BACKGROUND: Male circumcision confers partial protection against heterosexual HIV acquisition among men. The President's Emergency Plan for AIDS Relief (PEPFAR) has supported > 18,900,000 voluntary medical male circumcisions (VMMC). Glans injuries (GIs) are rare but devastating adverse events (AEs) that can occur during circumcision. To address this issue, PEPFAR has supported multiple interventions in the areas of surveillance, policy, education, training, supply chain, and AE management. METHODS: Since 2015, PEPFAR has conducted surveillance of GIs including rapid investigation by the in-country PEPFAR team. This information is collected on standardized forms, which were reviewed for this analysis. RESULTS: Thirty-six GIs were reported from 2015 to 2018; all patients were < 15 years old (~ 0.7 per 100,000 VMMCs in this age group) with a decreasing annual rate (2015: 0.7 per 100,000 VMMCs; 2018: 0.4 per 100,000 VMMC; p = 0.02). Most (64%) GIs were partial or complete amputations. All amputations among 10-14 year-olds occurred using the forceps-guided (FG) method, as opposed to the dorsal-slit (DS) method, and three GIs among infants occurred using a Mogen clamp. Of 19 attempted amputation repairs, reattached tissue was viable in four (21%) in the short term. In some cases, inadequate DS method training and being overworked, were found. CONCLUSION: Following numerous interventions by PEPFAR and other stakeholders, GIs are decreasing; however, they have not been eliminated and remain a challenge for the VMMC program. Preventing further cases of complete and partial amputation will likely require additional interventions that prevent use of the FG method in young patients and the Mogen clamp in infants. Improving management of GIs is critical to optimizing outcomes.

During November 8–December 25, 2017, health care personnel at an 80-bed acute care facility in West Virginia reported dermatologic, respiratory, and ophthalmic symptoms to management or the occupational health clinic, prompting concern about a common exposure, possibly related to construction activities. Symptoms of affected staff members, who performed a range of clinical and nonclinical duties, often improved hours to days after leaving the hospital, suggesting potential exposure to an environmental irritant. Initially, hospital leadership encouraged symptomatic persons to seek evaluation at the occupational health clinic, although systematic evaluations were not implemented. No etiology was identified by environmental sampling for fibers, volatile organic compounds, or mold. In the absence of a clear etiology, hospital leadership stopped inpatient admissions, transferred inpatients from the two wards where most symptomatic staff members worked, and completed cleaning to include associated air-handling systems. Dermatology and allergy consultants evaluated symptomatic staff members, but because of varying clinical manifestations, results were inconclusive. On December 26, one of the closed wards reopened; during the ensuing week, six additional workers reported symptoms, and onsite CDC assistance was requested to identify an etiology. A CDC team arrived on January 8, 2018, and met with hospital and union leadership, reviewed occupational health records, observed occupational health encounters, performed unstructured individual interviews with both affected and unaffected health care personnel, assessed the physical environment, and reviewed environmental testing results. Despite these efforts, investigators were unable to identify an etiology, and the outbreak resolved without intervention.