BACKGROUND: Shigella infections are an important cause of diarrhea in young children and can result in severe complications. Disparities in Shigella infections are well documented among US adults. Our objective was to characterize disparities in incidence and severity of Shigella infections among US children. METHODS: We analyzed laboratory-diagnosed Shigella infections reported to FoodNet, an active, population-based surveillance system in 10 US sites, among children during 2009-2018. We calculated the incidence rate stratified by sex, age, race/ethnicity, Shigella species, and disease severity. Criteria for severe classification were hospitalization, bacteremia, or death. The odds of severe infection were calculated using logistic regression. RESULTS: During 2009-2018, 10 537 Shigella infections were reported in children and 1472 (14.0%) were severe. The incidence rate was 9.5 infections per 100 000 child-years and the incidence rate of severe infections was 1.3 per 100 000 child-years. Incidence was highest among children aged 1-4 years (19.5) and lowest among children aged 13-17 years (2.3); however, children aged 13-17 years had the greatest proportion of severe infections (21.2%). Incidence was highest among Black (16.2 total; 2.3 severe), Hispanic (13.1 total; 2.3 severe), and American Indian/Alaska Native (15.2 total; 2.5 severe) children. Infections caused by non-sonnei species had higher odds of severity than infections caused by Shigella sonnei (adjusted odds ratio 2.58; 95% confidence interval 2.12-3.14). CONCLUSIONS: The incidence and severity of Shigella infections among US children vary by age, race/ethnicity, and Shigella species, warranting investigation of unique risk factors among pediatric subpopulations.

BACKGROUND: In 2018, CDC and the Vermont Department of Health investigated an outbreak of multidrug-resistant Shigella sonnei infections in a retirement community that offered a continuum of care from independent living through skilled nursing care. The investigation identified 24 culture-confirmed cases. Isolates were resistant to trimethoprim-sulfamethoxazole, ampicillin, and ceftriaxone, and had decreased susceptibility to azithromycin and ciprofloxacin. METHODS: To evaluate clinical and microbiologic response, we reviewed inpatient and outpatient medical records for treatment outcomes among the 24 patients with culture-confirmed S. sonnei infection. We defined clinical failure as diarrhea (≥3 loose stools per day) for ≥1 day after treatment finished, and microbiologic failure as a stool culture that yielded S. sonnei after treatment finished. We used broth microdilution to perform antimicrobial susceptibility testing, and whole genome sequencing to identify resistance mechanisms. RESULTS: Isolates contained macrolide resistance genes mph(A) and erm(B) and had azithromycin minimum inhibitory concentrations above the Clinical and Laboratory Standards Institute epidemiological cutoff value of ≤16 µg/mL. Among 24 patients with culture-confirmed Shigella infection, four were treated with azithromycin; all had clinical treatment failure and two also had microbiologic treatment failure. Isolates were susceptible to ciprofloxacin but contained a gyrA mutation; two patients failed treatment with ciprofloxacin. CONCLUSIONS: These azithromycin treatment failures demonstrate the importance of clinical breakpoints to aid clinicians in identifying alternative treatment options for resistant strains. Additionally, these treatment failures highlight a need for comprehensive susceptibility testing and systematic outcome studies, particularly given the emergence of multidrug-resistant Shigella among an expanding range of patient populations.

To our knowledge, environmental isolation of Burkholderia pseudomallei, the causative agent of melioidosis, from the continental United States has not been reported. We report a case of melioidosis in a Texas resident. Genomic analysis indicated that the isolate groups with B. pseudomallei isolates from patients in the same region, suggesting possible endemicity to this region.

Invasive Cronobacter infections among infants are associated with severe neurologic disabilities and death. Early Cronobacter reports typically featured hospitalized and preterm infants and recognized contaminated powdered infant formula (PIF) as a transmission vehicle. To clarify recent epidemiology, we reviewed all cases of bloodstream infection or meningitis among infants that were reported to the Centers for Disease Control and Prevention and in the literature (1961–2018; n = 183). Most infants were neonates (100/150 [67%]); 38% (42/112) died, and 79% (81/102) had reported recent PIF consumption. In the final quarter of the study period (2004–2018), case counts were significantly higher (global average 8.7 cases/year); among US cases, significantly higher proportions occurred among full-term (56% [27/48]) and nonhospitalized (78% [42/54]) infants. PIF contamination, most commonly from opened containers, was identified in 30% (21/71) of investigations. Our findings reaffirm the need to promote safer alternatives for infant feeding, particularly among neonates. | Contaminated powdered infant formula from opened containers is the most commonly identified transmission vehicle. | eng

During September 5–6, 2018, a total of 52 patients in Harare, Zimbabwe, were hospitalized with suspected cholera, an acute bacterial infection characterized by watery diarrhea. Rapid diagnostic testing was positive for Vibrio cholerae O1, and on September 6, Zimbabwe’s Ministry of Health and Child Care (MOHCC) declared an outbreak of cholera. From September 4, 2018, (date of the first reported cases) through March 12, 2019, a total of 10,730 cases and 69 (0.64%) deaths were reported nationally from nine of Zimbabwe’s 10 provinces (Figure). Most cases (94%) were reported from Harare Province, the country’s largest province, with a population of approximately 2 million.

Objective: Following Hurricanes Irma and Maria, the first case of human leptospirosis ever identified in the US Virgin Islands (USVI) was reported to the Virgin Islands Department of Health. Leptospirosis is a potentially fatal bacterial disease caused by Leptospira species found in animal urine and urine-contaminated water and soil. Outbreaks can occur following extreme weather events. Method: Additional cases of leptospirosis were identified in the 2.5 months post-hurricanes by reviewing emergency department (ED) records from territorial hospitals for patients demonstrating leptospirosis-consistent symptoms, testing symptomatic patients previously enrolled in the USVI arbovirus surveillance system (VIASS), and adding leptospirosis testing prospectively to VIASS. Available patient sera underwent local rapid diagnostic testing for anti-Leptospira IgM followed by confirmatory microscopic agglutination testing at the US Centers for Disease Control and Prevention. Water was collected from cisterns with epidemiologic links to confirmed cases and tested by real-time PCR (qPCR) for pathogenic Leptospira spp. Results: Sixteen retrospectively identified symptomatic patients were enrolled in VIASS; 15 with available samples tested negative. Based on review of 5226 ED charts, 6 patients were further investigated; of these, 5 were tested of which 1 was positive. Prospective leptospirosis surveillance tested 57 additional patients; of these, 1 was positive. Water from 1 of 5 tested cisterns was found positive by qPCR. Conclusions: This investigation documents the first 3 cases of leptospirosis reported in the USVI and demonstrates how VIASS successfully was adapted to establish leptospirosis surveillance. Contaminated cistern water was identified as a potential source for Leptospira spp. transmission, highlighting the need for additional post-hurricane remediation and disinfection guidance.

In August 2017, Hurricane Harvey caused unprecedented flooding and devastation to the Houston metropolitan area (1). Mold exposure was a serious concern because investigations after Hurricanes Katrina and Rita (2005) had documented extensive mold growth in flood-damaged homes (2,3). Because mold exposure can cause serious illnesses known as invasive mold infections (4,5), and immunosuppressed persons are at high risk for these infections (6,7), several federal agencies recommend that immunosuppressed persons avoid mold-contaminated sites (8,9). To assess the extent of exposure to mold and flood-damaged areas among persons at high risk for invasive mold infections after Hurricane Harvey, CDC and Texas health officials conducted a survey among 103 immunosuppressed residents in Houston. Approximately half of the participants (50) engaged in cleanup of mold and water-damaged areas; these activities included heavy cleanup (23), such as removing furniture or removing drywall, or light cleanup (27), such as wiping down walls or retrieving personal items. Among immunosuppressed persons who performed heavy cleanup, 43% reported wearing a respirator, as did 8% who performed light cleanup. One participant reported wearing all personal protective equipment (PPE) recommended for otherwise healthy persons (i.e., respirator, boots, goggles, and gloves). Immunosuppressed residents who are at high risk for invasive mold infections were exposed to mold and flood-damaged areas after Hurricane Harvey; recommendations from health care providers to avoid exposure to mold and flood-damaged areas could mitigate the risk to immunosuppressed persons.

On October 22, 2018, the Vermont Department of Health (VDH) notified CDC’s Waterborne Disease Prevention Branch of an outbreak of diarrhea caused by Shigella sonnei among residents, visitors, and staff members of a retirement community in Chittenden County, the state’s most populous county. High-quality single nucleotide polymorphism (SNP) analysis predicted initial isolates were multidrug resistant (MDR), and were closely related to a concurrent multistate cluster (differing by 0–11 SNPs). In the United States, rates of MDR shigellosis are increasing (1); outbreaks of MDR shigellosis are more common among men who have sex with men and are rare in retirement community settings (2). CDC collaborated with VDH to identify additional cases, determine transmission routes, and recommend prevention and control measures.

On October 16, 2017, the Harare City Health Department (HCHD) in Zimbabwe identified a suspected typhoid fever (typhoid) case in a resident of Harare’s Mbare suburb. Typhoid is a potentially fatal illness caused by Salmonella enterica serovar Typhi (Typhi). HCHD initiated an investigation and identified a cluster of 17 suspected typhoid cases, defined as the occurrence of fever and at least one of the following symptoms: headache, malaise, abdominal discomfort, vomiting, diarrhea, cough, or constipation. A confirmed case had Typhi isolated from blood, stool, or rectal swab culture (1). | | As of February 24, 2018 (the most recent publicly available data), 3,187 suspected and 191 confirmed cases were identified (Figure), with no reported deaths among confirmed cases. Among suspected cases, 1,696 (53%) patients were male, and median age was 17 years (range = 1 month–90 years). In addition to clusters in Mbare, clusters were detected in Harare’s western suburbs, including Kuwadzana, where high rates of ciprofloxacin-resistant Typhi were identified.

In January 2018, the Indiana State Department of Health (ISDH) was notified of a case of Cronobacter sakazakii meningitis in a female neonate who had been fed exclusively maternal breast milk. The infant was born by induced vaginal delivery at 37 weeks’ gestational age. She was discharged from the newborn nursery after 2 days and was clinically well until age 8 days, when she was admitted with poor feeding, fever of 100.4°F (38°C), and abnormal movements. Electroencephalography demonstrated multifocal seizures; MRI demonstrated multifocal restricted diffusion, leptomeningeal enhancement, and patchy hemorrhagic areas. Cultures from blood and cerebrospinal fluid yielded C. sakazakii, a gram-negative pathogenic bacillus. She was initially treated with meropenem, gentamicin, and antiepileptics to control seizures; when antibiotic sensitivity results were available, the antimicrobial regimen was narrowed to cefepime to complete a 21-day course. She was discharged home at age 33 days with early intervention therapies for global hypotonia and close monitoring of her development.