An all-oral, 6-month regimen of bedaquiline, pretomanid, and linezolid (BPaL) was approved by the US Food and Drug Administration (FDA) in the USA for the treatment of some forms of multidrug-resistant tuberculosis in 2019.1 The USA has a low incidence of tuberculosis, with 2·5 cases diagnosed per 100 000 population and 90 cases of multidrug-resistant tuberculosis reported in 2022. In February, 2022, the US Centers for Disease Control and Prevention (CDC) published initial guidance for the use of BPaL. In December, 2022, based on results from a subsequent international randomised trial,2 WHO recommended an alternative regimen—bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM)—for all patients with multidrug-resistant tuberculosis without fluoroquinolone resistance.3 Here we present data from all patients reported to the CDC as initiating the BPaLM regimen in the USA between Aug 14, 2019, and Dec 31, 2022, and from patients receiving BPaL, a regimen previously documented to have uptake in US tuberculosis programmes,4, 5 as a complement to the randomised TB-PRACTECAL study.6 | | US public health jurisdictions were invited to submit standardised, de-identified data for each patient receiving BPaL or BPaLM. Between Aug 14, 2019, and Dec 31, 2022, 116 patients started treatment with BPaL and 36 with BPaLM in 19 US states and territories (table). The majority of patients for whom data were available (103 [90%] of 114) started with linezolid 600 mg daily; 42 (37%) of these 114 patients had their doses of linezolid adjusted during treatment. Of the 113 (74%) of 152 patients who were reported to have completed treatment, none had their therapy terminated. The most common side-effect in both regimens was peripheral neuropathy, which could have occurred as a result of linezolid or previous tuberculosis medications received by the patient. As of June 30, 2023—26 weeks after the end of the monitoring period—one patient required additional medication in a prolonged regimen after BPaL treatment failure, three had their baseline treatment extended owing to delayed culture clearance, three had a relapse of tuberculosis, and four patients died. 84 (72%) of 116 patients who received BPaL and 29 (81%) of 36 patients who received BPaLM reported treatment completion.

During May 17–December 31, 2022, 125 probable or confirmed U.S. monkeypox (mpox)† cases were reported among patients aged <18 years, including 45 (36%) in children aged ≤12 years. Eighty-three cases in persons aged <18 years diagnosed during May 17–September 24, 2022 were previously described (1); 28 (34%) of these were in children aged ≤12 years, 29% of whom did not have reported information on exposure. Among 20 (71%) of 28 patients with documented information on exposure, most were exposed by a household contact. This report updates the previous report using data collected during September 25–December 31, 2022, proposes possible mpox exposure routes in children aged ≤12 years, and describes three U.S. mpox cases in neonates. Household members or caregivers with mpox, including pregnant women and their health care providers, should be informed of the risk of transmission to persons aged <18 years, and strategies to protect persons aged <18 years at risk for exposure, including isolating household contacts with mpox, should be implemented immediately. | | During September 25–December 31, 2022, 17 children aged ≤12 years with probable or confirmed mpox were identified through national surveillance. CDC provided a questionnaire to state and local health departments for collection of the child’s history of exposure to any person with mpox§ during the previous 3 weeks, exposure settings, types of contact (e.g., skin-to-skin, being held or cuddled, diaper change, or toilet use), and precautions taken by the person with mpox (e.g., practiced isolation or covered lesions). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.¶

Data on monkeypox in children and adolescents aged <18 years are limited (1,2). During May 17-September 24, 2022, a total of 25,038 monkeypox cases were reported in the United States,(dagger) primarily among adult gay, bisexual, and other men who have sex with men (3). During this period, CDC and U.S. jurisdictional health departments identified Monkeypox virus (MPXV) infections in 83 persons aged <18 years, accounting for 0.3% of reported cases. Among 28 children aged 0-12 years with monkeypox, 64% were boys, and most had direct skin-to-skin contact with an adult with monkeypox who was caring for the child in a household setting. Among 55 adolescents aged 13-17 years, most were male (89%), and male-to-male sexual contact was the most common presumed exposure route (66%). Most children and adolescents with monkeypox were non-Hispanic Black or African American (Black) (47%) or Hispanic or Latino (Hispanic) (35%). Most (89%) were not hospitalized, none received intensive care unit (ICU)-level care, and none died. Monkeypox in children and adolescents remains rare in the United States. Ensuring equitable access to monkeypox vaccination, testing, and treatment is a critical public health priority. Vaccination for adolescents with risk factors and provision of prevention information for persons with monkeypox caring for children might prevent additional infections.

As of October 21, 2022, a total of 27,884 monkeypox cases (confirmed and probable) have been reported in the United States.(§) Gay, bisexual, and other men who have sex with men have constituted a majority of cases, and persons with HIV infection and those from racial and ethnic minority groups have been disproportionately affected (1,2). During previous monkeypox outbreaks, severe manifestations of disease and poor outcomes have been reported among persons with HIV infection, particularly those with AIDS (3-5). This report summarizes findings from CDC clinical consultations provided for 57 patients aged ≥18 years who were hospitalized with severe manifestations of monkeypox(¶) during August 10-October 10, 2022, and highlights three clinically representative cases. Overall, 47 (82%) patients had HIV infection, four (9%) of whom were receiving antiretroviral therapy (ART) before monkeypox diagnosis. Most patients were male (95%) and 68% were non-Hispanic Black (Black). Overall, 17 (30%) patients received intensive care unit (ICU)-level care, and 12 (21%) have died. As of this report, monkeypox was a cause of death or contributing factor in five of these deaths; six deaths remain under investigation to determine whether monkeypox was a causal or contributing factor; and in one death, monkeypox was not a cause or contributing factor.** Health care providers and public health professionals should be aware that severe morbidity and mortality associated with monkeypox have been observed during the current outbreak in the United States (6,7), particularly among highly immunocompromised persons. Providers should test all sexually active patients with suspected monkeypox for HIV at the time of monkeypox testing unless a patient is already known to have HIV infection. Providers should consider early commencement and extended duration of monkeypox-directed therapy(††) in highly immunocompromised patients with suspected or laboratory-diagnosed monkeypox.(§§) Engaging all persons with HIV in sustained care remains a critical public health priority.

As of October 11, 2022, a total of 26,577 monkeypox cases had been reported in the United States.* Although most cases of monkeypox are self-limited, lesions that involve anatomically vulnerable sites can cause complications. Ocular monkeypox can occur when Monkeypox virus (MPXV) is introduced into the eye (e.g., from autoinoculation), potentially causing conjunctivitis, blepharitis, keratitis, and loss of vision (1). This report describes five patients who acquired ocular monkeypox during July-September 2022. All patients received treatment with tecovirimat (Tpoxx)(†); four also received topical trifluridine (Viroptic).(§) Two patients had HIV-associated immunocompromise and experienced delays between clinical presentation with monkeypox and initiation of monkeypox-directed treatment. Four patients were hospitalized, and one experienced marked vision impairment. To decrease the risk for autoinoculation, persons with monkeypox should be advised to practice hand hygiene and to avoid touching their eyes, which includes refraining from using contact lenses (2). Health care providers and public health practitioners should be aware that ocular monkeypox, although rare, is a sight-threatening condition. Patients with signs and symptoms compatible with ocular monkeypox should be considered for urgent ophthalmologic evaluation and initiation of monkeypox-directed treatment. Public health officials should be promptly notified of cases of ocular monkeypox. Increased clinician awareness of ocular monkeypox and of approaches to prevention, diagnosis, and treatment might reduce associated morbidity.

OBJECTIVES: During 2010-2018, the Arkansas Department of Health reported 21 genotype-matched cases of tuberculosis (TB) among residents of a rural county in Arkansas with a low incidence of TB and in nearby counties. The Arkansas Department of Health and the Centers for Disease Control and Prevention investigated to determine the extent of TB transmission and provide recommendations for TB control. METHODS: We reviewed medical and public health records, interviewed patients, and reviewed patients' social media posts to describe patient characteristics, identify epidemiologic links, and establish likely chains of transmission. RESULTS: We identified 21 cases; 11 reported during 2010-2013 and 10 during 2016-2018. All case patients were US-born non-Hispanic Black people. Eighteen case patients had the outbreak genotype, and 3 clinically diagnosed (non-culture-confirmed) case patients had epidemiologic links to patients with the outbreak genotype. Social media reviews revealed epidemiologic links among 10 case patients not previously disclosed during interviews. Eight case patients (38%) had ≥1 health care visit during their infectious period, and 7 patients had estimated infectious periods of >12 months. CONCLUSIONS: Delayed diagnoses and prolonged infectiousness led to TB transmission in this rural community. TB education and awareness is critical to reducing transmission, morbidity, and mortality, especially in areas where health care providers have limited TB experience. Use of social media can help elucidate people at risk, especially when traditional TB investigation techniques are insufficient.

Persons from the Republic of the Marshall Islands have among the highest rates of Hansen's disease (HD) in the world; the largest Marshallese community in the continental United States is in northwest Arkansas. In 2017, the HD Ambulatory Care Clinic in Springdale, Arkansas, informed the Arkansas Department of Health (ADH) that Marshallese persons with HD had severe disease with frequent complications. To characterize their illness, we reviewed ADH surveillance reports of HD among Marshallese persons in Arkansas treated during 2003-2017 (n = 42). Hansen's Disease prevalence among Marshallese in Arkansas (11.7/10,000) was greater than that in the general U.S. population. Complications included arthritis (38%), erythema nodosum leprosum (21%), and prolonged treatment lasting > 2 years (40%). The majority (82%) of patients treated for > 2 years had documented intermittent therapy. Culturally appropriate support for therapy and adherence is needed in Arkansas.

During August 2016-July 2017, Arkansas experienced a large mumps (parotitis) outbreak; however, mumps-negative cases of parotitis were also identified in this period. Nineteen of 215 samples (9%) randomly selected for influenza PCR testing were positive for influenza A virus. Practitioners should consider influenza as a cause of nonmumps parotitis.

BACKGROUND: In July 2018, the Arkansas Department of Health (ADH) was notified by Hospital A of three patients with bloodstream infections (BSIs) with a rapidly growing, nontuberculous Mycobacterium (NTM) species; on September 5, 2018, six additional BSIs were reported. All were among oncology patients at Clinic A. We investigated to identify sources and to prevent further infections. METHODS: ADH performed an onsite investigation at Clinic A on September 7, 2018 and reviewed patient charts, obtained environmental samples, and cultured isolates. Isolates were sequenced (whole genome, 16S, rpoB) by the Centers for Disease Control and Prevention to determine species identity and relatedness. RESULTS: By December 31, 2018, 52 (34%) of 151 oncology patients with chemotherapy ports accessed at Clinic A during March 22-September 12, 2018 had NTM BSIs. Infected patients received significantly more saline flushes than uninfected patients (P <0.001) during the risk period. NTM grew from 6 unused saline flushes compounded by Clinic A. The identified species was novel and designated Mycobacterium FVL 201832. Isolates from patients and saline flushes were highly related by whole-genome sequencing, indicating a common source. Clinic A changed to prefilled saline flushes on September 12 as recommended. CONCLUSIONS: Mycobacterium FVL 201832 caused BSIs in oncology clinic patients. Laboratory data allowed investigators to rapidly link infections to contaminated saline flushes; cooperation between multiple institutions resulted in timely outbreak resolution. New state policies being considered because of this outbreak include adding extrapulmonary NTM to ADH's reportable disease list and providing more oversight to outpatient oncology clinics.

From January to July 2017, the West Virginia Department of Health and Human Resources (WV DHHR) identified 10 cases of human immunodeficiency virus (HIV) infection in three counties where HIV diagnoses typically range from six to 13 annually (1). In these counties, the spread of bloodborne pathogens via injection drug use (IDU) is a major public health concern, and risk reduction programs offering syringe services were not available, although they were available in other counties (2,3). As of July 2017, nine of the 10 persons identified were men who have sex with men (MSM), two of whom had reported a prior history of IDU. Coinfections with syphilis (five patients), hepatitis B virus (three), and hepatitis C virus (HCV) (two) were also documented. By September 2017, the sexual or injection contacts named by persons in the investigation expanded the original assessment area to encompass 15 counties, 14 of which were among the nation’s top 220 counties thought to be particularly vulnerable to rapid spread of HIV and HCV infections via IDU (4). The investigated counties share some characteristics with rural Scott County, Indiana, where an HIV outbreak was linked to IDU in 2015 (5), including a high prevalence of drug overdose deaths, prescription opioid sales, and unemployment.