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%.

Importance: There are limited data describing SARS-CoV-2-specific immune responses and their durability following infection and vaccination in nursing home residents. Objective(s): To evaluate the quantitative titers and durability of binding antibodies detected after SARSCoV-2 infection and subsequent COVID-19 vaccination. Design(s): A prospective longitudinal evaluation included nine visits over 150 days; visits included questionnaire administration, blood collection for serology, and paired anterior nasal specimen collection for testing by BinaxNOWTM COVID-19 Ag Card (BinaxNOW), reverse transcription polymerase chain reaction (RT-PCR), and viral culture. Setting(s): A nursing home during and after a SARS-CoV-2 outbreak. Participant(s): 11 consenting SARS-CoV-2-positive nursing home residents. Main Outcomes and Measures: SARS-CoV-2 testing (BinaxNOWTM, RT-PCR, viral culture); quantitative titers of binding SARS-CoV-2 antibodies post-infection and post-vaccination (beginning after the first dose of the primary series). Result(s): Of 10 participants with post-infection serology results, 9 (90%) had detectable Pan-Ig, IgG, and IgA antibodies and 8 (80%) had detectable IgM antibodies. At first antibody detection post-infection, two-thirds (6/9, 67%) of participants were RT-PCR-positive but none were culture positive. Ten participants received vaccination; all had detectable Pan-Ig, IgG, and IgA antibodies through their final observation <=90 days post-first dose. Post-vaccination geometric means of IgG titers were 10-200-fold higher than post-infection. Conclusions and Relevance: Nursing home residents in this cohort mounted robust immune responses to SARS-CoV-2 post-infection and post-vaccination. The augmented antibody responses post-vaccination are potential indicators of enhanced protection that vaccination may confer on previously infected nursing home residents. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license.

PROBLEM/CONDITION: Each year, state and local public health departments report hundreds of foodborne illness outbreaks associated with retail food establishments (e.g., restaurants or caterers) to CDC. Typically, investigations involve epidemiology, laboratory, and environmental health components. Health departments voluntarily report epidemiologic and laboratory data from their foodborne illness outbreak investigations to CDC through the National Outbreak Reporting System (NORS); however, minimal environmental health data from outbreak investigations are reported to NORS. This report summarizes environmental health data collected during outbreak investigations and reported to the National Environmental Assessment Reporting System (NEARS). PERIOD COVERED: 2017-2019. DESCRIPTION OF SYSTEM: In 2014, CDC launched NEARS to complement NORS surveillance and to use these data to enhance prevention efforts. State and local health departments voluntarily enter data from their foodborne illness outbreak investigations of retail food establishments into NEARS. These data include characteristics of foodborne illness outbreaks (e.g., etiologic agent and factors contributing to the outbreak), characteristics of establishments with outbreaks (e.g., number of meals served daily), and food safety policies in these establishments (e.g., ill worker policy requirements). NEARS is the only available data source that collects environmental characteristics of retail establishments with foodborne illness outbreaks. RESULTS: During 2017-2019, a total of 800 foodborne illness outbreaks associated with 875 retail food establishments were reported to NEARS by 25 state and local health departments. Among outbreaks with a confirmed or suspected agent (555 of 800 [69.4%]), the most common pathogens were norovirus and Salmonella, accounting for 47.0% and 18.6% of outbreaks, respectively. Contributing factors were identified in 62.5% of outbreaks. Approximately 40% of outbreaks with identified contributing factors had at least one reported factor associated with food contamination by an ill or infectious food worker. Investigators conducted an interview with an establishment manager in 679 (84.9%) outbreaks. Of the 725 managers interviewed, most (91.7%) said their establishment had a policy requiring food workers to notify their manager when they were ill, and 66.0% also said these policies were written. Only 23.0% said their policy listed all five illness symptoms workers needed to notify managers about (i.e., vomiting, diarrhea, jaundice, sore throat with fever, and lesion with pus). Most (85.5%) said that their establishment had a policy restricting or excluding ill workers from working, and 62.4% said these policies were written. Only 17.8% said their policy listed all five illness symptoms that would require restriction or exclusion from work. Only 16.1% of establishments with outbreaks had policies addressing all four components relating to ill or infectious workers (i.e., policy requires workers to notify a manager when they are ill, policy specifies all five illness symptoms workers need to notify managers about, policy restricts or excludes ill workers from working, and policy specifies all five illness symptoms requiring restriction or exclusion from work). INTERPRETATION: Norovirus was the most commonly identified cause of outbreaks reported to NEARS, and contamination of food by ill or infectious food workers contributed to approximately 40% of outbreaks with identified contributing factors. These findings are consistent with findings from other national outbreak data sets and highlight the role of ill workers in foodborne illness outbreaks. Although a majority of managers reported their establishment had an ill worker policy, often these policies were missing components intended to reduce foodborne illness risk. Contamination of food by ill or infectious food workers is an important cause of outbreaks; therefore, the content and enforcement of existing policies might need to be re-examined and refined. PUBLIC HEALTH ACTION: Retail food establishments can reduce viral foodborne illness outbreaks by protecting food from contamination through proper hand hygiene and excluding ill or infectious workers from working. Development and implementation of policies that prevent contamination of food by workers are important to foodborne outbreak reduction. NEARS data can help identify gaps in food safety policies and practices, particularly those concerning ill workers. Future analyses of stratified data linking specific outbreak agents and foods with outbreak contributing factors can help guide the development of effective prevention approaches by describing how establishments' characteristics and food safety policies and practices relate to foodborne illness outbreaks.

A poor food safety culture has been described as an emerging risk factor for foodborne illness outbreaks, yet there has been little research on this topic in the retail food industry. The purpose of this study was to identify and validate conceptual domains around food safety culture and develop an assessment tool that can be used to assess food workers' perceptions of their restaurant's food safety culture. The study, conducted from March 2018 through March 2019, surveyed restaurant food workers for their level of agreement with 28 statements. We received 579 responses from 331 restaurants spread across eight different health department jurisdictions. Factor analysis and structural equation modeling supported a model composed of four primary constructs. The highest rated construct was Resource Availability (x¯=4.69, sd=0.57), which assessed the availability of resources to maintain good hand hygiene. The second highest rated construct was Employee Commitment (x¯=4.49, sd=0.62), which assessed workers' perceptions of their coworkers' commitment to food safety. The last two constructs were related to management. Leadership (x¯=4.28, sd=0.69) assessed the existence of food safety policies, training, and information sharing. Management Commitment (x¯=3.94, sd=1.05) assessed whether food safety was a priority in practice. Finally, the model revealed one higher-order construct, Worker Beliefs about Food Safety Culture (x¯=4.35, sd=0.53). The findings from this study can support efforts by the restaurant industry, food safety researchers, and health departments to examine the influence and effects of food safety culture within restaurants.

There are limited data describing SARS-CoV-2-specific immune responses and their durability following infection and vaccination in nursing home residents. We conducted a prospective longitudinal evaluation of 11 consenting SARS-CoV-2-positive nursing home residents to evaluate the quantitative titers and durability of binding antibodies detected after SARS-CoV-2 infection and subsequent COVID-19 vaccination. The evaluation included nine visits over 150 days from October 25, 2020, through April 1, 2021. Visits included questionnaire administration, blood collection for serology, and paired anterior nasal specimen collection for testing by BinaxNOW™ COVID-19 Ag Card (BinaxNOW), reverse transcription polymerase chain reaction (RT-PCR), and viral culture. We evaluated quantitative titers of binding SARS-CoV-2 antibodies post-infection and post-vaccination (beginning after the first dose of the primary series). The median age among participants was 74 years; one participant was immunocompromised. Of 10 participants with post-infection serology results, 9 (90%) had detectable Pan-Ig, IgG, and IgA antibodies, and 8 (80%) had detectable IgM antibodies. At first antibody detection post-infection, two-thirds (6/9, 67%) of participants were RT-PCR-positive, but none were culture- positive. Ten participants received vaccination; all had detectable Pan-Ig, IgG, and IgA antibodies through their final observation ≤90 days post-first dose. Post-vaccination geometric means of IgG titers were 10-200-fold higher than post-infection. Nursing home residents in this cohort mounted robust immune responses to SARS-CoV-2 post-infection and post-vaccination. The augmented antibody responses post-vaccination are potential indicators of enhanced protection that vaccination may confer on previously infected nursing home residents.

Repeated antigen testing of 12 SARS-CoV-2-positive nursing home residents using Abbott BinaxNOW™ identified 9/9 (100%) culture-positive specimens up to 6 days after initial positive test. Antigen positivity lasted 2-24 days. Antigen positivity might last beyond the infectious period, but was reliable in residents with evidence of early infection.

Ehrlichiosis has been infrequently described as transmissible through organ transplantation. Two donor derived clusters of ehrlichiosis are described here. During the summer of 2020, two cases of ehrlichiosis were reported to the Organ Procurement and Transplantation Network (OPTN) and the Centers for Disease Control and Prevention (CDC) for investigation. Additional transplant centers were contacted to investigate similar illness in other recipients and samples were sent to CDC. Two kidney recipients from a common donor developed fatal ehrlichiosis-induced hemophagocytic lymphocytic histiocytosis (HLH). Two kidney recipients and a liver recipient from another common donor developed ehrlichiosis. All three were successfully treated. Clinicians should consider donor-derived ehrlichiosis when evaluating recipients with fever early after transplantation after more common causes are ruled out, especially if the donor has epidemiological risk factors for infection. Suspected cases should be reported to the organ procurement organization (OPO) and the OPTN for further investigation by public health authorities.

BACKGROUND: To address high COVID-19 burden in U.S. nursing homes, rapid SARS-CoV-2 antigen tests have been widely distributed in those facilities. However, performance data are lacking, especially in asymptomatic people. OBJECTIVE: To evaluate the performance of SARS-CoV-2 antigen testing when used for facility-wide testing during a nursing home outbreak. DESIGN: A prospective evaluation involving 3 facility-wide rounds of testing where paired respiratory specimens were collected to evaluate the performance of the BinaxNOW antigen test compared with virus culture and real-time reverse transcription polymerase chain reaction (RT-PCR). Early and late infection were defined using changes in RT-PCR cycle threshold values and prior test results. SETTING: A nursing home with an ongoing SARS-CoV-2 outbreak. PARTICIPANTS: 532 paired specimens collected from 234 available residents and staff. MEASUREMENTS: Percentage of positive agreement (PPA) and percentage of negative agreement (PNA) for BinaxNOW compared with RT-PCR and virus culture. RESULTS: BinaxNOW PPA with virus culture, used for detection of replication-competent virus, was 95%. However, the overall PPA of antigen testing with RT-PCR was 69%, and PNA was 98%. When only the first positive test result was analyzed for each participant, PPA of antigen testing with RT-PCR was 82% among 45 symptomatic people and 52% among 343 asymptomatic people. Compared with RT-PCR and virus culture, the BinaxNOW test performed well in early infection (86% and 95%, respectively) and poorly in late infection (51% and no recovered virus, respectively). LIMITATION: Accurate symptom ascertainment was challenging in nursing home residents; test performance may not be representative of testing done by nonlaboratory staff. CONCLUSION: Despite lower positive agreement compared with RT-PCR, antigen test positivity had higher agreement with shedding of replication-competent virus. These results suggest that antigen testing could be a useful tool to rapidly identify contagious people at risk for transmitting SARS-CoV-2 during nascent outbreaks and help reduce COVID-19 burden in nursing homes. PRIMARY FUNDING SOURCE: None.

BACKGROUND: As of January 7, 2020, a total of 2558 hospitalized patients with nonfatal cases and 60 patients with fatal cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) had been reported to the Centers for Disease Control and Prevention (CDC). METHODS: In a national study, we compared the characteristics of patients with fatal cases of EVALI with those of patients with nonfatal cases to improve the ability of clinicians to identify patients at increased risk for death from the condition. Health departments reported cases of EVALI to the CDC and included, when available, data from medical-record abstractions and patient interviews. Analyses included all the patients with fatal or nonfatal cases of EVALI that were reported to the CDC as of January 7, 2020. We also present three case reports of patients who died from EVALI to illustrate the clinical characteristics common among such patients. RESULTS: Most of the patients with fatal or nonfatal cases of EVALI were male (32 of 60 [53%] and 1666 of 2498 [67%], respectively). The proportion of patients with fatal or nonfatal cases was higher among those who were non-Hispanic white (39 of 49 [80%] and 1104 of 1818 [61%], respectively) than among those in other race or ethnic groups. The proportion of patients with fatal cases was higher among those 35 years of age or older (44 of 60 [73%]) than among those younger than 35 years, but the proportion with nonfatal cases was lower among those 35 years of age or older (551 of 2514 [22%]). Among the patients who had an available medical history, a higher proportion of those with fatal cases than those with nonfatal cases had a history of asthma (13 of 57 [23%] vs. 102 of 1297 [8%]), cardiac disease (26 of 55 [47%] vs. 115 of 1169 [10%]), or a mental health condition (32 of 49 [65%] vs. 575 of 1398 [41%]). A total of 26 of 50 patients (52%) with fatal cases had obesity. Half the patients with fatal cases (25 of 54 [46%]) were seen in an outpatient setting before hospitalization or death. CONCLUSIONS: Chronic conditions, including cardiac and respiratory diseases and mental health conditions, were common among hospitalized patients with EVALI.

CDC, the Food and Drug Administration, state and local health departments, and other public health and clinical stakeholders are investigating a national outbreak of electronic-cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) (1). As of October 22, 2019, 49 states, the District of Columbia (DC), and the U.S. Virgin Islands have reported 1,604 cases of EVALI to CDC, including 34 (2.1%) EVALI-associated deaths in 24 states. Based on data collected as of October 15, 2019, this report updates data on patient characteristics and substances used in e-cigarette, or vaping, products (2) and describes characteristics of EVALI-associated deaths. The median age of EVALI patients who survived was 23 years, and the median age of EVALI patients who died was 45 years. Among 867 (54%) EVALI patients with available data on use of specific e-cigarette, or vaping, products in the 3 months preceding symptom onset, 86% reported any use of tetrahydrocannabinol (THC)-containing products, 64% reported any use of nicotine-containing products, and 52% reported use of both. Exclusive use of THC-containing products was reported by 34% of patients and exclusive use of nicotine-containing products by 11%, and for 2% of patients, no use of either THC- or nicotine-containing products was reported. Among 19 EVALI patients who died and for whom substance use data were available, 84% reported any use of THC-containing products, including 63% who reported exclusive use of THC-containing products; 37% reported any use of nicotine-containing products, including 16% who reported exclusive use of nicotine-containing products. To date, no single compound or ingredient used in e-cigarette, or vaping, products has emerged as the cause of EVALI, and there might be more than one cause. Because most patients reported using THC-containing products before symptom onset, CDC recommends that persons should not use e-cigarette, or vaping, products that contain THC. In addition, because the specific compound or ingredient causing lung injury is not yet known, and while the investigation continues, persons should consider refraining from the use of all e-cigarette, or vaping, products.

Forty-nine states, the District of Columbia, and one U.S. territory have reported 1,299 cases of lung injury associated with the use of electronic cigarette (e-cigarette), or vaping, products. Twenty-six deaths have been reported from 21 states. Based on the most current data, CDC's updated interim guidance provides a framework for health care providers in their initial assessment, evaluation, management, and follow-up of persons with symptoms of e-cigarette, or vaping, product use associated lung injury (EVALI). Rapid recognition by health care providers of patients with EVALI and an increased understanding of treatment considerations could reduce morbidity and mortality associated with this injury.

During March-July 2018, the Illinois Department of Public Health responded to an acute outbreak of severe coagulopathy among patients with recent synthetic cannabinoid use. Toxicological testing indicated that cases were exposed to brodifacoum, a long-acting anticoagulant rodenticide. A total of 174 confirmed and probable cases, including 5 deaths, were linked to this outbreak. On the basis of the experience of responding to this complex outbreak, we recommend several steps for consideration to improve health department preparation for acute outbreaks involving illicit substances including strengthening communication between public health and law enforcement agencies, reviewing legal authority to investigate noninfectious acute disease outbreaks, continuing strong partnerships with state poison control centers, partnering with substance abuse and mental health agencies to provide services to patients, and determining health department ability to rapidly enter into public-private partnership agreements.

Synthetic cannabinoids, also known as K2 and spice, are heterogeneous psychoactive compounds identified as substances of abuse (1,2). On March 22, 2018, the Illinois Department of Public Health was notified by the Illinois Poison Center of four patients seen in emergency departments (EDs) during the preceding 2 weeks with unexplained bleeding and high international normalized ratios (INRs; range from 5 to >20 [normal <1.1]), indicating a clotting disorder, and reported synthetic cannabinoid use during the previous 3 days. None reported taking prescription anticoagulants or exposure to anticoagulant rodenticides. An investigation by the Illinois Department of Public Health, the Illinois Poison Center, CDC, local health departments, and law enforcement agencies was initiated to identify additional cases, ascertain epidemiologic links among patients, and implement control measures.

Questions concerning longitudinal data quality and reproducibility of proteomic laboratories spurred the Protein Research Group of the Association of Biomolecular Resource Facilities (ABRF-PRG) to design a study to systematically assess the reproducibility of proteomic laboratories over an extended period of time. Developed as an open study, initially 64 participants were recruited from the broader mass spectrometry community to analyse provided aliquots of a 6 bovine protein tryptic digest mixture every month for a period of nine months. Data were uploaded to a central repository, and the operators answered an accompanying survey. Ultimately, 45 laboratories submitted a minimum of 8 LC-MSMS raw data files collected in data-dependent acquisition (DDA) mode. No standard operating procedures were enforced; rather the participants were encouraged to analyse the samples according to usual practices in the laboratory. Unlike previous studies, this investigation was not designed to compare laboratories or instrument configuration, but rather to assess the temporal intra-laboratory reproducibility. The outcome of the study was reassuring with 80% of the participating laboratories performing analyses at a medium to high level of reproducibility and quality over the 9 month period. For the groups that had one or more outlying experiments, the major contributing factor that correlated to the survey data was the performance of preventative maintenance prior to the LC-MSMS analyses. Thus, the ABRF-PRG recommends that laboratories closely scrutinise the quality control data following such events. Additionally, improved quality control recording is imperative. This longitudinal study provides evidence that mass spectrometry-based proteomics is reproducible. When quality control measures are strictly adhered to, such reproducibility is comparable amongst many disparate groups. Data from the study are available via ProteomeXchange under the accession code PXD002114.

OBJECTIVES: To examine reductions in diarrhea-associated health care utilization after rotavirus vaccine implementation and to assess direct and indirect effectiveness of vaccination. METHODS: Retrospective cohort analysis of claims data of commercially insured US children aged <5 years. We examined annual pentavalent (RV5) and monovalent (RV1) rotavirus vaccine coverage. We compared rates of diarrhea-associated health care utilization in prevaccine (2001-2006) versus postvaccine introduction (2007-2011) years, compared rates of diarrhea-associated health care utilization in vaccinated versus unvaccinated children and compared rates in unvaccinated children in postvaccine versus prevaccine years. RESULTS: Among children aged <5 years, RV5 and RV1 rotavirus vaccine coverage rates reached 58% and 5%, respectively, by December 31, 2010. Compared with the average rate of rotavirus-coded hospitalizations in 2001-2006, rates were reduced by 75% in 2007-2008, 60% in 2008-2009, 94% in 2009-2010, and 80% in 2010-2011. Compared with unvaccinated children, in 2010-2011, the rate of rotavirus-coded hospitalizations was reduced by 92% among RV5 recipients and 96% among RV1 recipients. Rotavirus-coded hospitalization rate reductions among RV5 recipients versus unvaccinated children ranged from 87% among <1-year-olds to 81% among 4-year-olds. Compared with prevaccine rates in 2001-2006, rotavirus-coded hospitalization rates among unvaccinated children decreased by 50% in 2007-2008, 77% in 2009-2010, and 25% in 2010-2011. CONCLUSIONS: Implementation of rotavirus vaccines has substantially reduced diarrhea health care utilization in US children. Both rotavirus vaccines conferred high protection against rotavirus hospitalizations; RV5 conferred durable protection through the fourth year of life. Vaccination also conferred indirect benefits to unvaccinated children.

BACKGROUND: Survival of blood transfusion recipients is a critical consideration in assessing the outcomes of transfusion. Data from the USA on the short- and long-term survival of recipients are limited. MATERIALS AND METHODS: Blood product recipients were identified through a look-back study of Creutzfeldt-Jakob disease. Survival data were obtained from searches of the National Death Index or the Social Security Death Master File. Short- and long-term survival of recipients was analysed through descriptive statistics, Kaplan-Meier survival analysis, and stratified Cox proportional hazard modelling. RESULTS: This study includes data from 575 blood product recipients. One half of the recipients died within the first year of transfusion and the median time to death was 1.1 years. Survival rates at 5, 10, 15, 20, and 25 years after transfusion were 32%, 22%, 15%, 12%, and 9%, respectively. Survival rates varied with age at transfusion and type of component received, but not by gender. Survival after transfusion varied by year of transfusion, with recipients transfused in 1980-1989 having longer post-transfusion survival than those transfused in 2000-2010 (p=0.049). In multivariate models, the type of component transfused, but not the year of transfusion, was a significant predictor of survival among recipients; this effect varied by age. DISCUSSION: We provide an estimate of survival time from a geographically diverse sample of blood product recipients in the USA. Predictors of post-transfusion survival are numerous and complex, and may include year of transfusion and type of component transfused.

Resource (core) facilities have played an ever-increasing role in furnishing the scientific community with specialized instrumentation and expertise for proteomics experiments in a cost-effective manner. The Proteomics Research Group (PRG) of the Association of Biomolecular Resource Facilities (ABRF) has sponsored a number of research studies designed to enable participants to try new techniques and assess their capabilities relative to other laboratories analyzing the same samples. Presented here are results from three PRG studies representing different samples that are typically analyzed in a core facility, ranging from simple protein identification to targeted analyses, and include intentional challenges to reflect realistic studies. The PRG2008 study compares different strategies for the qualitative characterization of proteins, particularly the utility of complementary methods for characterizing truncated protein forms. The use of different approaches for determining quantitative differences for several target proteins in human plasma was the focus of the PRG2009 study. The PRG2010 study explored different methods for determining specific constituents while identifying unforeseen problems that could account for unanticipated results associated with the different samples, and included (15) N-labeled proteins as an additional challenge. These studies provide a valuable educational resource to research laboratories and core facilities, as well as a mechanism for establishing good laboratory practices.