counties. METHODS: Interviewer-administered surveys collected data among 330 participants (65.9 % male; 63.9 % non-Hispanic white) whose initial use of any opioid was a pharmaceutical opioid. Retrospective discrete-time survival analysis identified predictors of heroin initiation, measured as self-reported age of first heroin use. RESULTS: Median age of first pharmaceutical opioid use was 17 years; 50.6 % initially acquired pharmaceutical opioids from an illicit source, 56.7 % first used pharmaceutical opioids for recreational purposes, and 86 % initiated heroin use. Average time from first pharmaceutical opioid use to first heroin use was 8.2 years. Drug/alcohol treatment (adjusted Hazard Ratio [aHR]: 0.67, 95 % CI: 0.50, 0.88) was associated with delayed time to heroin initiation. Obtaining opioids from non-medical sources (aHR: 2.21, 95 % CI: 1.55, 3.14) was associated with accelerated time to heroin initiation. Reporting supply problems with obtaining pharmaceutical opioids (e.g., unable to acquire pharmaceutical opioids) was associated with accelerated time to heroin initiation, but the magnitude of this effect was dependent on one's history of methamphetamine use (p < 0.05). CONCLUSIONS: Time to heroin initiation following pharmaceutical opioid use was accelerated among those reporting supply problems and delayed among those with exposure to substance use treatment. Interventions interrupting supply of opioids might benefit from coordination with evidence-based medication-assisted treatment to minimize the risk of transitioning to heroin use, particularly among those with a long history of non-prescribed pharmaceutical opioid use.

Diarrheal illness remains a leading cause of morbidity and mortality in children < 5 years in developing countries, and contaminated water contributes to diarrhea risk. To address this problem, a novel hollow fiber ultrafilter (HFU) was developed for household water treatment. To test its impact on water quality and infant health, we conducted a cluster-randomized longitudinal evaluation in 10 intervention and 10 comparison villages in Kenya, attempting to enroll all households with infants (< 12 months old). We conducted a baseline survey, distributed HFUs to intervention households, made biweekly home visits for 1 year to assess water treatment practices and diarrhea in infants, and tested water samples from both groups every 2 months for Escherichia coli. We enrolled 92 infants from intervention households and 74 from comparison households. During the 1-year study period, 45.7% of intervention households and 97.3% of comparison households had at least one stored water sample test positive for E. coli. Compared with comparison households, the odds of E. coli contamination in stored water was lower for intervention households (OR: 0.42, 95% CI: 0.24, 0.74), but there was no difference in the odds of reported diarrhea in infants, adjusting for covariates (OR: 1.19, 95% CI: 0.74, 1.90). Although nearly all water samples obtained from unprotected sources and filtered by the HFU were free of E. coli contamination, HFUs alone were not effective at reducing diarrhea in infants.

PURPOSE: Compare selected sociodemographic and sexual risk characteristics of black/African American (black) men who have sex with men only (MSMO) and men who have sex with men and women (MSMW) in the southeastern United States (the South). METHODS: We conducted bivariate and multivariable analyses to explore the sociodemographic characteristics and sexual risk behaviors of 584 MSMW and MSMO in the South. RESULTS: MSMW had lesser odds of having a college or graduate degree (aOR = 0.32; 95% CI = 0.19, 0.54) and having > 2 male oral sex partners (aOR = 0.20; 95% CI = 0.08, 0.48) compared to MSMO. MSMW had greater odds of being homeless (aOR = 3.11; 95% CI = 1.80, 5.38) and selecting "top" sexual position (aOR = 1.70; 95% CI = 1.07, 2.72) compared to MSMO. CONCLUSION: MSMW in the South experience social and structural factors that may affect their risk for HIV infection. Strategies to address these factors should be considered in prevention and care efforts for this population.

BACKGROUND: Over half of malaria cases reported in the United States occur among people traveling to visit friends and relatives (VFRs), predominantly to West Africa. Few studies have queried VFR travelers directly on barriers to seeking pre-travel care. We aim to describe the knowledge, attitudes, and practices of VFRs traveling to malaria-endemic countries from the United States. With these findings, we aim to design interventions to encourage preventive behaviors before and during travel. METHODS: Sixteen focus groups were held in two US metropolitan areas with West African immigrant populations: Minneapolis-St. Paul, MN, and New York City, NY. A total of 172 people from 13 African countries participated. Focus group discussions were audio-recorded and transcribed, and modified grounded theory analysis was performed. Participants reviewed themes to verify intent of statements. RESULTS: Participants described the high cost of provider visits and chemoprophylaxis, challenges in advocating for themselves in healthcare settings, and concerns about offending or inconveniencing hosts as barriers to malaria prevention. Cultural barriers to accessing pre-travel care included competing priorities when trip planning, such as purchasing gifts for family, travel logistics, and safety concerns. When participants sought pre-travel care, most consulted their primary care provider. Participants expressed low confidence in US providers' knowledge and training about malaria and other tropical diseases. CONCLUSION: Barriers to pre-travel care for VFR travelers are multifaceted and extend beyond their perception of disease risk. Only some barriers previously reported in anecdotal and qualitative literature were supported in our findings. Future interventions should be aimed at barriers identified by individual communities and involve primary and travel specialist healthcare providers. Additional work is needed to address systems-level barriers to accessing care and establishing community-based programs to support West African VFR traveler health.

The use of participatory approaches involving community stakeholders is novel in travel medicine research. We describe various community-based participatory methods, using the examples of community advisory boards (CABs), community-based organisations (CBOs), and focus groups as mechanisms for achieving a desired interventional outcome. While these methodologies can be applied to many settings, we used them to investigate barriers to malaria prevention in travellers visiting friends and relatives (VFRs) and to implement interventions targeting VFRs.

Since 2013, CDC has received reports and investigated serious complications among medical tourists (i.e., persons whose primary purpose for international travel is medical care) upon their return to the United States (1). On May 1, 2017, the New York City Department of Health and Mental Hygiene informed CDC of three patients with nontuberculous mycobacteria (NTM) surgical site infections (SSI), all of whom had undergone cosmetic surgical procedures by a single surgeon at Centro Internacional de Cirugía Plástica Avanzada (CIPLA) in the Dominican Republic (2). | | To identify additional patients, calls for cases were issued via CDC’s Epidemic Information Exchange (Epi-X), state-based health alert systems, the Infectious Diseases Society of America’s Emerging Infections Network, and the American Society of Plastic Surgeons’ email distribution list. State and local health department staff members interviewed reported patients to collect information about medical care received abroad, symptoms, and treatment received after their original surgical procedures. A confirmed case of cosmetic surgery–associated NTM infection was defined as a diagnosed SSI and laboratory evidence confirming the presence of NTM in a U.S. resident who underwent a cosmetic surgery procedure in the Dominican Republic since January 1, 2017.

Mass-gathering epidemiology is an emerging discipline in applied public health.1 High-profile mass gatherings include major sporting events (eg, the Olympics, the FIFA World Cup [Fedération Internationale Football Association]), religious events (eg, the Hajj, World Youth Day), cultural festivals (eg, Glastonbury Music Festival), and US National Special Security Events (eg, political conventions), among other locally defined events. These events may impose short-term pressures on local and regional public health infrastructure. In accordance with the International Health Regulations, the World Health Organization offers guidance for public health planning, surveillance, and response during mass gatherings.2,3 | Public health risks associated with mass gatherings are well documented and encompass a variety of focus areas, from environmental health hazards to infectious diseases.4,5 Because of the diverse nature of mass gatherings, different factors contribute to the health and safety risks for participants. A 2002 review of the mass-gathering medical literature categorized different variables and their possible causal relationships to health outcomes. These variables included weather, attendance, duration of event, location of event, event type, crowd mood, alcohol or drug use, crowd density, and age of attendees.5 Although infectious disease outbreaks and injury clusters have been reported during mass gatherings,1,6–9 the large number of annual events held worldwide without reports of adverse events suggests that these occurrences are relatively rare—though publication bias may have led to some underestimation. Nonetheless, a local public health agency must be prepared to enhance its surveillance capacity to detect and investigate an outbreak, mass exposure, or injury cluster that could damage the credibility of the event or exert a substantial human or economic impact.

During the past decade, widespread media attention has been paid to threats of emerging infectious diseases, including 2009 influenza A (H1N1), Ebola, and now Zika. The US public receives information about these diseases from various sources, including mainstream news providers, social networking sites, and other internet services.1 Even so, many members of the public may not know how to find evidence-based information about protecting their health during infectious disease outbreaks. Zika provides a good example. Much of the public may know that Zika virus infection during pregnancy can cause microcephaly and other severe birth defects,2 that the virus primarily spreads through infected mosquitoes, and that people can also get Zika virus through sex. Even so, rumor, fear, misinformation, and challenges in identifying evidence-based information can still lead to misperceptions about Zika virus and prevent people from adopting behaviors that might prevent Zika-related birth defects. | Public acceptance of a message often depends on the source.3 During difficult situations, people often turn to trusted leaders for advice. Trusted leaders can include community or religious leaders, such as pastors, priests, rabbis, and imams.4 These trusted leaders may even be a community’s first point of contact for health concerns such as Zika virus, even if it is not their area of expertise. Based on the influence that community and religious leaders may have on their constituents’ awareness and behaviors and the potential for Zika virus to cause harm, the US Department of Health and Human Services (HHS) developed the Health Ministers Guide on Zika5 and the Zika Action Guide for Health Ministers6 to help “health ministers” (ie, any ordained, certified, or lay leader in a community who is dedicated to improving the public’s health)7 guide Zika virus prevention in their communities (Table).

A qualitative inquiry was used to assess if incentives consisting of a hygiene kit, protein-fortified flour, and delivery kit reduced barriers to antenatal care and delivery services in Nyanza Province, Kenya. We conducted 40 interviews (baseline: five nurses, six mothers, one focus group of five mothers; follow-up: nine nurses, 19 mothers) to assess perceptions of these services. Mothers and nurses identified poor quality of care, fear of HIV diagnosis and stigma, inadequate transport, and cost of care as barriers. Nurses believed incentives encouraged women to use services; mothers described wanting good birth outcomes as their motivation. While barriers to care did not change during the study, incentives may have increased service use. These findings suggest that structural improvements-upgraded infrastructure, adequate staffing, improved treatment of women by nurses, low or no-cost services, and provision of transport-could increase satisfaction with and use of services, improving maternal and infant health.

The Commissioned Corps of the US Public Health Service (USPHS), one of America’s seven uniformed services, comprises more than 6700 public health professionals whose mission is to protect, promote, and advance the health and safety of the nation. The Scientist Category, one of 11 professional USPHS categories, includes more than 300 doctoral-level scientists stationed at various state and federal agencies. Among USPHS scientists’ varied work duties and responsibilities are activities related to the seven health priorities delineated in the National Prevention Strategy (NPS), a 2011 federal agenda developed by the Surgeon General–led National Prevention Council that aims to guide improvements in health and well-being in the United States.

We thank Klein1 for discussing human immunodeficiency virus (HIV) testing among older adults, whom we define for the purposes of routine HIV testing as persons ages 50–64 years. Citing the U.S. Preventive Services Taskforce (USPSTF) guidelines2, Klein suggests routine HIV testing is not warranted among older adults as their relatively low rates of HIV infection render it an inefficient use of resources. Neither those guidelines nor CDC’s 2006 HIV testing recommendations3 prescriptively defines what time periods constitute “routine” for healthcare visits or HIV tests; we4 use “the last 12 months” as a proxy for an annual primary care visit and opportunity to test. We respectfully disagree with Klein on several assertions, including that providers must document HIV prevalence prior to implementing routine HIV testing. The recommendations explicitly state the opposite: “Health-care providers should initiate screening unless prevalence of undiagnosed HIV infection in their patients has been documented to be <0.1%. In the absence of existing data for HIV prevalence, health-care providers should initiate voluntary HIV screening until they establish that the diagnostic yield is <1 per 1,000 patients screened.3 (p.7)” This letter focuses on two of our concerns: Klein (1) underestimates the need for HIV testing among older adults and (2) does not consider issues of equity. The resulting conclusion about the appropriateness of HIV testing is biased downwards.

During 2013, the Maryland Department of Health and Mental Hygiene in Baltimore, MD, USA, received report of 2 Maryland residents whose surgical sites were infected with rapidly growing mycobacteria after cosmetic procedures at a clinic (clinic A) in the Dominican Republic. A multistate investigation was initiated; a probable case was defined as a surgical site infection unresponsive to therapy in a patient who had undergone cosmetic surgery in the Dominican Republic. We identified 21 case-patients in 6 states who had surgery in 1 of 5 Dominican Republic clinics; 13 (62%) had surgery at clinic A. Isolates from 12 (92%) of those patients were culture-positive for Mycobacterium abscessus complex. Of 9 clinic A case-patients with available data, all required therapeutic surgical intervention, 8 (92%) were hospitalized, and 7 (78%) required ≥3 months of antibacterial drug therapy. Healthcare providers should consider infection with rapidly growing mycobacteria in patients who have surgical site infections unresponsive to standard treatment.

During the response to the 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa, CDC addressed the disease on two fronts: in the epidemic epicenter of West Africa and at home in the United States. Different needs drove the demand for information in these two regions. The severity of the epidemic was reflected not only in lives lost but also in the amount of fear, misinformation, and stigma that it generated worldwide. CDC helped increase awareness, promoted actions to stop the spread of Ebola, and coordinated CDC communication efforts with multiple international and domestic partners. CDC, with input from partners, vastly increased the number of Ebola communication materials for groups with different needs, levels of health literacy, and cultural preferences. CDC deployed health communicators to West Africa to support ministries of health in developing and disseminating clear, science-based messages and promoting science-based behavioral interventions. Partnerships in West Africa with local radio, television, and cell phone businesses made possible the dissemination of messages appropriate for maximum effect. CDC and its partners communicated evolving science and risk in a culturally appropriate way to motivate persons to adapt their behavior and prevent infection with and spread of Ebola virus. Acknowledging what is and is not known is key to effective risk communication, and CDC worked with partners to integrate health promotion and behavioral and cultural knowledge into the response to increase awareness of the actual risk for Ebola and to promote protective actions and specific steps to stop its spread. The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

BACKGROUND: Community-acquired methicillin-resistant Staphylococcus aureus and methicillin-sensitive S. aureus infections are common to south-western Alaska and have been associated with traditional steambaths. More than a decade ago, recommendations were made to affected communities that included preventive skin care, cleaning methods for steambath surfaces, and the use of protective barriers while in steambaths to reduce the risk of S. aureus infection. OBJECTIVE: A review of community medical data suggested that the number of skin infection clinical encounters has increased steadily over the last 3 years and we designed a public health investigation to seek root causes. STUDY DESIGN: Using a mixed methods approach with in-person surveys, a convenience sample (n=492) from 3 rural communities assessed the range of knowledge, attitudes and practices concerning skin infections, skin infection education messaging, prevention activities and home self-care of skin infections. RESULTS: We described barriers to implementing previous recommendations and evaluated the acceptability of potential interventions. Prior public health messages appear to have been effective in reaching community members and appear to have been understood and accepted. We found no major misconceptions regarding what a boil was or how someone got one. Overall, respondents seemed concerned about boils as a health problem and reported that they were motivated to prevent boils. We identified current practices used to avoid skin infections, such as the disinfection of steambaths. We also identified barriers to engaging in protective behaviours, such as lack of access to laundry facilities. CONCLUSIONS: These findings can be used to help guide public health strategic planning and identify appropriate evidence-based interventions tailored to the specific needs of the region.

The international response to Haiti's ongoing cholera outbreak has been multifaceted, including health education efforts by community health workers and the distribution of free water treatment products. Artibonite Department was the first region affected by the outbreak. Numerous organizations have been involved in cholera response efforts in Haiti with many focusing on efforts to improve water, sanitation, and hygiene (WASH). Multiple types of water treatment products have been distributed, creating the potential for confusion over correct dosage and water treatment methods. We utilized qualitative methods in Artibonite to determine the population's response to WASH messages, use and acceptability of water treatment products, and water treatment and sanitation knowledge, attitudes and practices at the household level. We conducted eighteen focus group discussions (FGDs): 17 FGDs were held with community members (nine among females, eight among males); one FGD was held with community health workers. Health messages related to WASH were well-retained, with reported improvements in hand-washing. Community health workers were identified as valued sources of health information. Most participants noted a paucity of water-treatment products. Sanitation, specifically the construction of latrines, was the most commonly identified need. Lack of funds was the primary reason given for not constructing a latrine. The construction and maintenance of potable water and sanitation services is needed to ensure a sustainable change.