Last data update: Apr 29, 2024. (Total: 46658 publications since 2009)
Records 1-30 (of 60 Records) |
Query Trace: Yoder JS [original query] |
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Estimating waterborne infectious disease burden by exposure route, United States, 2014
Gerdes ME , Miko S , Kunz JM , Hannapel EJ , Hlavsa MC , Hughes MJ , Stuckey MJ , Francois Watkins LK , Cope JR , Yoder JS , Hill VR , Collier SA . Emerg Infect Dis 2023 29 (7) 1357-1366 More than 7.15 million cases of domestically acquired infectious waterborne illnesses occurred in the United States in 2014, causing 120,000 hospitalizations and 6,600 deaths. We estimated disease incidence for 17 pathogens according to recreational, drinking, and nonrecreational nondrinking (NRND) water exposure routes by using previously published estimates. In 2014, a total of 5.61 million (95% credible interval [CrI] 2.97-9.00 million) illnesses were linked to recreational water, 1.13 million (95% CrI 255,000-3.54 million) to drinking water, and 407,000 (95% CrI 72,800-1.29 million) to NRND water. Recreational water exposure was responsible for 36%, drinking water for 40%, and NRND water for 24% of hospitalizations from waterborne illnesses. Most direct costs were associated with pathogens found in biofilms. Estimating disease burden by water exposure route helps direct prevention activities. For each exposure route, water management programs are needed to control biofilm-associated pathogen growth; public health programs are needed to prevent biofilm-associated diseases. |
Characterization of reported legionellosis outbreaks associated with buildings served by public drinking water systems: United States, 2001-2017
Holsinger H , Tucker N , Regli S , Studer K , Roberts VA , Collier S , Hannapel E , Edens C , Yoder JS , Rotert K . J Water Health 2022 20 (4) 702-711 This study examined 184 legionellosis outbreaks in the United States reported to the Centers for Disease Control and Prevention's Waterborne Disease and Outbreak Surveillance System, from 2001 to 2017. Drinking water characteristics examined include source water type, disinfectant type, exposure setting, geographical distribution by U.S. Census Divisions, and the public water system size (population served). This study found that most of the reported drinking water-associated legionellosis outbreaks occurred in eastern United States, including 35% in the South Atlantic, 32% in the Middle Atlantic, and 16% in the East North Central Census Divisions were linked with building water systems in healthcare and hotel settings; and were associated with buildings receiving drinking water from public water systems serving >10,000 people. Targeted evaluations and interventions may be useful to further determine the combination of factors, such as disinfectant residual type and drinking water system size that may lead to legionellosis outbreaks. |
Demographic differences in use of household tap water in a representative sample of US adults, FallStyles 2019
Vanden Esschert K , Barrett CE , Collier SA , Garcia-Williams AG , Hannapel E , Yoder JS , Benedict KM . J Water Health 2021 19 (6) 1014-1020 Tap water that is safe to consume may cause respiratory illness (e.g., Legionnaires' disease) when water conditions allow for proliferation and aerosolization of biofilm-associated pathogens. This study assessed household tap water consumption, exposure to aerosolized tap water, and associated demographics. A nationally representative FallStyles survey administered by Porter Novelli Public Services was sent to 4,677 US adult panelists in October 2019. There were 3,624 adults who completed the survey (77.5% response rate). Respondents were asked about self-reported use of household tap water for consumption (i.e., drinking, rinsing produce, or making ice) and use through water-aerosolizing devices (e.g., showerheads, humidifiers). Demographics included gender, age, race/ethnicity, education, income, region, and health status. Weighted analyses using complex sample survey procedures were used to assess tap water exposure by route and demographics. Most US adults are exposed to aerosolized tap water through showering (80.6%), and one in five are exposed through other water-aerosolizing devices (20.3%). Consumption and showering were greatest among older, White, higher educated, and higher-income adults. Aerosolized tap water can transmit waterborne pathogens and cause respiratory illness, especially among older age groups and people with weakened immune systems. These results will help target health messages for using water-aerosolizing devices safely. |
COVID-19 Vaccination Coverage Among Adolescents Aged 12-17 Years - United States, December 14, 2020-July 31, 2021.
Murthy BP , Zell E , Saelee R , Murthy N , Meng L , Meador S , Reed K , Shaw L , Gibbs-Scharf L , McNaghten AD , Patel A , Stokley S , Flores S , Yoder JS , Black CL , Harris LQ . MMWR Morb Mortal Wkly Rep 2021 70 (35) 1206-1213 Although severe COVID-19 illness and hospitalization are more common among adults, these outcomes can occur in adolescents (1). Nearly one third of adolescents aged 12-17 years hospitalized with COVID-19 during March 2020-April 2021 required intensive care, and 5% of those hospitalized required endotracheal intubation and mechanical ventilation (2). On December 11, 2020, the Food and Drug Administration (FDA) issued Emergency Use Authorization (EUA) of the Pfizer-BioNTech COVID-19 vaccine for adolescents aged 16-17 years; on May 10, 2021, the EUA was expanded to include adolescents aged 12-15 years; and on August 23, 2021, FDA granted approval of the vaccine for persons aged ≥16 years. To assess progress in adolescent COVID-19 vaccination in the United States, CDC assessed coverage with ≥1 dose* and completion of the 2-dose vaccination series(†) among adolescents aged 12-17 years using vaccine administration data for 49 U.S. states (all except Idaho) and the District of Columbia (DC) during December 14, 2020-July 31, 2021. As of July 31, 2021, COVID-19 vaccination coverage among U.S. adolescents aged 12-17 years was 42.4% for ≥1 dose and 31.9% for series completion. Vaccination coverage with ≥1 dose varied by state (range = 20.2% [Mississippi] to 70.1% [Vermont]) and for series completion (range = 10.7% [Mississippi] to 60.3% [Vermont]). By age group, 36.0%, 40.9%, and 50.6% of adolescents aged 12-13, 14-15, and 16-17 years, respectively, received ≥1 dose; 25.4%, 30.5%, and 40.3%, respectively, completed the vaccine series. Improving vaccination coverage and implementing COVID-19 prevention strategies are crucial to reduce COVID-19-associated morbidity and mortality among adolescents and to facilitate safer reopening of schools for in-person learning. |
Guidance for Implementing COVID-19 Prevention Strategies in the Context of Varying Community Transmission Levels and Vaccination Coverage.
Christie A , Brooks JT , Hicks LA , Sauber-Schatz EK , Yoder JS , Honein MA . MMWR Morb Mortal Wkly Rep 2021 70 (30) 1044-1047 COVID-19 vaccination remains the most effective means to achieve control of the pandemic. In the United States, COVID-19 cases and deaths have markedly declined since their peak in early January 2021, due in part to increased vaccination coverage (1). However, during June 19-July 23, 2021, COVID-19 cases increased approximately 300% nationally, followed by increases in hospitalizations and deaths, driven by the highly transmissible B.1.617.2 (Delta) variant* of SARS-CoV-2, the virus that causes COVID-19. Available data indicate that the vaccines authorized in the United States (Pfizer-BioNTech, Moderna, and Janssen [Johnson & Johnson]) offer high levels of protection against severe illness and death from infection with the Delta variant and other currently circulating variants of the virus (2). Despite widespread availability, vaccine uptake has slowed nationally with wide variation in coverage by state (range = 33.9%-67.2%) and by county (range = 8.8%-89.0%).(†) Unvaccinated persons, as well as persons with certain immunocompromising conditions (3), remain at substantial risk for infection, severe illness, and death, especially in areas where the level of SARS-CoV-2 community transmission is high. The Delta variant is more than two times as transmissible as the original strains circulating at the start of the pandemic and is causing large, rapid increases in infections, which could compromise the capacity of some local and regional health care systems to provide medical care for the communities they serve. Until vaccination coverage is high and community transmission is low, public health practitioners, as well as schools, businesses, and institutions (organizations) need to regularly assess the need for prevention strategies to avoid stressing health care capacity and imperiling adequate care for both COVID-19 and other non-COVID-19 conditions. CDC recommends five critical factors be considered to inform local decision-making: 1) level of SARS-CoV-2 community transmission; 2) health system capacity; 3) COVID-19 vaccination coverage; 4) capacity for early detection of increases in COVID-19 cases; and 5) populations at increased risk for severe outcomes from COVID-19. Among strategies to prevent COVID-19, CDC recommends all unvaccinated persons wear masks in public indoor settings. Based on emerging evidence on the Delta variant (2), CDC also recommends that fully vaccinated persons wear masks in public indoor settings in areas of substantial or high transmission. Fully vaccinated persons might consider wearing a mask in public indoor settings, regardless of transmission level, if they or someone in their household is immunocompromised or is at increased risk for severe disease, or if someone in their household is unvaccinated (including children aged <12 years who are currently ineligible for vaccination). |
Geographic range of recreational water-associated primary amebic meningoencephalitis, United States, 1978-2018
Gharpure R , Gleason M , Salah Z , Blackstock AJ , Hess-Homeier D , Yoder JS , Ali IKM , Collier SA , Cope JR . Emerg Infect Dis 2021 27 (1) 271-274 Naegleria fowleri is a free-living ameba that causes primary amebic meningoencephalitis (PAM), a rare but usually fatal disease. We analyzed trends in recreational water exposures associated with PAM cases reported during 1978-2018 in the United States. Although PAM incidence remained stable, the geographic range of exposure locations expanded northward. |
Estimate of burden and direct healthcare cost of infectious waterborne disease in the United States
Collier SA , Deng L , Adam EA , Benedict KM , Beshearse EM , Blackstock AJ , Bruce BB , Derado G , Edens C , Fullerton KE , Gargano JW , Geissler AL , Hall AJ , Havelaar AH , Hill VR , Hoekstra RM , Reddy SC , Scallan E , Stokes EK , Yoder JS , Beach MJ . Emerg Infect Dis 2021 27 (1) 140-149 Provision of safe drinking water in the United States is a great public health achievement. However, new waterborne disease challenges have emerged (e.g., aging infrastructure, chlorine-tolerant and biofilm-related pathogens, increased recreational water use). Comprehensive estimates of the health burden for all water exposure routes (ingestion, contact, inhalation) and sources (drinking, recreational, environmental) are needed. We estimated total illnesses, emergency department (ED) visits, hospitalizations, deaths, and direct healthcare costs for 17 waterborne infectious diseases. About 7.15 million waterborne illnesses occur annually (95% credible interval [CrI] 3.88 million-12.0 million), results in 601,000 ED visits (95% CrI 364,000-866,000), 118,000 hospitalizations (95% CrI 86,800-150,000), and 6,630 deaths (95% CrI 4,520-8,870) and incurring US $3.33 billion (95% CrI 1.37 billion-8.77 billion) in direct healthcare costs. Otitis externa and norovirus infection were the most common illnesses. Most hospitalizations and deaths were caused by biofilm-associated pathogens (nontuberculous mycobacteria, Pseudomonas, Legionella), costing US $2.39 billion annually. |
Surveillance for harmful algal bloom events and associated human and animal illnesses - One Health Harmful Algal Bloom System, United States, 2016-2018
Roberts VA , Vigar M , Backer L , Veytsel GE , Hilborn ED , Hamelin EI , Vanden Esschert KL , Lively JY , Cope JR , Hlavsa MC , Yoder JS . MMWR Morb Mortal Wkly Rep 2020 69 (50) 1889-1894 Harmful algal bloom events can result from the rapid growth, or bloom, of photosynthesizing organisms in natural bodies of fresh, brackish, and salt water. These events can be exacerbated by nutrient pollution (e.g., phosphorus) and warming waters and other climate change effects (1); have a negative impact on the health of humans, animals, and the environment; and damage local economies (2,3). U.S. harmful algal bloom events of public health concern are centered on a subset of phytoplankton: diatoms, dinoflagellates, and cyanobacteria (also called blue-green algae). CDC launched the One Health Harmful Algal Bloom System (OHHABS) in 2016 to inform efforts to prevent human and animal illnesses associated with harmful algal bloom events. A total of 18 states reported 421 harmful algal bloom events, 389 cases of human illness, and 413 cases of animal illness that occurred during 2016-2018. The majority of harmful algal bloom events occurred during May-October (413; 98%) and in freshwater bodies (377; 90%). Human and animal illnesses primarily occurred during June-September (378; 98%) and May-September (410; 100%). Gastrointestinal or generalized illness signs or symptoms were the most frequently reported (>40% of human cases and >50% of animal cases); however, multiple other signs and symptoms were reported. Surveillance data from harmful algal bloom events, exposures, and health effects provide a systematic description of these occurrences and can be used to inform control and prevention of harmful algal bloom-associated illnesses. |
Adoption of Strategies to Mitigate Transmission of COVID-19 During a Statewide Primary Election - Delaware, September 2020.
Leidman E , Hall NB , Kirby AE , Garcia-Williams AG , Aponte J , Yoder JS , Hong R , Albence A , Coronado F , Massetti GM . MMWR Morb Mortal Wkly Rep 2020 69 (43) 1571-1575 Elections occurring during the coronavirus disease 2019 (COVID-19) pandemic have been affected by notable changes in the methods of voting, the number and type of polling locations, and in-person voting procedures (1). To mitigate transmission of COVID-19 at polling locations, jurisdictions have adopted changes to protocols and procedures, informed by CDC's interim guidance, developed in collaboration with the Election Assistance Commission (2). The driving principle for this guidance is that voting practices with lower infection risk will be those which reduce the number of voters who congregate indoors in polling locations by offering a variety of methods for voting and longer voting periods. The guidance for in-person voting includes considerations for election officials, poll workers, and voters to maintain healthy environments and operations. To assess knowledge and adoption of mitigation strategies, CDC collaborated with the Delaware Department of Health and Social Services and the Delaware State Election Commission on a survey of poll workers who served during the statewide primary election on September 15, 2020. Among 522 eligible poll workers, 93% correctly answered all three survey questions about COVID-19 transmission. Respondents noted that most voters and poll workers wore masks. However, masks were not always worn correctly (i.e., covering both the nose and mouth). Responses suggest that mitigation measures recommended for both poll workers and voters were widely adopted and feasible, but also highlighted gaps in infection prevention control efforts. Strengthening of measures intended to minimize the risk of poll workers acquiring COVID-19 from ill voters, such as additional training and necessary personal protective equipment (PPE), as well as support for alternative voting options for ill voters, are needed. Adherence to mitigation measures is important not only to protect voters but also to protect poll workers, many of whom are older adults, and thus at higher risk for severe COVID-19-associated illness. Enhanced attention to reducing congregation in polling locations, correct mask use, and providing safe voting options for ill voters are critical considerations to minimize risk to voters and poll workers. Evidence from the Delaware election supports the feasibility and acceptability of implementing current CDC guidance for election officials, poll workers, and voters for mitigating COVID-19 transmission at polling locations (2). |
Melioidosis in a resident of Texas with no recent travel history, United States
Cossaboom CM , Marinova-Petkova A , Strysko J , Rodriguez G , Maness T , Ocampo J , Gee JE , Elrod MG , Gulvik CA , Liu L , Bower WA , Hoffmaster AR , Blaney DD , Salzer JS , Yoder JS , Mattioli MC , Sidwa TJ , Ringsdorf L , Morrow G , Ledezma E , Kieffer A . Emerg Infect Dis 2020 26 (6) 1295-1299 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. |
Evolving epidemiology of reported giardiasis cases in the United States, 1995-2016
Coffey CM , Collier SA , Gleason ME , Yoder JS , Kirk MD , Richardson AM , Fullerton KE , Benedict KM . Clin Infect Dis 2020 72 (5) 764-770 BACKGROUND: Giardiasis is the most common intestinal parasitic disease of humans identified in the United States and an important waterborne disease. In the United States, giardiasis has been variably reportable since 1992 and was made a nationally notifiable disease in 2002. Our objective was to describe the epidemiology of US giardiasis cases from 1995-2016 using National Notifiable Disease Surveillance System data. METHODS: Negative binomial regression models were used to compare incidence rates by age groups (0-4, 5-9, 10-19, 20-29, 30-39, 40-49, 50-64 and >/=65 years) during three time periods (1995-2001, 2002-2010 and 2011-2016). RESULTS: From 1995-2016, the average number of reported cases were 19 781 per year (range 14 623-27 778 cases). The annual incidence of reported giardiasis in the US decreased across all age groups. This decrease differs by age group and sex and may reflect either changes in surveillance methods (for example changes to case definitions or reporting practices) or changes in exposure. Incidence rates in males and older age groups did not decrease to the same extent as rates in females and children. CONCLUSIONS: Trends suggest that differences in exposures by sex and age group are important to the epidemiology of giardiasis. Further investigation into the risk factors of populations with higher rates of giardiasis will support prevention and control efforts. |
Response and remediation actions following the detection of Naegleria fowleri in two treated drinking water distribution systems, Louisiana, 2013-2014
Cope JR , Kahler AM , Causey J , Williams JG , Kihlken J , Benjamin C , Ames AP , Forsman J , Zhu Y , Yoder JS , Seidel CJ , Hill VR . J Water Health 2019 17 (5) 777-787 Naegleria fowleri causes the usually fatal disease primary amebic meningoencephalitis (PAM), typically in people who have been swimming in warm, untreated freshwater. Recently, some cases in the United States were associated with exposure to treated drinking water. In 2013, a case of PAM was reported for the first time in association with the exposure to water from a US treated drinking water system colonized with culturable N. fowleri. This system and another were found to have multiple areas with undetectable disinfectant residual levels. In response, the water distribution systems were temporarily converted from chloramine disinfection to chlorine to inactivate N. fowleri and reduced biofilm in the distribution systems. Once >1.0 mg/L free chlorine residual was attained in all systems for 60 days, water testing was performed; N. fowleri was not detected in water samples after the chlorine conversion. This investigation highlights the importance of maintaining adequate residual disinfectant levels in drinking water distribution systems. Water distribution system managers should be knowledgeable about the ecology of their systems, understand potential water quality changes when water temperatures increase, and work to eliminate areas in which biofilm growth may be problematic and affect water quality. |
Impact of public health interventions on drinking water-associated outbreaks of hepatitis A - United States, 1971-2017
Barrett CE , Pape BJ , Benedict KM , Foster MA , Roberts VA , Rotert K , Mattioli MC , Yoder JS . MMWR Morb Mortal Wkly Rep 2019 68 (35) 766-770 Hepatitis A virus (HAV) is an RNA virus primarily transmitted via the fecal-oral route and, in rare cases, causes liver failure and death in infected persons. Although drinking water-associated hepatitis A outbreaks in the United States are rarely reported (1), HAV was the most commonly reported etiology for outbreaks associated with untreated ground water during 1971-2008 (2), and HAV can remain infectious in water for months (3). This report analyzes drinking water-associated hepatitis A outbreaks reported to the Waterborne Disease and Outbreak Surveillance System (WBDOSS) during 1971-2017. During that period, 32 outbreaks resulting in 857 cases were reported, all before 2010. Untreated ground water was associated with 23 (72%) outbreaks, resulting in 585 (68.3%) reported cases. Reported outbreaks significantly decreased after introduction of Advisory Committee on Immunization Practices (ACIP) hepatitis A vaccination recommendations* and U.S. Environmental Protection Agency's (USEPA) public ground water system regulations.(dagger) Individual water systems, which are not required to meet national drinking water standards,( section sign) were the only contaminated drinking water systems to cause the last four reported hepatitis A outbreaks during 1995-2009. No waterborne outbreaks were reported during 2009-2017. Water testing and treatment are important considerations to protect persons who use these unregulated systems from HAV infection. |
Case-case analyses of cryptosporidiosis and giardiasis using routine national surveillance data in the United States - 2005-2015
Benedict KM , Collier SA , Marder EP , Hlavsa MC , Fullerton KE , Yoder JS . Epidemiol Infect 2019 147 e178 Understanding endemic infectious disease risk factors through traditional epidemiological tools is challenging. Population-based case-control studies are costly and time-consuming. A case-case analyses using surveillance data addresses these limitations by using resources more efficiently. We conducted a case-case analyses using routine surveillance data reported by 16 U.S. states (2005-2015), wherein reported cases of salmonellosis were used as a comparison group to identify exposure associations with reported cases of cryptosporidiosis and giardiasis. Odds ratios adjusted for age and reporting state (aOR) and 95% confidence intervals (95% CI) were calculated. A total of 10 704 cryptosporidiosis cases, 17 544 giardiasis cases, and 106 351 salmonellosis cases were included in this analyses. When compared with cases of salmonellosis, exposure to treated recreational water (aOR 4.7, 95% CI 4.3-5.0) and livestock (aOR: 3.2; 95% CI: 2.9-3.5) were significantly associated with cryptosporidiosis and exposure to untreated drinking (aOR 4.1, 95% CI 3.6-4.7) and recreational water (aOR 4.1, 95% CI 3.7-4.5) were associated with giardiasis. Our analyses shows that routine surveillance data with standardised exposure information can be used to identify associations of interest for cryptosporidiosis and giardiasis. |
The epidemiology and clinical features of Balamuthia mandrillaris disease in the United States, 1974 - 2016
Cope JR , Landa J , Nethercut H , Collier SA , Glaser C , Moser M , Puttagunta R , Yoder JS , Ali IK , Roy SL . Clin Infect Dis 2018 68 (11) 1815-1822 Background: Balamuthia mandrillaris is a free-living ameba that causes rare, nearly always fatal disease in humans and animals worldwide. B. mandrillaris has been isolated from soil, dust, and water. Initial entry of Balamuthia into the body is likely via the skin or lungs. To date, only individual case reports and small case series have been published. Methods: The Centers for Disease Control and Prevention (CDC) maintains a free-living ameba (FLA) registry and laboratory. To be entered into the registry, a Balamuthia case must be laboratory-confirmed. Several sources were used to complete entries in the registry, including case report forms, CDC laboratory results, published case reports, and media information. SAS(c) version 9.3 software was used to calculate descriptive statistics and frequencies. Results: We identified 109 case reports of Balamuthia disease between 1974 and 2016. Most (99%) had encephalitis. The median age was 36 years (range 4 months to 91 years). Males accounted for 68% of the case patients. California had the highest number of case reports followed by Texas and Arizona. Hispanics constituted 55% for those with documented ethnicity. Exposure to soil was commonly reported. Among those with a known outcome, 90% of patients died. Conclusions: Balamuthia disease in the United States is characterized by a highly fatal encephalitis that affects patients of all ages. Hispanics were disproportionately affected. The southwest region of the U.S. reported the most cases. Clinician awareness of Balamuthia as a cause of encephalitis might lead to earlier diagnosis and initiation of treatment, resulting in better outcomes. |
Prevention and control of youth camp-associated acute gastroenteritis outbreaks
Kambhampati AK , Marsh ZA , Hlavsa MC , Roberts VA , Vieira AR , Yoder JS , Hall AJ . J Pediatric Infect Dis Soc 2018 8 (5) 392-399 Background: Approximately 14 million children attend more than 14000 US camps every year. Shared accommodations and activities can facilitate acute gastroenteritis (AGE) outbreaks. Methods: We analyzed data from the National Outbreak Reporting System on US youth camp-associated AGE outbreaks that occurred between 2009 and 2016. We also conducted a systematic literature search of youth camp-associated AGE outbreaks that have occurred around the world and a gray literature search for existing recommendations on outbreak prevention and control at camps worldwide. Results: Thirty-nine US jurisdictions reported a total of 229 youth camp-associated AGE outbreaks to the National Outbreak Reporting System. Of the 226 outbreaks included in our analyses, 120 (53%) were reported to have resulted from person-to-person transmission, 42 (19%) from an unknown transmission mode, 38 (17%) from foodborne transmission, 19 (8%) from waterborne transmission, 5 (2%) from animal contact, and 2 (<1%) from environmental contamination. Among 170 (75%) outbreaks with a single suspected or confirmed etiology, norovirus (107 [63%] outbreaks), Salmonella spp (16 [9%]), and Shiga-toxin producing Escherichia coli (12 [7%]) were implicated most frequently. We identified 43 additional youth camp-associated AGE outbreaks in the literature that occurred in various countries between 1938 and 2014. Control measures identified through the literature search included camp closure, separation of ill campers, environmental disinfection, and education on food preparation and hand hygiene. Conclusions: Youth camp-associated AGE outbreaks are caused by numerous pathogens every year. These outbreaks are facilitated by factors that include improper food preparation, inadequate cleaning and disinfection, shared accommodations, and contact with animals. Health education focused on proper hygiene and preventing disease transmission could help control or prevent these outbreaks. |
Outbreaks associated with untreated recreational water - United States, 2000-2014
Graciaa DS , Cope JR , Roberts VA , Cikesh BL , Kahler AM , Vigar M , Hilborn ED , Wade TJ , Backer LC , Montgomery SP , Secor WE , Hill VR , Beach MJ , Fullerton KE , Yoder JS , Hlavsa MC . MMWR Morb Mortal Wkly Rep 2018 67 (25) 701-706 Outbreaks associated with untreated recreational water can be caused by pathogens, toxins, or chemicals in fresh water (e.g., lakes, rivers) or marine water (e.g., ocean). During 2000-2014, public health officials from 35 states and Guam voluntarily reported 140 untreated recreational water-associated outbreaks to CDC. These outbreaks resulted in at least 4,958 cases of disease and two deaths. Among the 95 outbreaks with a confirmed infectious etiology, enteric pathogens caused 80 (84%); 21 (22%) were caused by norovirus, 19 (20%) by Escherichia coli, 14 (15%) by Shigella, and 12 (13%) by Cryptosporidium. Investigations of these 95 outbreaks identified 3,125 cases; 2,704 (87%) were caused by enteric pathogens, including 1,459 (47%) by norovirus, 362 (12%) by Shigella, 314 (10%) by Cryptosporidium, and 155 (5%) by E. coli. Avian schistosomes were identified as the cause in 345 (11%) of the 3,125 cases. The two deaths were in persons affected by a single outbreak (two cases) caused by Naegleria fowleri. Public parks (50 [36%]) and beaches (45 [32%]) were the leading settings associated with the 140 outbreaks. Overall, the majority of outbreaks started during June-August (113 [81%]); 65 (58%) started in July. Swimmers and parents of young swimmers can take steps to minimize the risk for exposure to pathogens, toxins, and chemicals in untreated recreational water by heeding posted advisories closing the beach to swimming; not swimming in discolored, smelly, foamy, or scummy water; not swimming while sick with diarrhea; and limiting water entering the nose when swimming in warm freshwater. |
Outbreaks associated with treated recreational water - United States, 2000-2014
Hlavsa MC , Cikesh BL , Roberts VA , Kahler AM , Vigar M , Hilborn ED , Wade TJ , Roellig DM , Murphy JL , Xiao L , Yates KM , Kunz JM , Arduino MJ , Reddy SC , Fullerton KE , Cooley LA , Beach MJ , Hill VR , Yoder JS . MMWR Morb Mortal Wkly Rep 2018 67 (19) 547-551 Outbreaks associated with exposure to treated recreational water can be caused by pathogens or chemicals in venues such as pools, hot tubs/spas, and interactive water play venues (i.e., water playgrounds). During 2000-2014, public health officials from 46 states and Puerto Rico reported 493 outbreaks associated with treated recreational water. These outbreaks resulted in at least 27,219 cases and eight deaths. Among the 363 outbreaks with a confirmed infectious etiology, 212 (58%) were caused by Cryptosporidium (which causes predominantly gastrointestinal illness), 57 (16%) by Legionella (which causes Legionnaires' disease, a severe pneumonia, and Pontiac fever, a milder illness with flu-like symptoms), and 47 (13%) by Pseudomonas (which causes folliculitis ["hot tub rash"] and otitis externa ["swimmers' ear"]). Investigations of the 363 outbreaks identified 24,453 cases; 21,766 (89%) were caused by Cryptosporidium, 920 (4%) by Pseudomonas, and 624 (3%) by Legionella. At least six of the eight reported deaths occurred in persons affected by outbreaks caused by Legionella. Hotels were the leading setting, associated with 157 (32%) of the 493 outbreaks. Overall, the outbreaks had a bimodal temporal distribution: 275 (56%) outbreaks started during June-August and 46 (9%) in March. Assessment of trends in the annual counts of outbreaks caused by Cryptosporidium, Legionella, or Pseudomonas indicate mixed progress in preventing transmission. Pathogens able to evade chlorine inactivation have become leading outbreak etiologies. The consequent outbreak and case counts and mortality underscore the utility of CDC's Model Aquatic Health Code (https://www.cdc.gov/mahc) to prevent outbreaks associated with treated recreational water. |
Risk factors for sporadic Giardia infection in the USA: a case-control study in Colorado and Minnesota
Reses HE , Gargano JW , Liang JL , Cronquist A , Smith K , Collier SA , Roy SL , Vanden Eng J , Bogard A , Lee B , Hlavsa MC , Rosenberg ES , Fullerton KE , Beach MJ , Yoder JS . Epidemiol Infect 2018 146 (9) 1-8 Giardia duodenalis is the most common intestinal parasite of humans in the USA, but the risk factors for sporadic (non-outbreak) giardiasis are not well described. The Centers for Disease Control and Prevention and the Colorado and Minnesota public health departments conducted a case-control study to assess risk factors for sporadic giardiasis in the USA. Cases (N = 199) were patients with non-outbreak-associated laboratory-confirmed Giardia infection in Colorado and Minnesota, and controls (N = 381) were matched by age and site. Identified risk factors included international travel (aOR = 13.9; 95% CI 4.9-39.8), drinking water from a river, lake, stream, or spring (aOR = 6.5; 95% CI 2.0-20.6), swimming in a natural body of water (aOR = 3.3; 95% CI 1.5-7.0), male-male sexual behaviour (aOR = 45.7; 95% CI 5.8-362.0), having contact with children in diapers (aOR = 1.6; 95% CI 1.01-2.6), taking antibiotics (aOR = 2.5; 95% CI 1.2-5.0) and having a chronic gastrointestinal condition (aOR = 1.8; 95% CI 1.1-3.0). Eating raw produce was inversely associated with infection (aOR = 0.2; 95% CI 0.1-0.7). Our results highlight the diversity of risk factors for sporadic giardiasis and the importance of non-international-travel-associated risk factors, particularly those involving person-to-person transmission. Prevention measures should focus on reducing risks associated with diaper handling, sexual contact, swimming in untreated water, and drinking untreated water. |
Disparities in plain, tap and bottled water consumption among US adults: National Health and Nutrition Examination Survey (NHANES) 2007-2014
Rosinger AY , Herrick KA , Wutich AY , Yoder JS , Ogden CL . Public Health Nutr 2018 21 (8) 1-10 OBJECTIVE: Differences in bottled v. tap water intake may provide insights into health disparities, like risk of dental caries and inadequate hydration. We examined differences in plain, tap and bottled water consumption among US adults by sociodemographic characteristics. DESIGN: Cross-sectional analysis. We used 24 h dietary recall data to test differences in percentage consuming the water sources and mean intake between groups using Wald tests and multiple logistic and linear regression models. SETTING: National Health and Nutrition Examination Survey (NHANES), 2007-2014. SUBJECTS: A nationally representative sample of 20 676 adults aged >/=20 years. RESULTS: In 2011-2014, 81.4 (se 0.6) % of adults drank plain water (sum of tap and bottled), 55.2 (se 1.4) % drank tap water and 33.4 (se 1.4) % drank bottled water on a given day. Adjusting for covariates, non-Hispanic (NH) Black and Hispanic adults had 0.44 (95 % CI 0.37, 0.53) and 0.55 (95 % CI 0.45, 0.66) times the odds of consuming tap water, and consumed B=-330 (se 45) ml and B=-180 (se 45) ml less tap water than NH White adults, respectively. NH Black, Hispanic and adults born outside the fifty US states or Washington, DC had 2.20 (95 % CI 1.79, 2.69), 2.37 (95 % CI 1.91, 2.94) and 1.46 (95 % CI 1.19, 1.79) times the odds of consuming bottled water than their NH White and US-born counterparts. In 2007-2010, water filtration was associated with higher odds of drinking plain and tap water. CONCLUSIONS: While most US adults consumed plain water, the source (i.e. tap or bottled) and amount differed by race/Hispanic origin, nativity status and education. Water filters may increase tap water consumption. |
Waterborne disease outbreaks associated with environmental and undetermined exposures to water - United States, 2013-2014
McClung RP , Roth DM , Vigar M , Roberts VA , Kahler AM , Cooley LA , Hilborn ED , Wade TJ , Fullerton KE , Yoder JS , Hill VR . MMWR Morb Mortal Wkly Rep 2017 66 (44) 1222-1225 Waterborne disease outbreaks in the United States are associated with a wide variety of water exposures and are reported annually to CDC on a voluntary basis by state and territorial health departments through the National Outbreak Reporting System (NORS). A majority of outbreaks arise from exposure to drinking water (1) or recreational water (2), whereas others are caused by an environmental exposure to water or an undetermined exposure to water. During 2013-2014, 15 outbreaks associated with an environmental exposure to water and 12 outbreaks with an undetermined exposure to water were reported, resulting in at least 289 cases of illness, 108 hospitalizations, and 17 deaths. Legionella was responsible for 63% of the outbreaks, 94% of hospitalizations, and all deaths. Outbreaks were also caused by Cryptosporidium, Pseudomonas, and Giardia, including six outbreaks of giardiasis caused by ingestion of water from a river, stream, or spring. Water management programs can effectively prevent outbreaks caused by environmental exposure to water from human-made water systems, while proper point-of-use treatment of water can prevent outbreaks caused by ingestion of water from natural water systems. |
Surveillance for waterborne disease outbreaks associated with drinking water - United States, 2013-2014
Benedict KM , Reses H , Vigar M , Roth DM , Roberts VA , Mattioli M , Cooley LA , Hilborn ED , Wade TJ , Fullerton KE , Yoder JS , Hill VR . MMWR Morb Mortal Wkly Rep 2017 66 (44) 1216-1221 Provision of safe water in the United States is vital to protecting public health. Public health agencies in the U.S. states and territories report information on waterborne disease outbreaks to CDC through the National Outbreak Reporting System (NORS) (https://www.cdc.gov/healthywater/surveillance/index.html). During 2013-2014, 42 drinking water-associated outbreaks were reported, accounting for at least 1,006 cases of illness, 124 hospitalizations, and 13 deaths. Legionella was associated with 57% of these outbreaks and all of the deaths. Sixty-nine percent of the reported illnesses occurred in four outbreaks in which the etiology was determined to be either a chemical or toxin or the parasite Cryptosporidium. Drinking water contamination events can cause disruptions in water service, large impacts on public health, and persistent community concern about drinking water quality. Effective water treatment and regulations can protect public drinking water supplies in the United States, and rapid detection, identification of the cause, and response to illness reports can reduce the transmission of infectious pathogens and harmful chemicals and toxins. |
Risk Behaviors for Contact Lens-Related Eye Infections Among Adults and Adolescents - United States, 2016
Cope JR , Collier SA , Nethercut H , Jones JM , Yates K , Yoder JS . MMWR Morb Mortal Wkly Rep 2017 66 (32) 841-845 Contact lens-related eye infections, which can lead to serious outcomes, including blindness, are associated with several risk factors, including sleeping in lenses, exposing lenses to water, not adhering to replacement schedules, and reusing disinfecting solution. In some studies, adolescent and young adult contact lens wearers have been reported to be more likely than older adult contact lens wearers to develop eye infections and more likely to have poor contact lens hygiene practices. In 2015, CDC reported the number and demographics of adult contact lens wearers in the United States to define the population at risk for contact lens-related eye infections; however, this estimate did not include adolescents. To better understand this group of younger contact lens wearers and guide prevention efforts, a population-based survey was used to assess contact lens wear, care behaviors, risk factors, and demographics among persons aged 12-17 years (referred to as adolescents in this report), young adults aged 18-24 years, and older adults aged ≥25 years in the United States. In 2016, an estimated 3.6 million adolescents (14.5%) wore contact lenses. Of the adolescents who wore contact lenses, 85% reported at least one behavior that put them at risk for a contact lens-related eye infection, compared with 81% of young adults, and 88% of older adults. These findings can inform the creation of age-specific targeted prevention messages aimed at contact lens wearers and establish a baseline for evaluating trends in contact lens wear, care habits, and contact lens-related risk behaviors. |
Water exposure is a common risk behavior among soft and gas-permeable contact lens wearers
Zimmerman AB , Richdale K , Mitchell GL , Kinoshita BT , Lam DY , Wagner H , Sorbara L , Chalmers RL , Collier SA , Cope JR , Rao MM , Beach MJ , Yoder JS . Cornea 2017 36 (8) 995-1001 PURPOSE: To understand soft contact lens (SCL) and gas-permeable (GP) lens wearers' behaviors and knowledge regarding exposure of lenses to water. METHODS: The Contact Lens Risk Survey (CLRS) and health behavior questions were completed online by a convenience sample of 1056 SCL and 85 GP lens wearers aged 20 to 76 years. Participants were asked about exposing their lenses to water and their understanding of risks associated with these behaviors. Chi-square analyses examined relationships between patient behaviors and perceptions. RESULTS: GP lens wearers were more likely than SCL wearers to ever rinse or store lenses in water (rinsing: 91% GP, 31% SCL, P < 0.001; storing: 33% GP, 15% SCL P < 0.001). Among SCL wearers, men were more likely to store (24% vs. 13%, P = 0.003) or rinse (41% vs. 29%, P = 0.012) their lenses in water. Showering while wearing lenses was more common in SCL wearers (86%) than GP lens wearers (67%) (P < 0.0001). Swimming while wearing lenses was reported by 62% of SCL wearers and 48% of GP lens wearers (P = 0.027). Wearers who rinsed (SCL; P < 0.0001, GP; P = 0.11) or stored lenses in water (SCL; P < 0.0001, GP P = 0.007) reported that this behavior had little or no effect on their infection risk, compared with those who did not. Both SCL (P < 0.0001) and GP lens wearers (P < 0.0001) perceived that distilled water was safer than tap water for storing or rinsing lenses. CONCLUSIONS: Despite previously published evidence of Acanthamoeba keratitis' association with water exposure, most SCL, and nearly all GP lens wearers, regularly expose their lenses to water, with many unaware of the risk. |
Risk factors for Acanthamoeba keratitis-a multistate case-control study, 2008-2011
Brown AC , Ross J , Jones DB , Collier SA , Ayers TL , Hoekstra RM , Backensen B , Roy SL , Beach MJ , Yoder JS . Eye Contact Lens 2017 44 Suppl 1 S173-S178 OBJECTIVE: To identify modifiable risk factors contributing to Acanthamoeba keratitis (AK) infection. METHODS: A case-control investigation was conducted. Case patients were soft contact lens wearers with laboratory-confirmed AK. Control were soft contact lens wearers ≥12 years of age, with no history of AK. Case patients were recruited from 14 ophthalmology referral centers and a clinical laboratory. Control were matched on state of residence and type of primary eye care provider (ophthalmologist or optometrist). Participants were interviewed using a standardized questionnaire. Univariable and multivariable conditional logistic regression analyses were conducted. Matched odds ratios (mORs) were calculated. RESULTS: Participants included 88 case patients and 151 matched control. Case patients were more likely to be aged <25 years (unadjusted mOR 2.7, 95% confidence interval 1.3-5.5) or aged >53 years (mOR 2.5, 1.1-5.7), and more likely to be men (mOR 2.6, 1.4-4.8). Unadjusted analyses identified multiple risk factors: rinsing (mOR 6.3, 1.3-29.9) and storing lenses in tap water (mOR 3.9, 1.2-12.3), topping off solution in the lens case (mOR 4.0, 2.0-8.0), having worn lenses ≤5 years (mOR 2.4, 1.3-4.4), rinsing the case with tap water before storing lenses (mOR 2.1, 1.1-4.1), and using hydrogen peroxide (mOR 3.6, 1.1-11.7) versus multipurpose solution. Significant risk factors in multivariable modeling included age >53 years, male sex, topping off, and using saline solution. CONCLUSIONS: Numerous modifiable risk factors for AK were identified, mostly involving hygiene practices. To reduce the risk of AK, lens wearers should observe recommended lens care practices. |
Community laboratory testing for cryptosporidium: Multicenter study retesting public health surveillance stool samples positive for cryptosporidium by rapid cartridge assay with direct fluorescent antibody testing
Roellig DM , Yoder JS , Madison-Antenucci S , Robinson TJ , Van TT , Collier SA , Boxrud D , Monson T , Bates LA , Blackstock AJ , Shea S , Larson K , Xiao L , Beach M . PLoS One 2017 12 (1) e0169915 Cryptosporidium is a common cause of sporadic diarrheal disease and outbreaks in the United States. Increasingly, immunochromatography-based rapid cartridge assays (RCAs) are providing community laboratories with a quick cryptosporidiosis diagnostic method. In the current study, the Centers for Disease Control and Prevention (CDC), the Association of Public Health Laboratories (APHL), and four state health departments evaluated RCA-positive samples obtained during routine Cryptosporidium testing. All samples underwent "head to head" re-testing using both RCA and direct fluorescence assay (DFA). Community level results from three sites indicated that 54.4% (166/305) of Meridian ImmunoCard STAT! positives and 87.0% (67/77) of Remel Xpect positives were confirmed by DFA. When samples were retested by RCA at state laboratories and compared with DFA, 83.3% (155/186) of Meridian ImmunoCard STAT! positives and 95.2% (60/63) of Remel Xpect positives were confirmed. The percentage of confirmed community results varied by site: Minnesota, 39.0%; New York, 63.9%; and Wisconsin, 72.1%. The percentage of confirmed community results decreased with patient age; 12.5% of community positive tests could be confirmed by DFA for patients 60 years of age or older. The percentage of confirmed results did not differ significantly by sex, storage temperature, time between sample collection and testing, or season. Findings from this study demonstrate a lower confirmation rate of community RCA positives when compared to RCA positives identified at state laboratories. Elucidating the causes of decreased test performance in order to improve overall community laboratory performance of these tests is critical for understanding the epidemiology of cryptosporidiosis in the United States (US). |
Evolving epidemiology of reported cryptosporidiosis cases in the United States, 1995-2012
Painter JE , Gargano JW , Yoder JS , Collier SA , Hlavsa MC . Epidemiol Infect 2016 144 (8) 1792-802 Cryptosporidium is the leading aetiology of waterborne disease outbreaks in the United States. This report briefly describes the temporal and geographical distribution of US cryptosporidiosis cases and presents analyses of cryptosporidiosis case data reported in the United States for 1995-2012. The Cochran-Armitage test was used to assess changes in the proportions of cases by case status (confirmed vs. non-confirmed), sex, race, and ethnicity over the study period. Negative binomial regression models were used to estimate rate ratios (RR) and 95% confidence intervals (CI) for comparing rates across three time periods (1995-2004, 2005-2008, 2009-2012). The proportion of confirmed cases significantly decreased (P < 0.0001), and a crossover from male to female predominance in case-patients occurred (P < 0.0001). Overall, compared to 1995-2004, rates were higher in 2005-2008 (RR 2.92, 95% CI 2.08-4.09) and 2009-2012 (RR 2.66, 95% CI 1.90-3.73). However, rate changes from 2005-2008 to 2009-2012 varied by age group (P interaction < 0.0001): 0-14 years (RR 0.55, 95% CI 0.42-0.71), 15-44 years (RR 0.99, 95% CI 0.82-1.19), 45-64 years (RR 1.47, 95% CI 1.21-1.79) and 65 years (RR 2.18, 95% CI 1.46-3.25). The evolving epidemiology of cryptosporidiosis necessitates further identification of risk factors in population subgroups. Adding systematic molecular typing of Cryptosporidium specimens to US national cryptosporidiosis surveillance would help further identify risk factors and markedly expand understanding of cryptosporidiosis epidemiology in the United States. |
Acanthamoeba Keratitis among Rigid Gas Permeable Contact Lens Wearers in the United States, 2005 through 2011
Cope JR , Collier SA , Schein OD , Brown AC , Verani JR , Gallen R , Beach MJ , Yoder JS . Ophthalmology 2016 123 (7) 1435-41 PURPOSE: To describe the clinical presentation and outcomes of Acanthamoeba keratitis (AK) in rigid gas permeable (RGP) contact lens wearers and to identify modifiable risk factors. DESIGN: Case-control investigation. PARTICIPANTS: Patients were RGP contact lens-wearing United States residents with a diagnosis of AK from 2005 through 2011. Controls were RGP contact lens wearers with no history of AK who were at least 12 years of age. METHODS: Patients were identified during 2 multistate AK outbreak investigations. Controls from the first investigation in 2007 were identified using a reverse address directory. In the second investigation, controls were recruited from participating ophthalmology and optometry practices. Patients and controls were interviewed by phone using a standardized questionnaire. Odds ratios (ORs) and Fisher exact P values were calculated to assess risk factors associated with infection. MAIN OUTCOME MEASURES: Acanthamoeba keratitis, a rare eye disease primarily affecting contact lens wearers, is caused by free-living amebae, Acanthamoeba species. RESULTS: We identified 37 patients in the 2 investigations, 10 (27%) from the 2007 investigation and 27 (73%) from 2011. There were 17 healthy controls, 9 (53%) from 2007 and 8 (47%) from 2011. Among patients, 9 (24%) wore RGP lenses for orthokeratology or therapeutic indication; no controls wore RGP lenses for these indications. Significant risk factors for AK were wearing lenses for orthokeratology (OR, undefined; P = 0.02), sleeping while wearing lenses (OR, 8.00; P = 0.04), storing lenses in tap water (OR, 16.00; P = 0.001), and topping off contact lens solution in the case (OR, 4.80; P = 0.01). After stratifying by use of RGP lenses for orthokeratology, storing lenses in tap water and topping off remained significant exposures. CONCLUSIONS: Nearly one quarter of patients were orthokeratology wearers. Using tap water to store RGP lenses and topping off solution in the lens case were modifiable risk behaviors identified in RGP wearers who wore lenses for both orthokeratology and nonorthokeratology indications. Rigid gas permeable wearers should avoid exposing their lenses to tap water and should empty their cases and use fresh lens solution each time they take out their lenses. |
Giardiasis outbreaks in the United States, 1971-2011
Adam EA , Yoder JS , Gould LH , Hlavsa MC , Gargano JW . Epidemiol Infect 2016 144 (13) 1-12 Giardia intestinalis is the leading parasitic aetiology of human enteric infections in the United States, with an estimated 1.2 million cases occurring annually. To better understand transmission, we analysed data on all giardiasis outbreaks reported to the Centers for Disease Control and Prevention for 1971-2011. The 242 outbreaks, affecting ~41 000 persons, resulted from waterborne (74.8%), foodborne (15.7%), person-to-person (2.5%), and animal contact (1.2%) transmission. Most (74.6%) waterborne outbreaks were associated with drinking water, followed by recreational water (18.2%). Problems with water treatment, untreated groundwater, and distribution systems were identified most often during drinking water-associated outbreak investigations; problems with water treatment declined after the 1980s. Most recreational water-associated outbreaks were linked to treated swimming venues, with pools and wading pools implicated most often. Produce was implicated most often in foodborne outbreaks. Additionally, foods were most commonly prepared in a restaurant and contaminated by a food handler. Lessons learned from examining patterns in outbreaks over time can help prevent future disease. Groundwater and distribution system vulnerabilities, inadequate pool disinfection, fruit and vegetable contamination, and poor food handler hygiene are promising targets for giardiasis prevention measures. |
Diagnosis, clinical course, and treatment of primary amoebic meningoencephalitis in the United States, 1937-2013
Capewell LG , Harris AM , Yoder JS , Cope JR , Eddy BA , Roy SL , Visvesvara GS , Fox LM , Beach MJ . J Pediatric Infect Dis Soc 2015 4 (4) e68-75 BACKGROUND: Primary amoebic meningoencephalitis (PAM) is a rapidly progressing waterborne illness that predominately affects children and is nearly always fatal. PAM is caused by Naegleria fowleri, a free-living amoeba found in bodies of warm freshwater worldwide. METHODS: We reviewed exposure location, clinical signs and symptoms, diagnostic modalities, and treatment from confirmed cases of PAM diagnosed in the United States during 1937-2013. Patients were categorized into the early (ie, flu-like symptoms) or late (ie, central nervous system signs) group on the basis of presenting clinical characteristics. Here, we describe characteristics of the survivors and decedents. RESULT: The median age of the patients was 12 years (83% aged ≤18 years); males (76%) were predominately affected (N = 142). Most infections occurred in southern-tier states; however, 4 recent infections were acquired in northern states: Minnesota (2), Kansas (1), and Indiana (1). Most (72%) of the patients presented with central nervous system involvement. Cerebrospinal fluid analysis resembled bacterial meningitis with high opening pressures, elevated white blood cell counts with predominantly neutrophils (median, 2400 cells/muL [range, 5-26 000 cells/muL]), low glucose levels (median, 23 mg/dL [range, 1-92 mg/dL]), and elevated protein levels (median, 365 mg/dL [range, 24-1210 mg/dL]). Amoebas found in the cerebrospinal fluid were diagnostic, but PAM was diagnosed for only 27% of the patients before death. Imaging results were abnormal in approximately three-fourths of the patients but were not diagnostic for amoebic infection. Three patients in the United States survived. CONCLUSIONS: To our knowledge, this is the first comprehensive clinical case series of PAM presented in the United States. PAM is a fatal illness with limited treatment success and is expanding into more northern regions. Clinicians who suspect that they have a patient with PAM should contact the US Centers for Disease Control and Prevention at 770-488-7100 (available 24 hours/day, 7 days/week) to discuss diagnostic testing and treatment options (see cdc.gov/naegleria). |
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