CDC’s Vessel Sanitation Program (VSP) monitors cases of acute gastroenteritis (AGE) on board cruise ships traveling to a U.S. port (1). Persons who have ≥3 loose stools (or more than normal for that person) within a 24-hour period or vomiting plus one other sign or symptom (e.g., fever, diarrhea, bloody stool, myalgia, abdominal cramps, or headache) meet the case definition for reportable AGE (2). When the percentage of passengers or crew members with AGE is ≥2% and the ship is due to arrive at a U.S. port within 15 days, the Maritime Illness Disease Reporting System alerts VSP and activates an investigation (1). During the first week of January 2023, VSP was notified of cases of AGE affecting >2% of passengers on board a ship that had completed three voyages in Europe and was within 15 days of arriving at a U.S. port (voyage 4)* (Figure). Ship medical crew members submitted stool samples from ill travelers for testing. All samples tested positive for norovirus genotype II. While the ship was sailing to a U.S. port, VSP monitored AGE cases on board and reviewed case data. By mid-January, passenger AGE prevalence reached 3.4%.

We are writing to express concern over an article in press in Travel Medicine and Infectious Disease: Heggie TW and Kupper T, Surviving Naegleria fowleri infections: A successful case report and novel therapeutic approach (1). This article describes the successful treatment of a person infected with Naegleria fowleri primary amebic meningoencephalitis (PAM). | | In the March 2015 volume of Pediatrics, my colleagues and I published an authoritative report of this case (2). I am the clinician who oversaw the care of the patient. My co-authors are members of the medical team that cared for the patient and the CDC clinical and laboratory experts on N. fowleri who consulted on the case and performed specialized diagnostic tests at CDC laboratories. Our paper provided comprehensive clinical, diagnostic, and therapeutic review of this case, along with a detailed review of the history, pathophysiology, epidemiology, and therapeutic pharmacology of N. fowleri-associated PAM. | | In their paper in Travel Medicine and Infectious Disease, Heggie and Kupper fail to cite our definitive case report. Their description of the case differs from ours; they do not explain where they obtained their information about the case, which in some respects is erroneous. Heggie and Kupper are not known to us and had no role in caring for this patient. Though they do not explicitly claim to have been involved in the care of this patient, their article is written in a way that would leave the reader thinking they were. | | My concern, shared by colleagues here and at the CDC, is that Heggie and Kupper’s failure to cite our definitive case report denies their article’s readers the opportunity to examine the most accurate and comprehensive description of the case. This deficiency is aggravated by the fact that Heggie and Kupper’s paper contains errors with respect to the case. This situation is not to the advantage of clinicians seeking accurate information to optimally treat future patients, or researchers seeking to understand the disease and its treatment. |

Non-O157 Shiga toxin-producing Escherichia coli (STEC) can cause severe illness, including hemolytic uremic syndrome (HUS). STEC O145 is the sixth most commonly reported non-O157 STEC in the United States, although outbreaks have been infrequent. In April and May 2010, we investigated a multistate outbreak of STEC O145 infection. Confirmed cases were STEC O145 infections with isolate pulsed-field gel electrophoresis patterns indistinguishable from those of the outbreak strain. Probable cases were STEC O145 infections or HUS in persons who were epidemiologically linked. Case-control studies were conducted in Michigan and Ohio; food exposures were analyzed at the restaurant, menu, and ingredient level. Environmental inspections were conducted in implicated food establishments, and food samples were collected and tested. To characterize clinical findings associated with infections, we conducted a chart review for case patients who sought medical care. We identified 27 confirmed and 4 probable cases from five states. Of these, 14 (45%) were hospitalized, 3 (10%) developed HUS, and none died. Among two case-control studies conducted, illness was significantly associated with consumption of shredded romaine lettuce in Michigan (odds ratio [OR] = undefined; 95% confidence interval [CI] = 1.6 to undefined) and Ohio (OR = 10.9; 95% CI = 3.1 to 40.5). Samples from an unopened bag of shredded romaine lettuce yielded the predominant outbreak strain. Of 15 case patients included in the chart review, 14 (93%) had diarrhea and abdominal cramps and 11 (73%) developed bloody diarrhea. This report documents the first foodborne outbreak of STEC O145 infections in the United States. Current surveillance efforts focus primarily on E. coli O157 infections; however, non-O157 STEC can cause similar disease and outbreaks, and efforts should be made to identify both O157 and non-O157 STEC infections. Providers should test all patients with bloody diarrhea for both non-O157 and O157 STEC.