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Notes from the field: A cluster of multi-strain invasive pneumococcal disease among persons experiencing homelessness and use of pneumococcal conjugate vaccine - El Paso County, Colorado, 2022
Callaway J , Durbin K , Zachary H , Barnes MM , Kobayashi M , Chochua S , Gayou N , Albanese B . MMWR Morb Mortal Wkly Rep 2023 72 (46) 1277-1278 Persons experiencing homelessness are often at increased risk for invasive pneumococcal disease (IPD)* due to underlying health conditions or risk factors (risk conditions) (1,2). Homelessness alone is not an indication for pneumococcal vaccination according to current Advisory Committee on Immunization Practices (ACIP) recommendations (3): adults aged ≥65 years or 19–64 years with certain underlying medical conditions or risk factors† with no previous or unknown history of receipt of pneumococcal conjugate vaccine (PCV) should receive 1 dose of either 20-valent or 15-valent PCV (PCV20 or PCV15, respectively). On November 29, 2022, El Paso (Colorado) County Public Health (EPCPH) was informed by a single hospital of three cases of IPD among persons experiencing homelessness, with all illness onset dates occurring within a single week. |
Hypertension among persons living with HIV - Zambia, 2021; A cross-sectional study of a national electronic health record system (preprint)
Hines JZ , Prieto JT , Itoh M , Fwoloshi S , Zyambo KD , Zachary D , Chitambala C , Minchella PA , Mulenga LB , Agolory S . medRxiv 2023 16 Background Hypertension is a major risk factor for cardiovascular disease, which is a common cause of death in Zambia. Data on hypertension prevalence in Zambia are scarce and limited to specific geographic areas and/or populations. We measured hypertension prevalence among persons living with HIV (PLHIV) in Zambia using a national electronic health record (EHR) system. Methods We did a cross-sectional study of hypertension prevalence among PLHIV aged >=18 years in Zambia during 2021. Data were extracted from the SmartCare EHR, which covers ~90% of PLHIV on treatment in Zambia. PLHIV with >=2 recorded blood pressure (BP) readings in 2021 were included. Hypertension was defined as >=2 elevated BP readings (i.e., systolic BP of >=140 mmHg or diastolic BP of >=90 mmHg) during 2021 and/or on anti-hypertensive medication recorded in their EHR in the past five years. Multivariable logistic regression was used to assess associations between hypertension and independent variables. Results Among 750,098 PLHIV aged >=18 years with >=2 visits in SmartCare during 2021, 101,363 (13.5%) had >=2 blood pressure readings recorded in their EHR. Among these PLHIV, 14.7% (95% confidence interval [CI]: 14.5-14.9) had hypertension during 2021. Only 8.9% of PLHIV with hypertension had an antihypertensive medication recorded in their EHR. The odds of hypertension were greater in older age groups compared to PLHIV aged 18-29 years (adjusted odds ratio [aOR] for 30-44 years: 2.6 [95% CI: 2.4-2.9]; aOR for 45-49 years: 6.4 [95% CI: 5.8-7.0]; aOR for >=60 years: 14.5 [95% CI: 13.1-16.1]), urban areas (aOR: 1.9 [95% CI: 1.8-2.1]), and persons prescribed ART for >=6-month at a time (aOR: 1.1 [95% CI: 1.0-1.2]). Discussion Hypertension was common among a cohort of PLHIV in Zambia, with few having documentation of being on antihypertensive treatment. Most PLHIV were excluded from the analysis because of missing BP measurements in their EHR. Strengthening integrated management of non-communicable diseases in ART clinics might help to diagnose and treat hypertension in Zambia. Data completeness needs to be improved to routinely capture cardiovascular disease risk factors, including blood pressure readings consistently for PHLIV in their EHRs. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license. |
Hypertension among persons living with HIV-Zambia, 2021; A cross-sectional study of a national electronic health record system
Hines JZ , Prieto JT , Itoh M , Fwoloshi S , Zyambo KD , Sivile S , Mweemba A , Chisemba P , Kakoma E , Zachary D , Chitambala C , Minchella PA , Mulenga LB , Agolory S . PLOS Glob Public Health 2023 3 (7) e0001686 Hypertension is a major risk factor for cardiovascular disease, which is a common cause of death in Zambia. Data on hypertension prevalence in Zambia are scarce and limited to specific geographic areas and/or populations. We measured hypertension prevalence among persons living with HIV (PLHIV) in Zambia using a national electronic health record (EHR) system. We did a cross-sectional study of hypertension prevalence among PLHIV aged ≥18 years during 2021. Data were extracted from the SmartCare EHR, which covers ~90% of PLHIV on treatment in Zambia. PLHIV with ≥2 clinical visits in 2021 were included. Hypertension was defined as ≥2 elevated blood pressure readings (systolic ≥140 mmHg/diastolic ≥90 mmHg) during 2021 and/or on anti-hypertensive medication recorded in their EHR ≤5 years. Logistic regression was used to assess for associations between hypertension and demographic characteristics. Among 750,098 PLHIV aged ≥18 years with ≥2 visits during 2021, 101,363 (13.5%) had ≥2 recorded blood pressure readings. Among these PLHIV, 14.7% (95% confidence interval [CI]: 14.5-14.9) had hypertension. Only 8.9% of PLHIV with hypertension had an anti-hypertensive medication recorded in their EHR. The odds of hypertension were greater in older age groups compared to PLHIV aged 18-29 years (adjusted odds ratio [aOR] for 30-44 years: 2.6 [95% CI: 2.4-2.9]; aOR for 45-49 years: 6.4 [95% CI: 5.8-7.0]; aOR for ≥60 years: 14.5 [95% CI: 13.1-16.1]), urban areas (aOR: 1.9 [95% CI: 1.8-2.1]), and on ART for ≥6-month at a time (aOR: 1.1 [95% CI: 1.0-1.2]). Hypertension was common among PLHIV in Zambia, with few having documentation of treatment. Most PLHIV were excluded from the analysis because of missing BP measurements. Strengthening integrated management of non-communicable diseases in HIV clinics might help to diagnose and treat hypertension in Zambia. Addressing missing data of routine clinical data (like blood pressure) could improve non-communicable diseases surveillance in Zambia. |
Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions - United States, January-May 2020.
Lange SJ , Ritchey MD , Goodman AB , Dias T , Twentyman E , Fuld J , Schieve LA , Imperatore G , Benoit SR , Kite-Powell A , Stein Z , Peacock G , Dowling NF , Briss PA , Hacker K , Gundlapalli AV , Yang Q . Am J Transplant 2020 20 (9) 2612-2617 This article describes a significant decline in emergency department visits for acute life-threatening conditions during the COVID-19 pandemic, suggesting that patients may be delaying or avoiding care or unable to access care during the pandemic. |
Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12-25 Years Before and During the COVID-19 Pandemic - United States, January 2019-May 2021.
Yard E , Radhakrishnan L , Ballesteros MF , Sheppard M , Gates A , Stein Z , Hartnett K , Kite-Powell A , Rodgers L , Adjemian J , Ehlman DC , Holland K , Idaikkadar N , Ivey-Stephenson A , Martinez P , Law R , Stone DM . MMWR Morb Mortal Wkly Rep 2021 70 (24) 888-894 Beginning in March 2020, the COVID-19 pandemic and response, which included physical distancing and stay-at-home orders, disrupted daily life in the United States. Compared with the rate in 2019, a 31% increase in the proportion of mental health-related emergency department (ED) visits occurred among adolescents aged 12-17 years in 2020 (1). In June 2020, 25% of surveyed adults aged 18-24 years reported experiencing suicidal ideation related to the pandemic in the past 30 days (2). More recent patterns of ED visits for suspected suicide attempts among these age groups are unclear. Using data from the National Syndromic Surveillance Program (NSSP),* CDC examined trends in ED visits for suspected suicide attempts(†) during January 1, 2019-May 15, 2021, among persons aged 12-25 years, by sex, and at three distinct phases of the COVID-19 pandemic. Compared with the corresponding period in 2019, persons aged 12-25 years made fewer ED visits for suspected suicide attempts during March 29-April 25, 2020. However, by early May 2020, ED visit counts for suspected suicide attempts began increasing among adolescents aged 12-17 years, especially among girls. During July 26-August 22, 2020, the mean weekly number of ED visits for suspected suicide attempts among girls aged 12-17 years was 26.2% higher than during the same period a year earlier; during February 21-March 20, 2021, mean weekly ED visit counts for suspected suicide attempts were 50.6% higher among girls aged 12-17 years compared with the same period in 2019. Suicide prevention measures focused on young persons call for a comprehensive approach, that is adapted during times of infrastructure disruption, involving multisectoral partnerships (e.g., public health, mental health, schools, and families) and implementation of evidence-based strategies (3) that address the range of factors influencing suicide risk. |
Azithromycin and Ciprofloxacin Treatment Outcomes During an Outbreak of Multidrug-Resistant Shigella sonnei Infections in a Retirement Community-Vermont, 2018.
Gharpure R , Friedman CR , Fialkowski V , Collins JP , Strysko J , Marsh ZA , Chen JC , Meservey EH , Adediran AA , Schroeder MN , Wadhwa A , Fullerton KE , Watkins LF . Clin Infect Dis 2021 74 (3) 455-460 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. |
Emergency Department Visits for COVID-19 by Race and Ethnicity - 13 States, October-December 2020.
Smith AR , DeVies J , Caruso E , Radhakrishnan L , Sheppard M , Stein Z , Calanan RM , Hartnett KP , Kite-Powell A , Rodgers L , Adjemian J . MMWR Morb Mortal Wkly Rep 2021 70 (15) 566-569 Hispanic or Latino (Hispanic), non-Hispanic Black or African American (Black), and non-Hispanic American Indian or Alaska Native (AI/AN) persons have experienced disproportionately higher rates of hospitalization and death attributable to COVID-19 than have non-Hispanic White (White) persons (1-4). Emergency care data offer insight into COVID-19 incidence; however, differences in use of emergency department (ED) services for COVID-19 by racial and ethnic groups are not well understood. These data, most of which are recorded within 24 hours of the visit, might be an early indicator of changing patterns in disparities. Using ED visit data from 13 states obtained from the National Syndromic Surveillance Program (NSSP), CDC assessed the number of ED visits with a COVID-19 discharge diagnosis code per 100,000 population during October-December 2020 by age and race/ethnicity. Among 5,794,050 total ED visits during this period, 282,220 (4.9%) were for COVID-19. Racial/ethnic disparities in COVID-19 ED visit rates were observed across age groups. Compared with White persons, Hispanic, AI/AN, and Black persons had significantly more COVID-19-related ED visits overall (rate ratio [RR] range = 1.39-1.77) and in all age groups through age 74 years; compared with White persons aged ≥75 years, Hispanic and AI/AN persons also had more COVID-19-related ED visits (RR = 1.91 and 1.22, respectively). These differences in ED visit rates suggest ongoing racial/ethnic disparities in COVID-19 incidence and can be used to prioritize prevention resources, including COVID-19 vaccination, to reach disproportionately affected communities and reduce the need for emergency care for COVID-19. |
Trends in Geographic and Temporal Distribution of US Children With Multisystem Inflammatory Syndrome During the COVID-19 Pandemic.
Belay ED , Abrams J , Oster ME , Giovanni J , Pierce T , Meng L , Prezzato E , Balachandran N , Openshaw JJ , Rosen HE , Kim M , Richardson G , Hand J , Tobin-D'Angelo M , Wilson S , Hartley A , Jones C , Kolsin J , Mohamed H , Colles Z , Hammett T , Patel P , Stierman B , Campbell AP , Godfred-Cato S . JAMA Pediatr 2021 175 (8) 837-845 IMPORTANCE: Multiple inflammatory syndrome in children (MIS-C) occurs in association with the COVID-19 pandemic. OBJECTIVE: To describe the clinical characteristics and geographic and temporal distribution of the largest cohort of patients with MIS-C in the United States to date. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis was conducted on clinical and laboratory data collected from patients with MIS-C. The analysis included patients with illness onset from March 2020 to January 2021 and met MIS-C case definition. MAIN OUTCOMES AND MEASURES: Geographic and temporal distribution of MIS-C was compared with that of COVID-19 nationally, by region, and level of urbanicity by county. Clinical and laboratory findings and changes over time were described by age group and by presence or absence of preceding COVID-19. RESULTS: A total of 1733 patients with MIS-C were identified; 994 (57.6%) were male and 1117 (71.3%) were Hispanic or non-Hispanic Black. Gastrointestinal symptoms, rash, and conjunctival hyperemia were reported by 53% (n = 931) to 67% (n = 1153) of patients. A total of 937 patients (54%) had hypotension or shock, and 1009 (58.2%) were admitted for intensive care. Cardiac dysfunction was reported in 484 patients (31.0%), pericardial effusion in 365 (23.4%), myocarditis in 300 (17.3%), and coronary artery dilatation or aneurysms in 258 (16.5%). Patients aged 0 to 4 years had the lowest proportion of severe manifestations, although 171 patients (38.4%) had hypotension or shock and 197 (44.3%) were admitted for intensive care. Patients aged 18 to 20 years had the highest proportions with myocarditis (17 [30.9%]), pneumonia (20 [36.4%]), acute respiratory distress syndrome (10 [18.2%]), and polymerase chain reaction positivity (39 [70.9%]). These older adolescents also had the highest proportion reporting preceding COVID-19-like illness (63%). Nationally, the first 2 MIS-C peaks followed the COVID-19 peaks by 2 to 5 weeks. The cumulative MIS-C incidence per 100 000 persons younger than 21 years was 2.1 and varied from 0.2 to 6.3 by state. Twenty-four patients (1.4%) died. CONCLUSIONS AND RELEVANCE: In this cross-sectional study of a large cohort of patients with MIS-C, 2 peaks that followed COVID-19 peaks by 2 to 5 weeks were identified. The geographic and temporal association of MIS-C with the COVID-19 pandemic suggested that MIS-C resulted from delayed immunologic responses to SARS-CoV-2 infection. The clinical manifestations varied by age and by presence or absence of preceding COVID-19. |
Mass SARS-CoV-2 Testing in a Dormitory-Style Correctional Facility in Arkansas.
Tompkins LK , Gunn JKL , Cherney B , Ham JE , Horth R , Rossetti R , Bower WA , Benson K , Hagan LM , Crist MB , Mettee Zarecki SL , Dixon MG , Dillaha JA , Patil N , Dusseau C , Ross T , Matthews HS , Garner K , Starks AM , Weiner Z , Bowen MD , Bankamp B , Newton AE , Logan N , Schuh AJ , Trimble S , Pfeiffer H , James AE , Tian N , Jacobs JR , Ruiz F , McDonald K , Thompson M , Cooley L , Honein MA , Rose DA . Am J Public Health 2021 111 (5) e1-e10 Objectives. To assess SARS-CoV-2 transmission within a correctional facility and recommend mitigation strategies.Methods. From April 29 to May 15, 2020, we established the point prevalence of COVID-19 among incarcerated persons and staff within a correctional facility in Arkansas. Participants provided respiratory specimens for SARS-CoV-2 testing and completed questionnaires on symptoms and factors associated with transmission.Results. Of 1647 incarcerated persons and 128 staff tested, 30.5% of incarcerated persons (range by housing unit = 0.0%-58.2%) and 2.3% of staff tested positive for SARS-CoV-2. Among those who tested positive and responded to symptom questions (431 incarcerated persons, 3 staff), 81.2% and 33.3% were asymptomatic, respectively. Most incarcerated persons (58.0%) reported wearing cloth face coverings 8 hours or less per day, and 63.3% reported close contact with someone other than their bunkmate.Conclusions. If testing remained limited to symptomatic individuals, fewer cases would have been detected or detection would have been delayed, allowing transmission to continue. Rapid implementation of mass testing and strict enforcement of infection prevention and control measures may be needed to mitigate spread of SARS-CoV-2 in this setting. (Am J Public Health. Published online ahead of print March 18, 2021: e1-e10. https://doi.org/10.2105/AJPH.2020.306117). |
Use of US Public Health Travel Restrictions during COVID-19 Outbreak on Diamond Princess Ship, Japan, February-April 2020.
Medley AM , Marston BJ , Toda M , Kobayashi M , Weinberg M , Moriarty LF , Jungerman MR , Surpris ACA , Knust B , Acosta AM , Shockey CE , Daigle D , Schneider ZD , Charles J , Ishizumi A , Stewart A , Vonnahme LA , Brown C , White S , Cohen NJ , Cetron M . Emerg Infect Dis 2021 27 (3) 710-718 Public health travel restrictions (PHTR) are crucial measures during communicable disease outbreaks to prevent transmission during commercial airline travel and mitigate cross-border importation and spread. We evaluated PHTR implementation for US citizens on the Diamond Princess during its coronavirus disease (COVID-19) outbreak in Japan in February 2020 to explore how PHTR reduced importation of COVID-19 to the United States during the early phase of disease containment. Using PHTR required substantial collaboration among the US Centers for Disease Control and Prevention, other US government agencies, the cruise line, and public health authorities in Japan. Original US PHTR removal criteria were modified to reflect international testing protocols and enable removal of PHTR for persons who recovered from illness. The impact of PHTR on epidemic trajectory depends on the risk for transmission during travel and geographic spread of disease. Lessons learned from the Diamond Princess outbreak provide critical information for future PHTR use. |
Trends in U.S. Emergency Department Visits Related to Suspected or Confirmed Child Abuse and Neglect Among Children and Adolescents Aged <18 Years Before and During the COVID-19 Pandemic - United States, January 2019-September 2020.
Swedo E , Idaikkadar N , Leemis R , Dias T , Radhakrishnan L , Stein Z , Chen M , Agathis N , Holland K . MMWR Morb Mortal Wkly Rep 2020 69 (49) 1841-1847 Heightened stress, school closures, loss of income, and social isolation resulting from the coronavirus disease 2019 (COVID-19) pandemic have increased the risk for child abuse and neglect (1). Using National Syndromic Surveillance Program (NSSP) data from January 6, 2019-September 6, 2020, CDC tabulated weekly numbers of emergency department (ED) visits related to child abuse and neglect and calculated the proportions of such visits per 100,000 ED visits, as well as the percentage of suspected or confirmed ED visits related to child abuse and neglect ending in hospitalization, overall and stratified by age group (0-4, 5-11, and 12-17 years). The total number of ED visits related to child abuse and neglect began decreasing below the corresponding 2019 period during week 11 (March 15-March 22, 2020) for all age groups examined, coinciding with the declaration of a national emergency on March 13 (2); simultaneously, the proportion of these visits per 100,000 ED visits began increasing above the 2019 baseline for all age groups. Despite decreases in the weekly number of ED visits related to child abuse and neglect, the weekly number of these visits resulting in hospitalization remained stable in 2020; however, the yearly percentage of ED visits related to child abuse and neglect resulting in hospitalization increased significantly among all age groups. Although the increased proportion of ED visits related to child abuse and neglect might be associated with a decrease in the overall number of ED visits, these findings also suggest that health care-seeking patterns have shifted during the pandemic. Hospitalizations for child abuse and neglect did not decrease in 2020, suggesting that injury severity did not decrease during the pandemic, despite decreased ED visits. Child abuse is preventable; implementation of strategies including strengthening household economic supports and creating family-friendly work policies can reduce stress during difficult times and increase children's opportunities to thrive in safe, stable, and nurturing relationships and environments (3). |
Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection - United Kingdom and United States, March-August 2020.
Morris SB , Schwartz NG , Patel P , Abbo L , Beauchamps L , Balan S , Lee EH , Paneth-Pollak R , Geevarughese A , Lash MK , Dorsinville MS , Ballen V , Eiras DP , Newton-Cheh C , Smith E , Robinson S , Stogsdill P , Lim S , Fox SE , Richardson G , Hand J , Oliver NT , Kofman A , Bryant B , Ende Z , Datta D , Belay E , Godfred-Cato S . MMWR Morb Mortal Wkly Rep 2020 69 (40) 1450-1456 During the course of the coronavirus disease 2019 (COVID-19) pandemic, reports of a new multisystem inflammatory syndrome in children (MIS-C) have been increasing in Europe and the United States (1-3). Clinical features in children have varied but predominantly include shock, cardiac dysfunction, abdominal pain, and elevated inflammatory markers, including C-reactive protein (CRP), ferritin, D-dimer, and interleukin-6 (1). Since June 2020, several case reports have described a similar syndrome in adults; this review describes in detail nine patients reported to CDC, seven from published case reports, and summarizes the findings in 11 patients described in three case series in peer-reviewed journals (4-6). These 27 patients had cardiovascular, gastrointestinal, dermatologic, and neurologic symptoms without severe respiratory illness and concurrently received positive test results for SARS-CoV-2, the virus that causes COVID-19, by polymerase chain reaction (PCR) or antibody assays indicating recent infection. Reports of these patients highlight the recognition of an illness referred to here as multisystem inflammatory syndrome in adults (MIS-A), the heterogeneity of clinical signs and symptoms, and the role for antibody testing in identifying similar cases among adults. Clinicians and health departments should consider MIS-A in adults with compatible signs and symptoms. These patients might not have positive SARS-CoV-2 PCR or antigen test results, and antibody testing might be needed to confirm previous SARS-CoV-2 infection. Because of the temporal association between MIS-A and SARS-CoV-2 infections, interventions that prevent COVID-19 might prevent MIS-A. Further research is needed to understand the pathogenesis and long-term effects of this newly described condition. |
COVID-19 in Americans aboard the Diamond Princess cruise ship.
Plucinski MM , Wallace M , Uehara A , Kurbatova EV , Tobolowsky FA , Schneider ZD , Ishizumi A , Bozio CH , Kobayashi M , Toda M , Stewart A , Wagner RL , Moriarty LF , Murray R , Queen K , Tao Y , Paden C , Mauldin MR , Zhang J , Li Y , Elkins CA , Lu X , Herzig CTA , Novak R , Bower W , Medley AM , Acosta AM , Knust B , Cantey PT , Pesik NT , Halsey ES , Cetron MS , Tong S , Marston BJ , Friedman CR . Clin Infect Dis 2020 72 (10) e448-e457 BACKGROUND: The Diamond Princess cruise ship was the site of a large outbreak of coronavirus disease 2019 (COVID-19). Of 437 Americans and their travel companions on the ship, 114 (26%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS: We interviewed 229 American passengers and crew after disembarkation following a ship-based quarantine to identify risk factors for infection and characterize transmission onboard the ship. RESULTS: The attack rate for passengers in single-person cabins or without infected cabinmates was 18% (58/329), compared with 63% (27/43) for those sharing a cabin with an asymptomatic infected cabinmate, and 81% (25/31) for those with a symptomatic infected cabinmate. Whole genome sequences from specimens from passengers who shared cabins clustered together. Of 66 SARS-CoV-2-positive American travelers with complete symptom information, 14 (21%) were asymptomatic while on the ship. Among SARS-CoV-2-positive Americans, 10 (9%) required intensive care, of whom 7 were ≥70 years. CONCLUSION: Our findings highlight the high risk of SARS-CoV-2 transmission on cruise ships. High rates of SARS-CoV-2 positivity in cabinmates of individuals with asymptomatic infections suggest that triage by symptom status in shared quarters is insufficient to halt transmission. A high rate of intensive care unit admission among older individuals complicates the prospect of future cruise travel during the pandemic, given typical cruise passenger demographics. The magnitude and severe outcomes of this outbreak were major factors contributing to the Centers for Disease Control and Prevention's decision to halt cruise ship travel in U.S. waters in March 2020. |
Detection and Genetic Characterization of Community-Based SARS-CoV-2 Infections - New York City, March 2020.
Greene SK , Keating P , Wahnich A , Weiss D , Pathela P , Harrison C , Rakeman J , Langley G , Tong S , Tao Y , Uehara A , Queen K , Paden CR , Szymczak W , Orner EP , Nori P , Lai PA , Jacobson JL , Singh HK , Calfee DP , Westblade LF , Vasovic LV , Rand JH , Liu D , Singh V , Burns J , Prasad N , Sell J , CDC COVID-19 Surge Laboratory Group , Abernathy Emily , Anderson Raydel , Bankamp Bettina , Bell Melissa , Galloway Renee , Graziano James , Kim Gimin , Kondas Ashley , Lee Christopher , Radford Kay , Rogers Shannon , Smith Peyton , Tiller Rebekah , Weiner Zachary , Wharton Adam , Whitaker Brett . MMWR Morb Mortal Wkly Rep 2020 69 (28) 918-922 To limit introduction of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), the United States restricted travel from China on February 2, 2020, and from Europe on March 13. To determine whether local transmission of SARS-CoV-2 could be detected, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) conducted deidentified sentinel surveillance at six NYC hospital emergency departments (EDs) during March 1-20. On March 8, while testing availability for SARS-CoV-2 was still limited, DOHMH announced sustained community transmission of SARS-CoV-2 (1). At this time, twenty-six NYC residents had confirmed COVID-19, and ED visits for influenza-like illness* increased, despite decreased influenza virus circulation.(†) The following week, on March 15, when only seven of the 56 (13%) patients with known exposure histories had exposure outside of NYC, the level of community SARS-CoV-2 transmission status was elevated from sustained community transmission to widespread community transmission (2). Through sentinel surveillance during March 1-20, DOHMH collected 544 specimens from patients with influenza-like symptoms (ILS)(§) who had negative test results for influenza and, in some instances, other respiratory pathogens.(¶) All 544 specimens were tested for SARS-CoV-2 at CDC; 36 (6.6%) tested positive. Using genetic sequencing, CDC determined that the sequences of most SARS-CoV-2-positive specimens resembled those circulating in Europe, suggesting probable introductions of SARS-CoV-2 from Europe, from other U.S. locations, and local introductions from within New York. These findings demonstrate that partnering with health care facilities and developing the systems needed for rapid implementation of sentinel surveillance, coupled with capacity for genetic sequencing before an outbreak, can help inform timely containment and mitigation strategies. |
Potential Indirect Effects of the COVID-19 Pandemic on Use of Emergency Departments for Acute Life-Threatening Conditions - United States, January-May 2020.
Lange SJ , Ritchey MD , Goodman AB , Dias T , Twentyman E , Fuld J , Schieve LA , Imperatore G , Benoit SR , Kite-Powell A , Stein Z , Peacock G , Dowling NF , Briss PA , Hacker K , Gundlapalli AV , Yang Q . MMWR Morb Mortal Wkly Rep 2020 69 (25) 795-800 On March 13, 2020, the United States declared a national emergency in response to the coronavirus disease 2019 (COVID-19) pandemic. Subsequently, states enacted stay-at-home orders to slow the spread of SARS-CoV-2, the virus that causes COVID-19, and reduce the burden on the U.S. health care system. CDC* and the Centers for Medicare & Medicaid Services (CMS)(dagger) recommended that health care systems prioritize urgent visits and delay elective care to mitigate the spread of COVID-19 in health care settings. By May 2020, national syndromic surveillance data found that emergency department (ED) visits had declined 42% during the early months of the pandemic (1). This report describes trends in ED visits for three acute life-threatening health conditions (myocardial infarction [MI, also known as heart attack], stroke, and hyperglycemic crisis), immediately before and after declaration of the COVID-19 pandemic as a national emergency. These conditions represent acute events that always necessitate immediate emergency care, even during a public health emergency such as the COVID-19 pandemic. In the 10 weeks following the emergency declaration (March 15-May 23, 2020), ED visits declined 23% for MI, 20% for stroke, and 10% for hyperglycemic crisis, compared with the preceding 10-week period (January 5-March 14, 2020). EDs play a critical role in diagnosing and treating life-threatening conditions that might result in serious disability or death. Persons experiencing signs or symptoms of serious illness, such as severe chest pain, sudden or partial loss of motor function, altered mental state, signs of extreme hyperglycemia, or other life-threatening issues, should seek immediate emergency care, regardless of the pandemic. Clear, frequent, highly visible communication from public health and health care professionals is needed to reinforce the importance of timely care for medical emergencies and to assure the public that EDs are implementing infection prevention and control guidelines that help ensure the safety of their patients and health care personnel. |
SARS-CoV-2 Infections and Serologic Responses from a Sample of U.S. Navy Service Members - USS Theodore Roosevelt, April 2020.
Payne DC , Smith-Jeffcoat SE , Nowak G , Chukwuma U , Geibe JR , Hawkins RJ , Johnson JA , Thornburg NJ , Schiffer J , Weiner Z , Bankamp B , Bowen MD , MacNeil A , Patel MR , Deussing E , CDC COVID-19 Surge Laboratory Group , Tiller Rebekah , Galloway Rene , Rogers Shannon , Whitaker Brett , Kondas Ashley , Smith Peyton , Lee Christopher , Graziano James , Gillingham BL . MMWR Morb Mortal Wkly Rep 2020 69 (23) 714-721 Compared with the volume of data on coronavirus disease 2019 (COVID-19) outbreaks among older adults, relatively few data are available concerning COVID-19 in younger, healthy persons in the United States (1,2). In late March 2020, the aircraft carrier USS Theodore Roosevelt arrived at port in Guam after numerous U.S. service members onboard developed COVID-19. In April, the U.S. Navy and CDC investigated this outbreak, and the demographic, epidemiologic, and laboratory findings among a convenience sample of 382 service members serving aboard the aircraft carrier are reported in this study. The outbreak was characterized by widespread transmission with relatively mild symptoms and asymptomatic infection among this sample of mostly young, healthy adults with close, congregate exposures. Service members who reported taking preventive measures had a lower infection rate than did those who did not report taking these measures (e.g., wearing a face covering, 55.8% versus 80.8%; avoiding common areas, 53.8% versus 67.5%; and observing social distancing, 54.7% versus 70.0%, respectively). The presence of neutralizing antibodies, which represent antibodies that inhibit SARS-CoV-2, among the majority (59.2%) of those with antibody responses is a promising indicator of at least short-term immunity. This report improves the understanding of COVID-19 in the U.S. military and among young adults in congregate settings and reinforces the importance of preventive measures to lower risk for infection in similar environments. |
Outbreak of Salmonella Newport Infections with Decreased Susceptibility to Azithromycin Linked to Beef Obtained in the United States and Soft Cheese Obtained in Mexico - United States, 2018-2019.
Plumb ID , Schwensohn CA , Gieraltowski L , Tecle S , Schneider ZD , Freiman J , Cote A , Noveroske D , Kolsin J , Brandenburg J , Chen JC , Tagg KA , White PB , Shah HJ , Francois Watkins LK , Wise ME , Friedman CR . MMWR Morb Mortal Wkly Rep 2019 68 (33) 713-717 In September 2018, CDC identified Salmonella enterica serotype Newport (Newport) infections that were multidrug resistant (MDR), with decreased susceptibility to azithromycin, a recommended oral treatment agent. Until 2017, decreased susceptibility to azithromycin had occurred in fewer than 0.5% of Salmonella isolates from U.S. residents. This report summarizes the investigation of a multistate MDR Salmonella outbreak conducted by CDC, state and local health departments, and the U.S. Department of Agriculture's Food Safety and Inspection Service. During June 2018-March 2019, 255 cases of infection with the outbreak strain were identified in 32 states; 43% of patients (89 of 206 with information on travel) reported recent travel to Mexico. Infections were linked to consumption of soft cheese obtained in Mexico and beef obtained in the United States. Consumers should avoid eating soft cheese that could be made from unpasteurized milk, regardless of the source of the cheese. When preparing beef, a food thermometer should be used to ensure that appropriate cooking temperatures are reached. When antibiotic treatment is needed for a patient, clinicians should choose antibiotics based on susceptibility testing wherever possible. |
Heteroresistance to the model antimicrobial peptide polymyxin B in the emerging Neisseria meningitidis linage11.2 urethritis clade: mutations in the pilMNOPQ operon.
Tzeng YL , Berman Z , Toh E , Bazan JA , Turner AN , Retchless AC , Wang X , Nelson DE , Stephens DS . Mol Microbiol 2019 111 (1) 254-268 Clusters of Neisseria meningitidis (Nm) urethritis among primarily heterosexual males in multiple US cities have been attributed to a unique non-encapsulated meningococcal clade (the US Nm urethritis clade, US_NmUC) within the hypervirulent clonal complex 11. Resistance to antimicrobial peptides (AMPs) is a key feature of urogenital pathogenesis of the closely related species, Neisseria gonorrhoeae. The US_NmUC isolates were found to be highly resistant to the model AMP, polymyxin B (PmB, MICs 64-256 microg ml(-1) ). The isolates also demonstrated stable subpopulations of heteroresistant colonies that showed near total resistant to PmB (MICs 384-1024 microg ml(-1) ) and colistin (MIC 256 microg ml(-1) ) as well as enhanced LL-37 resistance. This is the first observation of heteroresistance in N. meningitidis. Consistent with previous findings, overall PmB resistance in US_NmUC isolates was due to active Mtr efflux and LptA-mediated lipid A modification. However, whole genome sequencing, variant analyses and directed mutagenesis revealed that the heteroresistance phenotypes and very high-level AMP resistance were the result of point mutations and IS1655 element movement in the pilMNOPQ operon, encoding the type IV pilin biogenesis apparatus. Cross-resistance to other classes of antibiotics was also observed in the heteroresistant colonies. High-level resistance to AMPs may contribute to the pathogenesis of US_NmUC. |
Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014.
Baio J , Wiggins L , Christensen DL , Maenner MJ , Daniels J , Warren Z , Kurzius-Spencer M , Zahorodny W , Robinson Rosenberg C , White T , Durkin MS , Imm P , Nikolaou L , Yeargin-Allsopp M , Lee LC , Harrington R , Lopez M , Fitzgerald RT , Hewitt A , Pettygrove S , Constantino JN , Vehorn A , Shenouda J , Hall-Lande J , Van Naarden Braun K , Dowling NF . MMWR Surveill Summ 2018 67 (6) 1-23 PROBLEM/CONDITION: Autism spectrum disorder (ASD). PERIOD COVERED: 2014. DESCRIPTION OF SYSTEM: The Autism and Developmental Disabilities Monitoring (ADDM) Network is an active surveillance system that provides estimates of the prevalence of autism spectrum disorder (ASD) among children aged 8 years whose parents or guardians reside within 11 ADDM sites in the United States (Arizona, Arkansas, Colorado, Georgia, Maryland, Minnesota, Missouri, New Jersey, North Carolina, Tennessee, and Wisconsin). ADDM surveillance is conducted in two phases. The first phase involves review and abstraction of comprehensive evaluations that were completed by professional service providers in the community. Staff completing record review and abstraction receive extensive training and supervision and are evaluated according to strict reliability standards to certify effective initial training, identify ongoing training needs, and ensure adherence to the prescribed methodology. Record review and abstraction occurs in a variety of data sources ranging from general pediatric health clinics to specialized programs serving children with developmental disabilities. In addition, most of the ADDM sites also review records for children who have received special education services in public schools. In the second phase of the study, all abstracted information is reviewed systematically by experienced clinicians to determine ASD case status. A child is considered to meet the surveillance case definition for ASD if he or she displays behaviors, as described on one or more comprehensive evaluations completed by community-based professional providers, consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria for autistic disorder; pervasive developmental disorder-not otherwise specified (PDD-NOS, including atypical autism); or Asperger disorder. This report provides updated ASD prevalence estimates for children aged 8 years during the 2014 surveillance year, on the basis of DSM-IV-TR criteria, and describes characteristics of the population of children with ASD. In 2013, the American Psychiatric Association published the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which made considerable changes to ASD diagnostic criteria. The change in ASD diagnostic criteria might influence ADDM ASD prevalence estimates; therefore, most (85%) of the records used to determine prevalence estimates based on DSM-IV-TR criteria underwent additional review under a newly operationalized surveillance case definition for ASD consistent with the DSM-5 diagnostic criteria. Children meeting this new surveillance case definition could qualify on the basis of one or both of the following criteria, as documented in abstracted comprehensive evaluations: 1) behaviors consistent with the DSM-5 diagnostic features; and/or 2) an ASD diagnosis, whether based on DSM-IV-TR or DSM-5 diagnostic criteria. Stratified comparisons of the number of children meeting either of these two case definitions also are reported. RESULTS: For 2014, the overall prevalence of ASD among the 11 ADDM sites was 16.8 per 1,000 (one in 59) children aged 8 years. Overall ASD prevalence estimates varied among sites, from 13.1-29.3 per 1,000 children aged 8 years. ASD prevalence estimates also varied by sex and race/ethnicity. Males were four times more likely than females to be identified with ASD. Prevalence estimates were higher for non-Hispanic white (henceforth, white) children compared with non-Hispanic black (henceforth, black) children, and both groups were more likely to be identified with ASD compared with Hispanic children. Among the nine sites with sufficient data on intellectual ability, 31% of children with ASD were classified in the range of intellectual disability (intelligence quotient [IQ] <70), 25% were in the borderline range (IQ 71-85), and 44% had IQ scores in the average to above average range (i.e., IQ >85). The distribution of intellectual ability varied by sex and race/ethnicity. Although mention of developmental concerns by age 36 months was documented for 85% of children with ASD, only 42% had a comprehensive evaluation on record by age 36 months. The median age of earliest known ASD diagnosis was 52 months and did not differ significantly by sex or race/ethnicity. For the targeted comparison of DSM-IV-TR and DSM-5 results, the number and characteristics of children meeting the newly operationalized DSM-5 case definition for ASD were similar to those meeting the DSM-IV-TR case definition, with DSM-IV-TR case counts exceeding DSM-5 counts by less than 5% and approximately 86% overlap between the two case definitions (kappa = 0.85). INTERPRETATION: Findings from the ADDM Network, on the basis of 2014 data reported from 11 sites, provide updated population-based estimates of the prevalence of ASD among children aged 8 years in multiple communities in the United States. The overall ASD prevalence estimate of 16.8 per 1,000 children aged 8 years in 2014 is higher than previously reported estimates from the ADDM Network. Because the ADDM sites do not provide a representative sample of the entire United States, the combined prevalence estimates presented in this report cannot be generalized to all children aged 8 years in the United States. Consistent with reports from previous ADDM surveillance years, findings from 2014 were marked by variation in ASD prevalence when stratified by geographic area, sex, and level of intellectual ability. Differences in prevalence estimates between black and white children have diminished in most sites, but remained notable for Hispanic children. For 2014, results from application of the DSM-IV-TR and DSM-5 case definitions were similar, overall and when stratified by sex, race/ethnicity, DSM-IV-TR diagnostic subtype, or level of intellectual ability. PUBLIC HEALTH ACTION: Beginning with surveillance year 2016, the DSM-5 case definition will serve as the basis for ADDM estimates of ASD prevalence in future surveillance reports. Although the DSM-IV-TR case definition will eventually be phased out, it will be applied in a limited geographic area to offer additional data for comparison. Future analyses will examine trends in the continued use of DSM-IV-TR diagnoses, such as autistic disorder, PDD-NOS, and Asperger disorder in health and education records, documentation of symptoms consistent with DSM-5 terminology, and how these trends might influence estimates of ASD prevalence over time. The latest findings from the ADDM Network provide evidence that the prevalence of ASD is higher than previously reported estimates and continues to vary among certain racial/ethnic groups and communities. With prevalence of ASD ranging from 13.1 to 29.3 per 1,000 children aged 8 years in different communities throughout the United States, the need for behavioral, educational, residential, and occupational services remains high, as does the need for increased research on both genetic and nongenetic risk factors for ASD. |
Evolution and Transmission of Carbapenem-Resistant Klebsiella pneumoniae Expressing the blaOXA-232 Gene During an Institutional Outbreak Associated With Endoscopic Retrograde Cholangiopancreatography.
Yang S , Hemarajata P , Hindler J , Li F , Adisetiyo H , Aldrovandi G , Sebra R , Kasarskis A , MacCannell D , Didelot X , Russell D , Rubin Z , Humphries R . Clin Infect Dis 2017 64 (7) 894-901 Background: Whole-genome sequencing (WGS) is an emerging and powerful technique by which to perform epidemiological studies in outbreak situations. Methods: WGS was used to identify and evaluate an outbreak of OXA-232-expressing carbapenem-resistant Klebsiella pneumoniae (CRKP) transmitted to 16 patients over the course of 40 weeks via endoscopic retrograde cholangiopancreatography procedures at a single institution. WGS was performed on 32 OXA-232 CRKP isolates (1-7 per patient) and single-nucleotide variants (SNVs) were analyzed, with reference to the index patient's isolate. Results: Interhost genetic diversity of isolates was between 0 and 15 SNVs during the outbreak; molecular clock calculations estimated 12.31 substitutions per genome per year (95% credibility interval, 7.81-17.05). Both intra- and interpatient diversification at the plasmid and transposon level was observed, significantly impacting the antibiogram of outbreak isolates. The majority of isolates evaluated (n = 27) harbored a blaCTX-M-15 gene, but some (n = 5) lacked the transposon carrying this gene, which resulted in susceptibility to aztreonam and third- and fourth-generation cephalosporins. Similarly, an isolate from a colonized patient lacked the transposon carrying rmtF and aac(6')lb genes, resulting in susceptibility to aminoglycosides. Conclusions: This study broadens the understanding of how bacteria diversify at the genomic level over the course of a defined outbreak and provides reference for future outbreak investigations. |
Evaluation of selected Borrelia burgdorferi lp54 encoded gene products expressed during mammalian infection as antigens to improve serodiagnostic testing for early Lyme disease.
Weiner ZP , Crew RM , Brandt KS , Ullmann AJ , Schriefer ME , Molins CR , Gilmore RD . Clin Vaccine Immunol 2015 22 (11) 1176-86 Laboratory testing for the diagnosis of Lyme disease is performed primarily by serologic assays and is accurate for detection beyond the acute stage of the infection. Serodiagnostic assays to detect the early stages of infection, however, are limited in their sensitivity and improvement is warranted. We analyzed a series of Borrelia burgdorferi proteins known to be induced either within feeding ticks and/or during mammalian infection for their utility as serodiagnostic markers against a comprehensive panel of Lyme disease patient serum samples. The antigens were assayed for IgM and IgG reactivity in line immunoblots and separately by ELISA, with a focus on reactivity against early Lyme erythema migrans (EM), early disseminated Lyme neuroborreliosis, and early Lyme carditis patient serum samples. By IgM immunoblotting, we found that recombinant proteins BBA65, BBA70, and BBA73 reacted with early Lyme EM samples at levels comparable to the OspC antigen used in the current IgM blotting criteria. Additionally, these proteins reacted with serum samples from patients with early neuroborreliosis and early carditis suggesting value in detecting early stages of this disease progression. We also found serological reactivity against recombinant proteins BBA69 and BBA73 with early Lyme samples using IgG immunoblotting and ELISA. Significantly, some samples that had been scored negative by the Centers for Disease Control and Prevention recommended 2-tiered testing algorithm demonstrated positive reactivity to one or more of the antigens by IgM/IgG immunoblot and ELISA. These results suggest that incorporating additional in vivo expressed antigens in the current IgM/IgG immunoblotting tier in a recombinant protein platform assay may improve the performance of early Lyme disease serologic testing. |
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