Rationale & Objective: Hepatitis B virus (HBV) transmission in hemodialysis units has become a rare event since implementation of hemodialysis-specific infection control guidelines: performing hemodialysis for hepatitis B surface antigen (HBsAg)-positive patients in an HBV isolation room, vaccinating HBV-susceptible (HBV surface antibody and HBsAg negative) patients, and monthly HBsAg testing in HBV-susceptible patients. Mutations in HBsAg can result in false-negative HBsAg results, leading to failure to identify HBsAg seroconversion from negative to positive. We describe 4 unique cases of HBsAg seroconversion caused by mutant HBV infection or reactivation in hemodialysis patients. Study Design: Following identification of a possible HBsAg seroconversion and mutant HBV infection, public health investigations were launched to conduct further HBV testing of case patients and potentially exposed patients. A case patient was defined as a hemodialysis patient with suspected mutant HBV infection because of false-negative HBsAg testing results. Confirmed case patients had HBV DNA sequences demonstrating S-gene mutations. Setting & Participants: Case patients and patients potentially exposed to the case patient in the respective hemodialysis units in multiple US states. Results: 4 cases of mutant HBV infection in hemodialysis patients were identified; 3 cases were confirmed using molecular sequencing. Failure of some HBsAg testing platforms to detect HBV mutations led to delays in applying HBV isolation procedures. Testing of potentially exposed patients did not identify secondary transmissions. Limitations: Lack of access to information on past HBsAg testing platforms and results led to challenges in ascertaining when HBsAg seroconversion occurred and identifying and testing all potentially exposed patients. Conclusions: Mutant HBV infections should be suspected in patients who test HBsAg negative and concurrently test positive for HBV DNA at high levels. Dialysis providers should consider using HBsAg assays that can also detect mutant HBV strains for routine HBV testing.

We report a fatal case of Lassa fever diagnosed in the United States in a Liberian traveler. We describe infection control protocols and public health response. One contact at high risk became symptomatic, but her samples tested negative for Lassa virus; no secondary cases occurred among health care, family, and community contacts.

BACKGROUND: In October 2014, the New Jersey Department of Health received reports of 3 patients who developed Enterococcus faecalis endocarditis after undergoing surgical procedures at the same oral surgery practice in New Jersey. Bacterial endocarditis is an uncommon but life-threatening condition; 3 patients with enterococcal endocarditis associated with a single oral surgery practice is unusual. An investigation was initiated because of the potential ongoing public health risk. METHODS: Public health officials conducted retrospective surveillance to identify additional patients with endocarditis associated with the practice. They interviewed patients using a standardized questionnaire. An investigative public health team inspected the office environment, interviewed staff, and reviewed medical records. RESULTS: Public health officials identified 15 confirmed patients with enterococcal endocarditis of those patients who underwent procedures from December 2012 through August 2014. Among these patients, 12 (80%) underwent cardiac surgery. One (7%) patient died from complications of endocarditis and subsequent cardiac surgery. Breaches of recommended infection prevention practices were identified that might have resulted in transmission of enterococci during the administration of intravenous sedation, including failure to perform hand hygiene and failure to maintain aseptic technique when performing procedures and handling medications. CONCLUSIONS: This investigation highlights the importance of adhering to infection prevention recommendations in dental care settings. No additional patients with endocarditis were identified after infection prevention and control recommendations were implemented. PRACTICAL IMPLICATIONS: Infection prevention training should be emphasized at all levels of professional dental training. All dental health care personnel establishing intravenous treatment and administering intravenous medications should be trained in safe injection practices.

OBJECTIVE: We characterized evacuations related to Hurricane Sandy, which made landfall in New Jersey on October 29, 2012. METHODS: We analyzed data from the 2014 New Jersey Behavioral Risk Factor Survey. The proportion of respondents reporting evacuation was used to estimate the number of New Jersey adults who evacuated. We determined evacuation rates in heavily impacted and less-impacted municipalities, as well as evacuation rates for municipalities under and not under mandatory evacuation orders. We tested associations between demographic and health factors, such as certain chronic health conditions, and evacuation. RESULTS: Among respondents, 12.7% (95% CI: 11.8%-13.6%) reported evacuating, corresponding to approximately 880,000 adults. In heavily impacted municipalities, 17.0% (95% CI: 15.2%-18.7%) evacuated, compared with 10.1% (95% CI: 9.0%-11.2%) in less-impacted municipalities. In municipalities under mandatory evacuation orders, 42.5% (95% CI: 35.1%-49.8%) evacuated, compared with 11.8% (95% CI: 10.9%-12.9%) in municipalities not under mandatory orders. Female gender (odds ratio [OR]: 1.36; 95% CI: 1.14-1.64), unmarried status (OR: 1.22; 95% CI: 1.02-1.46), shorter length of residence (OR: 1.28; 95% CI: 1.03-1.60), and living in a heavily impacted municipality (OR: 1.84; 95% CI: 1.54-2.20) were significantly associated with evacuation. History of stroke (OR: 1.61; 95% CI: 1.02-2.53) was the only chronic condition associated with evacuation. CONCLUSIONS: Approximately 880,000 New Jersey adults evacuated because of Hurricane Sandy. Those in heavily impacted municipalities and municipalities under mandatory evacuation orders had higher evacuation rates; however, still fewer than half evacuated. These findings can be used for future disaster planning. (Disaster Med Public Health Preparedness. 2017;page 1 of 9).

OBJECTIVES: To describe changes in mortality after Hurricane Sandy made landfall in New Jersey on October 29, 2012. METHODS: We used electronic death records to describe changes in all-cause and cause-specific mortality overall, in persons aged 76 years or older, and by 3 Sandy impact levels for the month and quarter following Hurricane Sandy compared with the same periods in earlier years adjusted for trends. RESULTS: All-cause mortality increased 6% (95% confidence interval [CI] = 2%, 11%) for the month, 5%, 8%, and 12% by increasing Sandy impact level; and 7% (95% CI = 5%, 10%) for the quarter, 5%, 8%, and 15% by increasing Sandy impact level. In elderly persons, all-cause mortality rates increased 10% (95% CI = 5%, 15%) and 13% (95% CI = 10%, 16%) in the month and quarter, respectively. Deaths that were cardiovascular disease-related increased by 6% in both periods, noninfectious respiratory disease-related by 24% in the quarter, infection-related by 20% in the quarter, and unintentional injury-related by 23% in the month. CONCLUSIONS: Mortality increased, heterogeneous by cause, for both periods after Hurricane Sandy, particularly in communities more severely affected and in the elderly, who may benefit from supportive services. (Am J Public Health. Published online ahead of print June 22, 2017: e1-e4. doi:10.2105/AJPH.2017.303826).

In response to a university-based serogroup B meningococcal disease outbreak, the serogroup B meningococcal vaccine Trumenba was recommended for students, a rare instance in which a specific vaccine brand was recommended. This outbreak highlights the challenges of using molecular and immunologic data to inform real-time response.

On March 22, 2015, the Agency for Toxic Substances and Disease Registry (ATSDR) was notified by the U.S. Environmental Protection Agency (EPA) of four cases of suspected acute methyl bromide toxicity among family members vacationing at a condominium resort in the U.S. Virgin Islands. Methyl bromide is a pesticide that has been banned in the United States for use in homes and other residential settings. An investigation conducted by the U.S. Virgin Islands Department of Health (VIDOH), the U.S. Virgin Islands Department of Planning and Natural Resources (DPNR), and EPA confirmed that methyl bromide had been used as a fumigant on March 18 in the building where the family had been residing, 2 days before they were transported to the hospital; three family members had life-threatening illness. On March 25, 2015, a stop-use order for methyl bromide was issued by DPNR to the pest control company that had performed the fumigation. Subsequent investigation revealed that previous fumigation with methyl bromide had occurred on October 20, 2014, at the same condominium resort. In addition to the four ill family members, 37 persons who might have been exposed to methyl bromide as a result of the October 2014 or March 2015 fumigations were identified by VIDOH and ATSDR. Standardized health questionnaires were administered to 16 of the 20 persons for whom contact information was available; six of 16 had symptoms consistent with methyl bromide exposure, including headache and fatigue. Pest control companies should be aware that use of methyl bromide is banned in homes and other residential settings, and clinicians should be aware of the toxicologic syndrome that exposure to methyl bromide can cause.