OBJECTIVE: To assess the frequency of hepatitis C virus (HCV) testing among a population-based cohort of perinatally exposed children and identify factors associated with testing. METHODS: Using a population-based surveillance cohort of perinatally exposed children born from 2018 to 2020 from 4 US jurisdictions (Georgia; Massachusetts; Allegheny County, Pennsylvania; and Los Angeles County, California), we describe the frequency, timing, and type of HCV testing among children and identify characteristics associated with having an HCV test result by the age of 2 to 3 years. Data were obtained from electronic laboratory reporting, vital records, and medical records. RESULTS: Of 803 perinatally exposed children, 7 (1%) died before the age of 24 months. Of 796 children, health departments were unable to find medical records or laboratory reports for 181 (23%). Among those with medical record abstraction at 24 months or testing reported before the age of 3 years (n = 615), 50% had an HCV test. The majority (70% of those tested) were tested for HCV antibodies at the age of 18 months or later, although 9% had an HCV nucleic acid test at ages 2 to <6 months. No characteristics examined were found to be significantly associated with having testing reported. CONCLUSIONS: In this surveillance report, we identify the gaps in current testing among children perinatally exposed to hepatitis C. Provider education and resources for health departments for follow-up and linkage to care can improve the identification of children requiring treatment, a vital piece of HCV elimination.

Background: Free-living amoebas (FLAs) can cause severe and fatal central nervous system infections that are difficult to diagnose. Methods: We present the case of a 74-year-old immunocompetent woman admitted for focal neurological symptoms with enhancing lesions in the right cerebellar hemisphere. A first cerebral biopsy showed granulomatous inflammation, but no microorganisms were identified. After transient clinical improvement, she eventually deteriorated 4 months after initial presentation, with an MRI confirming multiple new masses affecting all cerebral lobes. Results: A second brain biopsy revealed granulomatous and acute inflammation with organisms containing a large central nucleus with prominent karyosome, consistent with FLAs. Immunohistochemical and polymerase chain reaction assays performed at CDC were positive for Acanthamoeba spp, confirming the diagnosis of granulomatous amoebic encephalitis (GAE) caused by Acanthamoeba spp. The patient was treated with combination therapy recommended by CDC, but died a few days later. Upon histopathological rereview, amoebic cysts and trophozoites were identified by histochemical and immunohistochemical methods in the first cerebral biopsy. Conclusion: FLA infections can be challenging to diagnose because of the low incidence, non-specific clinical and radiological presentation, lack of accessible diagnostic tools, and clinicians' unfamiliarity. This case highlights the importance of recognizing FLA as a potential cause of granulomatous encephalitis, even in the absence of risk factors, as early treatment might be associated with favourable outcomes in case reports. When suspected, CDC laboratories offer tests to confirm the diagnosis promptly. | Historique : Les amibes libres peuvent causer des infections du système nerveux central graves et fatales qui sont difficiles à diagnostiquer. Méthodologie : Les auteurs présentent le cas d'une femme immunocompétente de 74 ans hospitalisée à cause de symptômes neurologiques focaux avec lésions rehaussantes dans l'hémisphère cérébelleux droit. Une première biopsie cérébrale a révélé une inflammation granulomateuse, mais aucun microorganisme n'a été décelé. Après une amélioration clinique transitoire, son état s'est détérioré quatre mois après la première consultation, et l'IRM a confirmé de multiples nouvelles masses touchant tous les lobes cérébraux. Résultats : Une deuxième biopsie cérébrale a révélé une inflammation granulomateuse aiguë par des organismes dont les gros noyaux centraux et les caryosomes volumineux étaient évocateurs d'amibes libres. L'immunohistochimie et l'amplification en chaîne par polymérase effectuées aux CDC se sont avérés positives pour Acanthamoeba spp, ce qui a confirmé un diagnostic d'encéphalite amibienne granulomateuse causée par Acanthamoeba spp. La patiente a reçu une polythérapie recommandée par les CDC, mais est malheureusement décédée quelques jours plus tard. À la reprise de l'analyse histopathologique, des kystes amibiens et des trophozoïtes ont été décelés dans la première biopsie cérébrale par des méthodes histochimiques et immunohistochimiques. Conclusion : Les infections par des amibes libres peuvent être difficiles à diagnostiquer en raison de leur faible incidence, de leur présentation clinique et radiologique non spécifique, de l'absence d'outils diagnostiques accessibles et de la méconnaissance des cliniciens. Ce cas renforce l'importance d'inclure les amibes libres dans les causes potentielles d'encéphalite granulomateuse, même en l'absence de facteurs de risque, car un traitement rapide a été associé à des résultats favorables dans certains rapports de cas. Lorsqu'on en soupçonne la présence, les laboratoires des CDC offrent des tests pour confirmer rapidement le diagnostic.

Alcohol use during pregnancy is a major preventable cause of adverse alcohol-related outcomes, including birth defects and developmental disabilities.* Alcohol screening and brief intervention (ASBI) is an evidence-based primary care tool that has been shown to prevent or reduce alcohol consumption during pregnancy; interventions have resulted in an increase in the proportion of pregnant women reporting abstinence (odds ratio = 2.26; 95% CI = 1.43-3.56) (1). Previous national estimates have not characterized ASBI in populations of pregnant persons. Using 2017 and 2019 Behavioral Risk Factor Surveillance System (BRFSS) data, CDC examined prevalence of ASBI and characteristics of pregnant persons and nonpregnant women aged 18-49 years (reproductive-aged women) residing in jurisdictions that participated in the BRFSS ASBI module. During their most recent health care visit within the past 2 years, approximately 80% of pregnant persons reported being asked about their alcohol use; however, only 16% of pregnant persons who self-reported current drinking at the time of the survey (at least one alcoholic beverage in the past 30 days) were advised by a health care provider to quit drinking or reduce their alcohol use. Further, the prevalence of screening among pregnant persons who did not graduate from high school was lower than that among those who did graduate from high school or had at least some college education. This gap between screening and brief intervention, along with disparities in screening based on educational level, indicate missed opportunities to reduce alcohol use during pregnancy. Strategies to enhance ASBI during pregnancy include integrating screenings into electronic health records, increasing reimbursement for ASBI services, developing additional tools, including electronic ASBI, that can be implemented in a variety of settings (2,3).

BACKGROUND: HIV/AIDS program managers in Ho Chi Minh City (HCMC), Vietnam have always relied on the police reports and the UNAIDS Estimation and Projection Package for population size estimation of People Who Inject Drugs (PWID). METHODS: We used Respondent-driven Sampling (RDS) to implement a two-source capture-recapture study to estimate the population size of PWID in HCMC in 2017. The study was implemented in seven out of 24 districts and included men and women ages 18 years and older who reported injecting illicit drugs in the last 90 days, and who had lived in the city for the past six months. Estimates of the PWID population size for each of the seven districts were calculated accounting for the RDS sampling design. These were then adjusted to account for the district sampling probabilities to give an estimate for HCMC. Chapman two-source capture-recapture estimates of population size, based on simple random sampling assumptions, were also calculated for comparison. RESULTS: The estimates resulted in a population size for HCMC of 19,155 [95% Confidence Interval (CI): 17,006-25,039] using the RDS approach and 17,947 (95% CI: 15,968-19,928), using the Chapman approach. CONCLUSION: The two-survey capture-recapture exercise provided estimates of PWID in HCMC - based on Chapman estimator and RDS approach - are similar. For planning HIV prevention and care service needs among PWID in HCMC, both estimates may need to be taken into consideration together with size estimates from other sources.

IntroductionCandida auris is an emerging multidrug-resistant yeast that has been systematically incorrectly identified by phenotypic methods in clinical microbiology laboratories. VITEK(R)2 automated identification system (bioMerieux) recently included C. auris in its database (version 8.01).Material and methodsWe evaluated the performance of VITEK(R)2 (YST ID Card) to identify C. auris and related species. A panel of 44 isolates of Candida species (C. auris, n=35; C. haemulonii, n=5; C. duobushaemulonii, n=4) were tested by three different hospital-based microbiology laboratories.ResultsAmong 35 isolates of C. auris, VITEK(R)2 yielded correct identification in an average of 52% of tested samples. Low discrimination results were obtained in an average of 27% with inability to distinguish between C. auris, C. duobushaemulonii and C. famata. Incorrect identification results were obtained in an average of 21%, the majority (91%) of which were reported as C duobushaemulonii and 9% as C. lusitaniae/C. duobushaemulonii. Proportion of correct identification was not statistically different across different centers (p=0,78). Stratification by genetic clades demonstrated that 100% (n=8) of the strains of the South American clade were correctly identified, compared to 7% (n=10) and 0% (n=4) from the African and East Asian clade respectively. None of the non-auris Candida strains (n=9) were incorrectly identified as C. aurisConclusionOur results show that VITEK(R)2 (version 8.01) yeast identification system has a limited ability to correctly identify C. auris This data suggests that an identification result for C. duobushaemulonii should warrant further testing to rule out C. auris Overall performance of VITEK(R)2 seems to differ according to C. auris genetic clade with the South American isolates yielding the most accurate result.

BACKGROUND: Enteroviruses (EV) and parechoviruses (PeV) are ubiquitous viruses that cause a range of illness, including acute illness in children aged <1 year. OBJECTIVES: We describe EV and PeV infections among children from 2 US study sites aged <1 year and hospitalized with acute infections. For EV- and PeV-negative case-patients, we explored other viral etiologies. METHODS: Participants were aged <1 year, hospitalized during 2016, and had cerebrospinal fluid (CSF) collected for routine diagnostic testing. Demographic and clinical data were abstracted from medical charts, and residual specimens were sent to CDC for confirmatory testing and typing. RESULTS: Of 472 eligible case-patients, CSF specimen was available for 319 (67.6%). Among those, 13 (4.1%) were positive for EV and 11 (3.4%) for PeV. Most case-patients (86.8%, n = 277) were aged <2 months, as were all EV- or PeV-positive case-patients. None of the positive case-patients had underlying conditions, and the chief complaint for 91.7% (n = 22) was fever. Twelve positive case-patients were admitted to intensive care (ICU) and had brief hospital stays (median 2 days). Sequencing revealed a variety of EV types and the predominance of PeV-A3 among the PeV-positive case-patients. CONCLUSIONS: A range of EV and PeV types were associated with acute febrile illnesses leading to hospitalization in children aged <2 months. Approximately half of EV and PeV case-patients were admitted to ICU, but length of hospital stay was brief and illnesses were generally self-limiting. Clinicians should consider EV and PeV infections in infants presenting with febrile illness.

BACKGROUND: There is limited population size estimation of female sex workers (FSWs) in Ho Chi Minh City (HCMC)-the largest city in Vietnam. Only 1 population size estimation among venue-based female sex workers (VFSWs) was conducted in 2012 in HCMC. Appropriate estimates of the sizes of key populations are critical for resource allocation to prevent HIV infection. OBJECTIVE: The aim of this study was to estimate the population size of the VFSWs from December 2016 to January 2017 in HCMC, Vietnam. METHODS: A multistage capture-recapture study was conducted in HCMC. The capture procedures included selection of districts using stratified probability proportion to size, mapping to identify venues, approaching all VFSWs to screen their eligibility, and then distribution of a unique object (a small pink makeup bag) to all eligible VFSWs in all identified venues. The recapture exercise included equal probability random selection of a sample of venues from the initial mapping and then approaching FSWs in those venues to determine the number and proportion of women who received the unique object. The proportion and associated confidence bounds, calculated using sampling weights and accounting for study design, were then divided by the number of objects distributed to calculate the number of VFSWs in the selected districts. This was then multiplied by the inverse of the proportion of districts selected to calculate the number of VFSWs in HCMC as a whole. RESULTS: Out of 24 districts, 6 were selected for the study. Mapping identified 573 venues across which 2317 unique objects were distributed in the first capture. During the recapture round, 103 venues were selected and 645 VFSWs were approached and interviewed. Of those, 570 VFSWs reported receiving the unique object during the capture round. Total estimated VFSWs in the 6 selected districts were 2616 (95% CI 2445-3014), accounting for the fact that only 25% (6/24) of total districts were selected gives an overall estimate of 10,465 (95% CI 9782-12,055) VFSWs in HCMC. CONCLUSIONS: The capture-recapture exercise provided an estimated number of VFSWs in HCMC. However, for planning HIV prevention and care service needs among all FSWs, studies are needed to assess the number of sex workers who are not venue-based, including those who use social media platforms to sell services.

The findings and conclusions in this article are those of the authors and do not necessarily represent the official positions of the United States Centers for Disease Control and Prevention.

Histoplasmosis is one of the most common mycoses endemic to the United States, but it was reportable in only 10 states during 2016, when a national case definition was approved. To better characterize the epidemiologic features of histoplasmosis, we analyzed deidentified surveillance data for 2011-2014 from the following 12 states: Alabama, Arkansas, Delaware, Illinois, Indiana, Kentucky, Michigan, Minnesota, Mississippi, Nebraska, Pennsylvania, and Wisconsin. We examined epidemiologic and laboratory features and calculated state-specific annual and county-specific mean annual incidence rates. A total of 3,409 cases were reported. Median patient age was 49 (interquartile range 33-61) years, 2,079 (61%) patients were male, 1,273 (57%) patients were hospitalized, and 76 (7%) patients died. Incidence rates varied markedly between and within states. The high hospitalization rate suggests that histoplasmosis surveillance underestimates the true number of cases. Improved surveillance standardization and surveillance by additional states would provide more comprehensive knowledge of histoplasmosis in the United States.

BACKGROUND: The Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist is used worldwide to drive quality improvement in laboratories in developing countries and to assess the effectiveness of interventions such as the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme. However, the paperbased format of the checklist makes administration cumbersome and limits timely analysis and communication of results. Development of e-Tool: In early 2012, the SLMTA team in Vietnam developed an electronic SLIPTA checklist tool. The e-Tool was pilot tested in Vietnam in mid-2012 and revised. It was used during SLMTA implementation in Vietnam and Cambodia in 2012 and 2013 and further revised based on auditors' feedback about usability. OUTCOMES: The SLIPTA e-Tool enabled rapid turn-around of audit results, reduced workload and language barriers and facilitated analysis of national results. Benefits of the e-Tool will be magnified with in-country scale-up of laboratory quality improvement efforts and potential expansion to other countries.

OBJECTIVES: The objective of this study was to determine the prevalence and correlates of pretreatment drug resistance (PDR) to first-line antiretroviral drugs among people initiating therapy for HIV in Vietnam. METHODS: Blood was collected during November 2009 to October 2010 from people consecutively initiating ART in four purposively selected public outpatient clinics in three Vietnamese cities. At each study site, recruitment lasted for 6-10 months until the target sample size (range 120-130 individuals) had been reached. The viral load was measured in 501 samples; 490 samples (viral load ≥1000 copies/mL) were genotyped using a nucleotide population-based sequencing assay. Self-reported demographic and clinical data were elicited through interviews. We classified drug-resistance-associated mutations (DRMs) according to the 2009 WHO surveillance list. RESULTS: DRMs were identified in 17/490 participants (3.5%; 95% CI 2.2%-5.5%). The prevalence of DRMs was 1.6% (8/490) against NRTIs, 1.6% (8/490) against NNRTIs and 0.8% (4/490) against PIs; three (0.6%) participants were resistant to both NRTIs and NNRTIs. The overall prevalence of PDR to first-line drugs was low [2.7% (13/490); 95% CI 1.6%-4.4%]. The prevalence of PDR to first-line drugs was greater among 198 HIV-infected participants who injected drugs than among 286 participants who reported risks for sexually acquired HIV (4.0% versus 1.4%, P = 0.079). Multivariable logistic regression analysis suggested that PDR to first-line drugs was significantly higher among people who injected drugs (OR = 3.94; 95% CI 1.13-13.68). CONCLUSIONS: With low PDR, first-line ART may be effective in Vietnam and pretreatment genotyping may be unnecessary. Continuing strategies for the prevention and surveillance of antiretroviral resistance are important for maintaining a low prevalence of antiretroviral resistance in Vietnam. The association between resistance and injection drug use warrants further research.

Advances in DNA sequencing technology have improved our ability to characterize most genomic diversity. However, accurate resolution of large structural events is challenging because of the short read lengths of second-generation technologies. Third-generation sequencing technologies, which can yield longer multikilobase reads, have the potential to address limitations associated with genome assembly. Here we combine sequencing data from second- and third-generation DNA sequencing technologies to assemble the two-chromosome genome of a recent Haitian cholera outbreak strain into two nearly finished contigs at >99.9% accuracy. Complex regions with clinically relevant structure were completely resolved. In separate control assemblies on experimental and simulated data for the canonical N16961 cholera reference strain, we obtained 14 scaffolds of greater than 1 kb for the experimental data and 8 scaffolds of greater than 1 kb for the simulated data, which allowed us to correct several errors in contigs assembled from the short-read data alone. This work provides a blueprint for the next generation of rapid microbial identification and full-genome assembly.

Hantaviruses are distributed throughout the United States and are the etiologic agents for hantavirus pulmonary syndrome and hemorrhagic fever with renal syndrome. Hantavirus genotypes and epidemiologic patterns vary spatially across the United States. While several longitudinal studies have been performed in the western United States, little is known about the virus in the eastern United States. We undertook a longitudinal study of hantaviruses in the primary rodent reservoir host in central Pennsylvania, Peromyscus leucopus. Prevalence of hantavirus antibodies varied both by year and site, but was not correlated with host abundance. Males were significantly more likely to have antibodies to a hantavirus than females, and both antibody sero-conversion and antibody prevalence increased with mass class (indicator for age). Our findings suggest that one or more hantaviruses are present and circulating among P. leucopus of central Pennsylvania, and understanding the dynamics in this region could help prevent zoonotic transmission to humans. Our aim was to describe the differences in epizootiology of hantavirus infection in rodents from various geographical locations to enable improved analysis of the risk of rodent-to-human transmission and obtain insights that may indicate improved means of disease intervention.