Lagomorphs-principally rabbits and hares-have been implicated as hosts for vectors and reservoirs for pathogens associated with multiple rickettsial diseases. Western North America is home to diverse rickettsial pathogens which circulate among multiple wild and domestic hosts and tick and flea vectors. The purpose of this study was to assess lagomorphs and their ectoparasites in 2 locations in northern Baja California, Mexico, for exposure to and infection with rickettsial organisms. In total, 55 desert cottontail rabbits (Sylvilagus audubonii) (Baird) and 2 black-tailed jackrabbits (Lepus californicus) (Gray) were captured. In Mexicali, ticks were collected from 44% (14/32) of individuals, and were exclusively Haemaphysalis leporispalustris Neumann (Acari: Ixodidae); in Ensenada, ticks were collected from 70% (16/23) individuals, and 95% were Dermacentor parumapertus. Euhoplopsyllus glacialis affinis Baker (Siphonaptera: Pulicidae) fleas were collected from 72% of rabbits and 1 jackrabbit from Mexicali, while the few fleas found on hosts in Ensenada were Echidnophaga gallinacea Westwood (Siphonaptera: Pulicidae) and Cediopsylla inaequalis (Siphonaptera: Pulicidae). Rickettsia bellii was the only rickettsial organism detected and was identified in 88% of D. parumapertus and 67% of H. leporispalustris ticks from Ensenada. A single tissue sample from a jackrabbit was positive for R. belli (Rickettsiales: Rickettsiaceae). Hosts in Ensenada had a significantly higher prevalence of rickettsial antibodies than hosts in Mexicali (52.3% vs. 21.4%). Although R. bellii is not regarded as pathogenic in humans or other mammals, it may contribute to immunity to other rickettsiae. The marked difference in distribution of ticks, fleas, and rickettsial exposure between the 2 locations suggests that disease transmission risk may vary markedly between communities within the same region.

OBJECTIVES: Although many people who are incarcerated have risk factors for hepatitis A virus (HAV) infection, the proportion of hepatitis A cases among people with a recent incarceration is unknown. We examined the relationship between recent incarceration and HAV infection during community-based, person-to-person outbreaks to inform public health recommendations. METHODS: The Centers for Disease Control and Prevention surveyed health departments in 33 jurisdictions reporting person-to-person HAV outbreaks during 2016-2020 on the number of outbreak-associated cases, HAV-infected people recently incarcerated, and HAV-associated hospitalizations and deaths. RESULTS: Twenty-five health departments reported 18 327 outbreak-associated hepatitis A cases during January 11, 2016-January 24, 2020. In total, 2093 (11.4%) HAV-infected people had been recently incarcerated. Of those with complete data, 1402 of 1462 (95.9%) had been held in a local jail, and 1513 of 1896 (79.8.%) disclosed hepatitis A risk factors. Eighteen jurisdictions reported incarceration timing relative to the exposure period. Of 9707 cases in these jurisdictions, 991 (10.2%) were among recently incarcerated people; 451 of 688 (65.6%) people with complete data had been incarcerated during all (n = 55) or part (n = 396) of their exposure period. CONCLUSIONS: Correctional facilities are important settings for reaching people with risk factors for HAV infection and can also be venues where transmission occurs. Providing HAV vaccination to incarcerated people, particularly people housed in jails, can be an effective component of community-wide outbreak response.

OBJECTIVES: Sixty-four state, local, and territorial health departments (HDs) in the United States (US) report monthly performance metrics on COVID-19 case investigation and contact tracing (CI/CT) activities. We describe national CI/CT efforts during October 25, 2020-December 24, 2021 which included three peaks in COVID-19 case reporting. METHODS: Standardized CI/CT data elements submitted by the 64 HDs were summarized as monthly performance metrics for each HD and the nation. These included measures of CI/CT completeness, timeliness, and workloads. We calculated contact tracing efficacy as the proportion of new cases that occurred in persons identified as contacts within the 14 days prior to being reported as a case. RESULTS: A total of 44,309,796 COVID-19 cases were reported to HDs, of which 18,153,353 (41%) completed HD interviews. Less than half of interviews yielded 1 contact. A total of 19,939,376 contacts were identified; 11,632,613 were notified (58%), with 3,618,846 undergoing SARS-CoV-2 testing within 14 days of notification. Of the total reported cases, 2,559,383 occurred in recently identified contacts. CONCLUSION: We document the resource-intense nationwide effort by US HDs to mitigate the impact of COVID-19 through CI/CT before and after vaccines became widely available. These results document the coverage and performance of CI/CT despite case surges and fluctuating workforce and workloads.

Case investigation and contact tracing are core public health tools used to interrupt transmission of pathogens, including SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19); timeliness is critical to effectiveness (1,2). In May 2020, CDC funded* 64 state, local, and territorial health departments(†) to support COVID-19 response activities. As part of the monitoring process, case investigation and contact tracing metrics for June 25-July 24, 2020, were submitted to CDC by 62 health departments. Descriptive analyses of case investigation and contact tracing load, timeliness, and yield (i.e., the number of contacts elicited divided by the number of patients prioritized for interview) were performed. A median of 57% of patients were interviewed within 24 hours of report of the case to a health department (interquartile range [IQR] = 27%-82%); a median of 1.15 contacts were identified per patient prioritized for interview(§) (IQR = 0.62-1.76), and a median of 55% of contacts were notified within 24 hours of identification by a patient (IQR = 32%-79%). With higher caseloads, the percentage of patients interviewed within 24 hours of case report was lower (Spearman coefficient = -0.68), and the number of contacts identified per patient prioritized for interview also decreased (Spearman coefficient = -0.60). The capacity to conduct timely contact tracing varied among health departments, largely driven by investigators' caseloads. Incomplete identification of contacts affects the ability to reduce transmission of SARS-CoV-2. Enhanced staffing capacity and ability and improved community engagement could lead to more timely interviews and identification of more contacts.

In November 2019, the Southern Nevada Public Health Laboratory of the Southern Nevada Health District (SNHD) identified a male urethral gonococcal isolate later demonstrating reduced susceptibility to cefixime (minimum inhibitory concentration [MIC] = 2.0 μg/mL) and ceftriaxone (MIC = 1.0 μg/mL) but susceptible to azithromycin (MIC = 0.25 μg/mL). Molecular testing by CDC in the United States revealed the emerging mosaic penA60 allele, first identified in Japan in 2016 (1), which confers reduced susceptibility to cephalosporins and increases the risk for treatment failure. The penA60 allele has been identified in China (2), Canada (3,4), Denmark (5), Australia (6), France (7), and the United Kingdom (8). The Nevada case is the first identified case of a Neisseria gonorrhoeae isolate harboring the mosaic penA60 allele reported in the United States.

The 2014 Ebola outbreak revealed biosafety vulnerabilities across the United States. We distributed $24.1 million to health departments to support public health laboratories (PHLs) and sentinel clinical laboratory partners to improve biosafety practices. We used 9 indicators to evaluate PHLs and associated clinical laboratories from March 2015 through April 2018 using descriptive statistics. On average, over 6 reporting periods, 59 awardee PHLs and 4,040 clinical laboratories responded. By April 2018, 92% (57 of 62) of PHLs had conducted at least 1 risk assessment for work with Ebola and another highly infectious disease. The number of PHLs having a policy for risk assessments increased from 32 of 61 (52%) to 49 of 54 (91%). The percentage of awardees meeting the target (80%) for associated clinical laboratories with staff certifications to package/ship rose from 32% (19 of 60) to 46% (25 of 54). The percentage of awardees meeting the target (70%) for associated clinical laboratories with risk assessment policies increased from 18% (8 of 44) to 28% (15 of 54). Awardees reported improvement among Ebola treatment centers/Ebola assessment hospitals with policies to perform risk assessments from 48% (20 of 42) to 67% (34 of 51). Public health laboratories and their clinical partners made progress on their abilities to address biosafety concerns and implement consistent biosafety practices, improving their ability to work safely with biological threats. More attention is needed to address gaps in the clinical community. Support for biosafety activities is critical to continuing to achieve progress.

Because clinicians may be the first to encounter cases of emerging infectious diseases, they need to be able to work together with public health departments to quickly identify and respond to infectious disease outbreaks. Infectious diseases are a constant threat in many parts of the United States, including rural areas. For example, from 2004 to 2016 reports of diseases from mosquito, tick, and flea bites—which are known to affect rural areas—have tripled in the United States.1 During this period, 9 new pathogens spread by infected mosquitoes and ticks were discovered or introduced, and >640,000 cases of these diseases were reported in the United States. Although state and local health departments and vector control organizations are the nation’s main defense against this threat, 84% of local vector control organizations lack at least 1 of 5 core vector control competencies.1

CONTEXT: CDC's Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Cooperative Agreement aims to help health departments strengthen core epidemiology capacity needed to respond to a variety of emerging infectious diseases. In fiscal year 2014, $6 million was awarded to 41 health departments for flexible epidemiologists (FEs). FEs were intended to help meet health departments' unique needs and support unanticipated events that could require the diversion of resources to specific emerging or reemerging diseases. OBJECTIVE: Explore multiple perspectives to characterize how FEs are utilized and to understand the perceived value of this strategy from the health department perspective. DESIGN, SETTING, AND PARTICIPANTS: We conducted 14 in-depth interviews using a semistructured questionnaire with a heterogeneous sample of 8 state health departments; 2 different instruments were administered to ELC principal investigators (PIs) or supervisors, and FEs. The team produced a codebook consisting of both structural and data-driven codes to prepare for a thematic analysis of the data. RESULTS: Three major patterns emerged to describe how FEs are being used in health departments; most commonly, FEs were used to support priorities and gaps across a range of infectious diseases, with an emphasis on enteric diseases. Almost all of the health departments utilized FEs to assist in investigating and responding to outbreaks, maintaining and upgrading surveillance systems, and coordinating and collaborating with partners. Both PIs and supervisors highly valued the flexibility it offered to their programs because FEs were cross-trained and could be used to help with situations where additional staff members were needed. CONCLUSION: ELC enhances epidemiology capacity in health departments by providing flexible personnel that help sustain areas with losses in capacity, addressing programmatic gaps, and supporting unanticipated events. Our findings support the notion that flexible personnel could be an effective model for strengthening epidemiology capacity among health departments. IMPLICATIONS FOR POLICY & PRACTICE: Our findings have practical implications for addressing the overall decline in the public health workforce, as well as the current context and environment of public health funding at both state and federal levels.

On October 12, 2012, the Nellis Air Force Base Public Health Flight (Nellis Public Health), near Las Vegas, Nevada, was notified by the Mike O'Callaghan Federal Medical Center (MOFMC) emergency department (ED) of three active-duty military patients who went to the ED during October 10-12 with fever, vomiting, and hemorrhagic diarrhea. Initial interviews by clinical staff members indicated that all three patients had participated October 6-7 in a long-distance obstacle adventure race on a cattle ranch in Beatty, Nevada, in which competitors frequently fell face first into mud or had their heads submerged in surface water. An investigation by Nellis Public Health, coordinated with local and state health officials, identified 22 cases (18 probable and four confirmed) of Campylobacter coli infection among active-duty service members and civilians. A case-control study using data provided by patients and healthy persons who also had participated in the race showed a statistically significant association between inadvertent swallowing of muddy surface water during the race and Campylobacter infection (odds ratio = 19.4; p<0.001). Public health agencies and adventure race organizers should consider informing race attendees of the hazards of inadvertent ingestion of surface water.

A healthcare-use survey was conducted in the Kibera informal settlement in Nairobi, Kenya, in July 2005 to inform subsequent surveillance in the site for infectious diseases. Sets of standardized questionnaires were administered to 1,542 caretakers and heads of households with one or more child(ren) aged less than five years. The average household-size was 5.1 (range 1-15) persons. Most (90%) resided in a single room with monthly rents of US$ 4.50-7.00. Within the previous two weeks, 49% of children (n=1,378) aged less than five years (under-five children) and 18% of persons (n = 1,139) aged > or = 5 years experienced febrile, diarrhoeal or respiratory illnesses. The large majority (> 75%) of illnesses were associated with healthcare-seeking. While licensed clinics were the most-frequently visited settings, kiosks, unlicensed care providers, and traditional healers were also frequently visited. Expense was cited most often (50%) as the reason for not seeking healthcare. Of those who sought healthcare, 34-44% of the first and/or the only visits were made with non-licensed care providers, potentially delaying opportunities for early optimal intervention. The proportions of patients accessing healthcare facilities were higher with diarrhoeal disease and fever (but not for respiratory diseases in under-five children) than those reported from a contemporaneous study conducted in a rural area in Kenya. The findings support community-based rather than facility-based surveillance in this setting to achieve objectives for comprehensive assessment of the burden of disease.