On January 7, 2019, the Oregon Public Health Division (OPHD) was contacted by a local health department regarding an Oregon teen who, on December 24, 2018, was bitten by a macaque monkey (Figure) in a public park in Phuket, Thailand. The bleeding wound was immediately rinsed with bottled water without soap. Subsequently, hotel staff members applied a topical pain reliever. The following day, the teen went to a local clinic in Thailand and received the first dose of rabies postexposure prophylaxis vaccine; rabies immune globulin was not administered. She received 2 additional doses of rabies vaccine while in Thailand. | | On January 5, 2019, the patient left Thailand and was evaluated by a physician in Oregon on January 7. The physician contacted the local health department, seeking guidance about when to administer the final dose of rabies vaccine. Upon learning about the macaque bite, the local health department contacted OPHD, where staff members expressed concern about possible exposure to Macacine herpesvirus 1 (B virus). This virus, commonly found in macaques,* can, in rare cases, cause severe encephalitic infection in humans if not treated promptly (1). The case fatality rate of untreated B virus infection approaches 80% (2). OPHD contacted CDC, and the National B Virus Resource Center (NBVRC) in Atlanta, Georgia, to discuss testing.†

OBJECTIVE: The objective of the current study is to report on urine, blood and serum metal concentrations to characterize exposures to trace elements and micronutrient levels in both pregnant women and women of child-bearing age in the U.S. National Health and Nutrition Examination Survey (NHANES) years 1999-2016. METHODS: Urine and blood samples taken from NHANES participants were analyzed for thirteen urine metals, three blood metals, three serum metals, speciated mercury in blood and speciated arsenic in urine. Adjusted and unadjusted least squares geometric means and 95% confidence intervals were calculated for all participants among women aged 15-44 years. Changes in exposure levels over time were also examined. Serum cotinine levels were used to adjust for smoke exposure, as smoking is a source of metal exposure. RESULTS: Detection rates for four urine metals from the ATSDR Substance Priority List: arsenic, lead, mercury and cadmium were ~83-99% for both pregnant and non-pregnant women of child bearing age. A majority of metal concentrations were higher in pregnant women compared to non-pregnant women. Pregnant women had higher mean urine total arsenic, urine mercury, and urine lead; however, blood lead and mercury were higher in non-pregnant women. Blood lead, cadmium, mercury, as well as urine antimony, cadmium and lead in women of childbearing age decreased over time, while urine cobalt increased over time. CONCLUSIONS: Pregnant women in the US have been exposed to several trace metals, with observed concentrations for some trace elements decreasing since 1999.

Consumption of fish containing methylmercury can pose serious health concerns including neurotoxic effects in adults and toxicity to the fetuses of mothers exposed during pregnancy. In the study described in this article, the authors examined fish consumption patterns and measured hair mercury levels of women of childbearing age in a coastal county in Florida. Women from the community participated in a risk factor assessment survey (N = 703). Hair samples (n = 698) were collected and analyzed for mercury. The authors identified 74.8% below detection limit; 25.2% had detectable limits of mercury, while 7% exceeded 1 mcg/g. Hair mercury levels increased with fish consumption and age. Race, income, and education levels were also associated with increased hair mercury levels. Women of Asian/Pacific Islander origin had the highest levels. Although reported fish consumption exceeded the recommendations for women of childbearing age, the study population had lower mercury levels than other comparative studies in Florida and at national levels.

In August 2008, a resident at a Florida assisted living facility for adults with mental illness was diagnosed with infectious pulmonary tuberculosis (TB). From October 2008 to May 2009, 14 additional residents and three nonresidents were diagnosed with TB. The index patient was contagious for approximately 8 months before he was diagnosed in August 2008. He first sought medical attention for a cough and general malaise in April 2008, at a local psychiatric hospital where he felt comfortable receiving care because of his frequent previous hospitalizations there. He was evaluated by an internist and admitted for acute psychiatric decompensation for 8 days to a locked ward that held approximately 25 patients. Although cough was documented on admission, medical records did not reveal any detail on how the patient described his symptoms, and further evaluation was not performed at that time. During the course of his infectious period, the patient did not seek treatment at a medical facility for his worsening TB symptoms. He was held for one night in a one-person cell at the county jail and was hospitalized three more times at the psychiatric hospital for stays ranging from 2 to 8 days. He was assessed by an internist at each admission, and a cough was documented in each admission note. When the patient was hospitalized for the fourth time at the psychiatric facility in August 2008, a provider noted that his cough had persisted and ordered chest radiography, which revealed evidence of a cavitary lesion suggestive of pulmonary TB. The patient was transferred to a medical hospital, where sputum smear microscopy was positive for acid-fast bacilli, and confirmatory testing revealed Mycobacterium tuberculosis. After 2 weeks of TB treatment, the patient left against medical advice and returned to the assisted living facility. Three days later, supervisors from the assisted living facility brought him to another medical hospital for admission under direct one-to-one observation. He attempted to leave the hospital multiple times, requiring transfer to an isolation unit at the local jail and then to the A.G. Holley State Hospital, a Department of Health facility specializing in tuberculosis, in accordance with Florida state law permitting the involuntary examination and treatment of persons with mental illness who may be a harm to others, such as patients who have dangerous infectious diseases like tuberculosis.

The Aptima HIV-1 RNA Qualitative Assay tested with a WHO-approved HIV-1 RNA standard in 16- and 32-member pools detected 100% of the pools (1,070 and 2,130 HIV-1 RNA copies/ml/pool, respectively) thus exceeding the FDA-required lower limit of detection. The Aptima test can be used to screen for acute HIV-infection.

Pesticide metabolites are routinely measured in the urine of children in the United States. Although the sources of these metabolites are believed to include residues in food from agricultural applications and residues from applications in everyday environments (e.g., homes), few studies have been able to demonstrate an association between indoor residential pesticide applications and pesticide metabolite concentrations. To better quantify the effects of potential risk factors related to demographics, household characteristics, occupation, and pesticide use practices on urinary biomarker levels, we performed a study in a city (Jacksonville, Florida) previously determined to have elevated rates of pesticide use. We enrolled a convenience sample of 203 children ranging in age from 4 to 6 years; their caregivers completed a questionnaire and the children provided a urine sample, which was analyzed for a series of organophosphorus and pyrethroid insecticide metabolites. The questionnaire responses substantiated much higher pesticide use for the study participants as compared to other studies. Urinary metabolite concentrations were approximately an order of magnitude higher than concentrations reported for young children in other studies. Few statistically significant differences (at the p<0.05 level) were observed, however, several trends are worth noting. In general, mean urinary pesticide metabolite concentrations were higher for males, Caucasians, and those children living in homes with an indoor pesticide application occurring within the past four weeks. Comparing the urinary pesticide metabolite concentrations in this study to those reported in the NHANES and GerES studies showed that the children living in Jacksonville had substantially higher pyrethroid pesticide exposures than the general populations of the United States and Germany. Further research is needed in communities where routine pesticide use has been documented to obtain information on the most important routes and pathways of exposure and to develop the most effective strategies for reducing pesticide exposures for children.