In late August and early September of 2017, Hurricanes Harvey and Irma swept through the Caribbean and made landfall in the continental United States. As Texas and Florida readied for direct impacts of the storms, nearby states prepared for the arrival of internally displaced persons. During the weeks surrounding the storms, the Tennessee Department of Health (TDH) supported all-hazards situational awareness for public health partners by enhancing syndromic surveillance activities, i.e., the monitoring of symptom combinations or other indicators within a population to inform public health action (1). | | TDH collects and analyzes emergency department (ED) data from 70 hospitals across Tennessee using the Electronic Surveillance System for Early Notification of Community-Based Epidemics (ESSENCE) (2). ESSENCE is a tool in the BioSense Platform made available to public health jurisdictions through CDC’s National Syndromic Surveillance Program (NSSP) (3). Syndromic surveillance typically supplements disease- or condition-specific surveillance; however, it can also improve situational awareness during an event or disaster.

CONTEXT: In the United States, state laws require health care providers to report specific diseases and events to public health authorities, a fundamental facet of disease surveillance. However, reporting by providers is often inconsistent, infrequent, and delayed. OBJECTIVE: To examine knowledge, attitudes, and practices regarding provider disease reporting and to understand current barriers to provider disease reporting. DESIGN: A cross-sectional study was conducted via an anonymous, standardized electronic survey. SETTING: The survey was conducted at Vanderbilt University Medical Center, a large, tertiary academic medical center in Nashville, Tennessee. PARTICIPANTS: Health care providers in 4 specialties (internal medicine, pediatrics, obstetrics-gynecology, and emergency medicine). MAIN OUTCOME MEASURE(S): Knowledge of and attitudes regarding provider reporting of diseases to public health authorities in Tennessee. RESULTS: The majority of providers acknowledged they cared for patients with reportable diseases (362/435, 83.2%) and believed that it was their responsibility to report to public health authorities (429/436, 98.4%); however, less than half had ever reported a case (206/436, 47.2%). The median percent correct on the knowledge assessment of Tennessee reportable diseases and conditions was 81.3% (interquartile range = 68.8-87.5). Providers cited a lack of knowledge of which diseases are reportable (186/429, 43.3%) and the logistics of reporting (153/429, 35.7%) as the primary barriers for compliance. CONCLUSION: Most providers acknowledged they cared for patients with reportable diseases and believed they had an obligation to report to public health authorities. However, a lack of knowledge about reporting was frequently described as a limitation to report effectively. Many knowledge deficits were significantly greater among residents than other providers. IMPLICATIONS FOR POLICY & PRACTICE: The policy and practice implications of these findings include a demonstrated need for education of providers about disease reporting as well as development of more convenient reporting mechanisms. Fundamental knowledge of reportable disease requirements and procedures is critical for participation in the broader public health system.

On April 15, 2016, local public health officials in Shelby County, Tennessee, were notified of a positive measles immunoglobulin M (IgM) test for a male aged 18 months (patient A). On April 18, 2016, a second positive measles IgM test was reported for a man aged 50 years (patient B). Both patients had rash onset on April 9, 2016. The Shelby County Health Department initiated an investigation, and confirmatory testing for measles virus on oropharyngeal swabs by polymerase chain reaction (PCR) at CDC was positive for both patients. On April 21, 2016, public health officials were notified of a third suspected measles case in a female aged 7 months (patient C) who had developed a rash on April 14; PCR testing was positive. Genotyping conducted at CDC identified genotype B3 measles virus in all three cases. Genotype B3 is known to be circulating globally and has previously been associated with imported cases in the United States.

We describe multidrug-resistant (MDR) Salmonella Heidelberg infections associated with mechanically separated chicken (MSC) served at a county correctional facility. Twenty-three inmates met the case definition. All reported diarrhea, 19 (83%) reported fever, 16 (70%) reported vomiting, 4 (17%) had fever ≥103 degrees F, and 3 (13%) were hospitalized. A case-control study found no single food item significantly associated with illness. Salmonella Heidelberg with an indistinguishable pulsed-field gel electrophoresis pattern was isolated from nine stool specimens; two isolates displayed resistance to a total of five drug classes, including the third-generation cephalosporin, ceftriaxone. MDR Salmonella Heidelberg might have contributed to the severity of illness. Salmonella Heidelberg indistinguishable from the outbreak subtype was isolated from unopened MSC. The environmental health assessment identified cross-contamination through poor food-handling practices as a possible contributing factor. Proper hand-washing techniques and safe food-handling practices were reviewed with the kitchen supervisor.

Because of widespread distribution of the influenza A (H1N1) 2009 monovalent vaccine (pH1N1 vaccine) and the prior association between Guillain-Barre syndrome (GBS) and the 1976 H1N1 influenza vaccine, enhanced surveillance was implemented to estimate the magnitude of any increased GBS risk following administration of pH1N1 vaccine. The authors conducted active, population-based surveillance for incident cases of GBS among 45 million persons residing at 10 Emerging Infections Program sites during October 2009-May 2010; GBS was defined according to published criteria. The authors determined medical and vaccine history for GBS cases through medical record review and patient interviews. The authors used vaccine coverage data to estimate person-time exposed and unexposed to pH1N1 vaccine and calculated age- and sex-adjusted rate ratios comparing GBS incidence in these groups, as well as age- and sex-adjusted numbers of excess GBS cases. The authors received 411 reports of confirmed or probable GBS. The rate of GBS immediately following pH1N1 vaccination was 57% higher than in person-time unexposed to vaccine (adjusted rate ratio = 1.57, 95% confidence interval: 1.02, 2.21), corresponding to 0.74 excess GBS cases per million pH1N1 vaccine doses (95% confidence interval: 0.04, 1.56). This excess risk was much smaller than that observed during the 1976 vaccine campaign and was comparable to some previous seasonal influenza vaccine risk assessments.

BACKGROUND: A mean of ≥1000 foodborne disease outbreaks (FBDOs) causing ≥20 000 illnesses are reported to the Centers for Disease Control and Prevention (CDC) annually. We evaluated characteristics of successful outbreak investigations (ie, those that identified an etiologic agent or food vehicle) in the Foodborne Diseases Active Surveillance Network (FoodNet). METHODS: FBDOs were defined as the occurrence of ≥2 cases of a similar illness resulting from ingestion of a common food. FBDOs reported to CDC Foodborne Disease Outbreak Surveillance System during 2003-2008 with FoodNet supplemental data available were included in the analyses. RESULTS: Data regarding 1200 FBDOs were available. An etiologic agent was confirmed in 715 (60%); a food vehicle was identified in 387 (32%). At least 4 fecal specimens were collected in 425 of 639 outbreaks (67%) with a confirmed etiologic agent and 48 of 232 (21%) without a confirmed etiologic agent (odds ratio [OR], 7.6; 95% confidence interval [CI], 5.3-10.9). A food vehicle was identified in 314 (47%) of 671 outbreaks investigated using a case-control or cohort study, compared with only 73 (14%) of 529 outbreaks investigated by using other methods (OR, 5.5; 95% CI, 4.1-7.3). At least 1 barrier affecting the success of the investigation was reported for 655 outbreaks, including too few patients (n = 172; 26%), too few stool specimens (n = 167; 25%), and too few control subjects (n = 152; 23%). CONCLUSINS: Etiologic agent and vehicle are frequently undetermined in FBDOs. Greater emphasis on fecal specimen collection and overcoming barriers to pursuing analytic epidemiologic studies can improve ascertainment of these factors.

We evaluated the validity of single versus paired serologic testing for La Crosse virus (LACV) encephalitis surveillance. Compared with paired serology, a single positive IgG or IgM immunoflourescent antibody titre appears useful for LACV encephalitis surveillance with sensitivity, 75%; specificity, 98%; positive predictive value, 95%; and overall test efficiency 92%.

In 2009, the Tennessee Department of Health received reports of 5 tuberculin skin test (TST) conversions among employees of an elephant refuge and isolation of Mycobacterium tuberculosis from a resident elephant. To determine the extent of the outbreak and identify risk factors for TST conversion, we conducted a cohort study and onsite assessment. Risk for conversion was increased for elephant caregivers and administrative employees working in the barn housing the M. tuberculosis-infected elephant or in offices connected to the barn (risk ratio 20.3, 95% confidence interval 2.8-146.7). Indirect exposure to aerosolized M. tuberculosis and delayed or inadequate infection control practices likely contributed to transmission. The following factors are needed to reduce risk for M. tuberculosis transmission in the captive elephant industry: increased knowledge about M. tuberculosis infection in elephants, improved infection control practices, and specific occupational health programs.