Phylogenetic analysis of a clinical isolate associated with subclinical Burkholderia pseudomallei infection revealed probable exposure in the British Virgin Islands, where reported infections are limited. Clinicians should consider this geographic distribution when evaluating possible infection among persons with compatible travel history.

A cluster of five human Salmonella Guinea cases was identified among Ohio residents through core genome multilocus sequence typing of clinical isolates. An investigation was conducted to characterize illnesses and identify common exposures. Four patients were aged ≤5 years and three of four patients with information available regarding exposure to animals reported prior exposure to bearded dragons. Practices that potentially increased the risk for Salmonella transmission from reptiles to humans included allowing pet reptiles to roam freely in the home, cleaning reptile habitats indoors, and kissing reptiles. These findings prompted a multistate investigation that resulted in the identification of additional closely related Salmonella Guinea isolates from patients across multiple states. The investigation of cases in Ohio and information shared by other states indicated the potential association between human Salmonella Guinea infections and reptiles, particularly bearded dragons. To prevent Salmonella transmission from reptiles, continued educational efforts should address pet owners and focus on specific reptile ownership practices.

During December 2018-February 2019, a multistate investigation identified 101 patients with vaccination-associated adverse events among an estimated 940 persons in Kentucky, Indiana, and Ohio who had received influenza; hepatitis A; pneumococcal; or tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines at the workplace during September 11-November 28, 2018. These vaccines had been administered by staff members of a third-party health care company contracted by 24 businesses. Company A provided multiple vaccine types during workplace vaccination events across 54 locations in these adjoining states. Injection-site wound isolates from patients yielded Mycobacterium porcinum, a nontuberculous mycobacteria (NTM) species in the Mycobacterium fortuitum group; subtyping using pulsed-field gel electrophoresis of all 28 available isolates identified two closely related clusters. Site visits to company A and interviews with staff members identified inadequate hand hygiene, improper vaccine storage and handling, lack of appropriate medical record documentation, and lack of reporting to the Vaccine Adverse Event Reporting System (VAERS). Vaccination-associated adverse events can be prevented by training health care workers responsible for handling or administering vaccines in safe vaccine handling, administration, and storage practices, timely reporting of any suspected vaccination-associated adverse events to VAERS, and notifying public health authorities of any adverse event clusters.

IMPORTANCE: Extensively drug-resistant Campylobacter jejuni infections cannot be treated with any commonly recommended antibiotics and pose an increasing public health threat. OBJECTIVES: To investigate cases of extensively drug-resistant C jejuni associated with pet store puppies and describe the epidemiologic and laboratory characteristics of these infections. DESIGN, SETTING, AND PARTICIPANTS: In August 2017, health officials identified, via survey, patients with C jejuni infections who reported contact with puppies sold by pet stores. In conjunction with state and federal partners, the Centers for Disease Control and Prevention investigated cases of culture-confirmed C jejuni infections in US patients with an epidemiologic or molecular association with pet store puppies between January 1, 2016, and February 29, 2020. Available records from cases occurring before 2016 with genetically related isolates were also obtained. MAIN OUTCOMES AND MEASURES: Patients were interviewed about demographic characteristics, health outcomes, and dog exposure during the 7 days before illness onset. Core genome multilocus sequence typing was used to assess isolate relatedness, and genomes were screened for resistance determinants to predict antibiotic resistance. Isolates resistant to fluoroquinolones, macrolides, and 3 or more additional antibiotic classes were considered to be extensively drug resistant. Cases before 2016 were identified by screening all sequenced isolates submitted for surveillance using core genome multilocus sequence typing. RESULTS: A total of 168 patients (median [interquartile range] age, 37 [19.5-51.0] years; 105 of 163 female [64%]) with an epidemiologic or molecular association with pet store puppies were studied. A total of 137 cases occurred from January 1, 2016, to February 29, 2020, with 31 additional cases dating back to 2011. Overall, 117 of 121 patients (97%) reported contact with a dog in the week before symptom onset, of whom 69 of 78 (88%) with additional information reported contact with a pet store puppy; 168 isolates (88%) were extensively drug resistant. Traceback investigation did not implicate any particular breeder, transporter, distributer, store, or chain. CONCLUSIONS AND RELEVANCE: Strains of extensively drug-resistant C jejuni have been circulating since at least 2011 and are associated with illness among pet store customers, employees, and others who come into contact with pet store puppies. The results of this study suggest that practitioners should ask about puppy exposure when treating patients with Campylobacter infection, especially when they do not improve with routine antibiotics, and that the commercial dog industry should take action to help prevent the spread of extensively drug-resistant C jejuni from pet store puppies to people.

OBJECTIVES: To describe the demographics, clinical characteristics, and hospital course among persons <21 years of age with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated death. METHODS: We conducted a retrospective case series of suspected SARS-CoV-2-associated deaths in the United States in persons <21 years of age during February 12 to July 31, 2020. All states and territories were invited to participate. We abstracted demographic and clinical data, including laboratory and treatment details, from medical records. RESULTS: We included 112 SARS-CoV-2-associated deaths from 25 participating jurisdictions. The median age was 17 years (IQR 8.5-19 years). Most decedents were male (71, 63%), 31 (28%) were Black (non-Hispanic) persons, and 52 (46%) were Hispanic persons. Ninety-six decedents (86%) had at least 1 underlying condition; obesity (42%), asthma (29%), and developmental disorders (22%) were most commonly documented. Among 69 hospitalized decedents, common complications included mechanical ventilation (75%) and acute respiratory failure (82%). The sixteen (14%) decedents who met multisystem inflammatory syndrome in children (MIS-C) criteria were similar in age, sex, and race and/or ethnicity to decedents without MIS-C; 11 of 16 (69%) had at least 1 underlying condition. CONCLUSIONS: SARS-CoV-2-associated deaths among persons <21 years of age occurred predominantly among Black (non-Hispanic) and Hispanic persons, male patients, and older adolescents. The most commonly reported underlying conditions were obesity, asthma, and developmental disorders. Decedents with coronavirus disease 2019 were more likely than those with MIS-C to have underlying medical conditions.

In the United States, outbreaks of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), were initially reported in densely populated urban areas (1); however, outbreaks have since been reported in rural communities (2,3). Rural residents might be at higher risk for severe COVID-19-associated illness because, on average, they are older, have higher prevalences of underlying medical conditions, and have more limited access to health care services.* In May, after a cluster of seven COVID-19 cases was identified in a rural Ohio Amish community, access to testing was increased. Among 30 additional residents tested by real-time reverse transcription-polymerase chain reaction (RT-PCR; TaqPath COVID-19 Combo Kit),(†) 23 (77%) received positive test results for SARS-CoV-2. Rapid and sustained transmission of SARS-CoV-2 was associated with multiple social gatherings. Informant interviews revealed that community members were concerned about having to follow critical mitigation strategies, including social distancing(§) and mask wearing.(¶) To help reduce the ongoing transmission risk in a community, state and county health department staff members and community leaders need to work together to develop, deliver, and promote culturally responsive health education messages to prevent SARS-CoV-2 transmission and ensure that access to testing services is timely and convenient. Understanding the dynamics of close-knit communities is crucial to reducing SARS-CoV-2 transmission.

Since February 12, 2020, approximately 6.5 million cases of SARS-CoV-2 infection, the cause of coronavirus disease 2019 (COVID-19), and 190,000 SARS-CoV-2-associated deaths have been reported in the United States (1,2). Symptoms associated with SARS-CoV-2 infection are milder in children compared with adults (3). Persons aged <21 years constitute 26% of the U.S. population (4), and this report describes characteristics of U.S. persons in that population who died in association with SARS-CoV-2 infection, as reported by public health jurisdictions. Among 121 SARS-CoV-2-associated deaths reported to CDC among persons aged <21 years in the United States during February 12-July 31, 2020, 63% occurred in males, 10% of decedents were aged <1 year, 20% were aged 1-9 years, 70% were aged 10-20 years, 45% were Hispanic persons, 29% were non-Hispanic Black (Black) persons, and 4% were non-Hispanic American Indian or Alaska Native (AI/AN) persons. Among these 121 decedents, 91 (75%) had an underlying medical condition,* 79 (65%) died after admission to a hospital, and 39 (32%) died at home or in the emergency department (ED).(†) These data show that nearly three quarters of SARS-CoV-2-associated deaths among infants, children, adolescents, and young adults have occurred in persons aged 10-20 years, with a disproportionate percentage among young adults aged 18-20 years and among Hispanics, Blacks, AI/ANs, and persons with underlying medical conditions. Careful monitoring of SARS-CoV-2 infections, deaths, and other severe outcomes among persons aged <21 years remains particularly important as schools reopen in the United States. Ongoing evaluation of effectiveness of prevention and control strategies will also be important to inform public health guidance for schools and parents and other caregivers.

Preventing coronavirus disease 2019 (COVID-19) in correctional and detention facilities* can be challenging because of population-dense housing, varied access to hygiene facilities and supplies, and limited space for isolation and quarantine (1). Incarcerated and detained populations have a high prevalence of chronic diseases, increasing their risk for severe COVID-19-associated illness and making early detection critical (2,3). Correctional and detention facilities are not closed systems; SARS-CoV-2, the virus that causes COVID-19, can be transmitted to and from the surrounding community through staff member and visitor movements as well as entry, transfer, and release of incarcerated and detained persons (1). To better understand SARS-CoV-2 prevalence in these settings, CDC requested data from 15 jurisdictions describing results of mass testing events among incarcerated and detained persons and cases identified through earlier symptom-based testing. Six jurisdictions reported SARS-CoV-2 prevalence of 0%-86.8% (median = 29.3%) from mass testing events in 16 adult facilities. Before mass testing, 15 of the 16 facilities had identified at least one COVID-19 case among incarcerated or detained persons using symptom-based testing, and mass testing increased the total number of known cases from 642 to 8,239. Case surveillance from symptom-based testing has likely underestimated SARS-CoV-2 prevalence in correctional and detention facilities. Broad-based testing can provide a more accurate assessment of prevalence and generate data to help control transmission (4).

During 2018–2019, the Ohio Department of Health (ODH) reported three cases of multidrug-resistant tuberculosis (MDR TB)* in persons who worked in two food processing facilities. The National Tuberculosis Molecular Surveillance Center† performed whole genome sequencing of a Mycobacterium tuberculosis isolate from each patient; phylogenetic analysis revealed the isolates were genetically identical. Prompted by concern for MDR TB transmission associated with these workplaces and surrounding communities, ODH began an investigation in February 2019. CDC was invited to assist with the investigation and deployed a team to Ohio on April 14, 2019.

BACKGROUND: Persons who inject drugs (PWID) have frequent healthcare encounters related to their injection drug use (IDU) but are often not tested for human immunodeficiency virus (HIV). We sought to quantify missed opportunities for HIV testing during an HIV outbreak among PWID. METHODS: PWID with HIV diagnosed in 5 Cincinnati/Northern Kentucky counties during January 2017-September 2018 who had ≥1 encounter 12 months prior to HIV diagnosis in 1 of 2 Cincinnati/Northern Kentucky area healthcare systems were included in the analysis. HIV testing and encounter data were abstracted from electronic health records. A missed opportunity for HIV testing was defined as an encounter for an IDU-related condition where an HIV test was not performed and had not been performed in the prior 12 months. RESULTS: Among 109 PWID with HIV diagnosed who had ≥1 healthcare encounter, 75 (68.8%) had ≥1 IDU-related encounters in the 12 months before HIV diagnosis. These 75 PWID had 169 IDU-related encounters of which 86 (50.9%) were missed opportunities for HIV testing and occurred among 46 (42.2%) PWID. Most IDU-related encounters occurred in the emergency department (118/169; 69.8%). Using multivariable generalized estimating equations, HIV testing was more likely in inpatient compared with emergency department encounters (adjusted relative risk [RR], 2.72; 95% confidence interval [CI], 1.70-4.33) and at the healthcare system receiving funding for emergency department HIV testing (adjusted RR, 1.76; 95% CI, 1.10-2.82). CONCLUSIONS: PWID have frequent IDU-related encounters in emergency departments. Enhanced HIV screening of PWID in these settings can facilitate earlier diagnosis and improve outbreak response.

PURPOSE: Youth suicide clusters may be exacerbated by suicide contagion-the spread of suicidal behaviors. Factors promoting suicide contagion are poorly understood, particularly in the advent of social media. Using cross-sectional data from an ongoing youth suicide cluster in Ohio, this study examines associations between suicide cluster-related social media and suicidal behaviors. METHODS: We surveyed 7th- to 12th-grade students in northeastern Ohio during a 2017-2018 suicide cluster to assess the prevalence of suicidal ideation (SI), suicide attempts (SAs), and associations with potential contagion-promoting factors such as suicide cluster-related social media, vigils, memorials, news articles, and watching the Netflix series 13 Reasons Why before or during the cluster. Generalized estimating equations examined associations between potential contagion-promoting factors and SI/SA, adjusting for nonmodifiable risk factors. Subgroup analyses examined whether associations between cluster-related factors and SI/SA during the cluster varied by previous history of SI/SA. RESULTS: Among participating students, 9.0% (876/9,733) reported SI and 4.9% attempted suicide (481/9,733) during the suicide cluster. Among students who posted suicide cluster-related content to social media, 22.9% (267/1,167) reported SI and 15.0% (175/1,167) attempted suicide during the suicide cluster. Posting suicide cluster-related content was associated with both SI (adjusted odds ratio 1.7, 95% confidence interval 1.4-2.0) and SA during the cluster (adjusted odds ratio 1.7, 95% confidence interval 1.2-2.5). In subgroup analyses, seeing suicide cluster-related posts was uniquely associated with increased odds of SI and SA during the cluster among students with no previous history of SI/SA. CONCLUSIONS: Exposure to suicide cluster-related social media is associated with both SI and SA during a suicide cluster. Suicide interventions could benefit from efforts to mitigate potential negative effects of social media and promote prevention messages.

OBJECTIVES: To estimate the proportion of opioid misuse attributable to adverse childhood experiences (ACEs) among adolescents. STUDY DESIGN: A cross-sectional survey was administered to 10,546 7th12th grade students in northeastern Ohio in Spring 2018. Study measures included self-reported lifetime exposure to 10 ACEs and past 30 day use of nonmedical prescription opioid or heroin. Using generalized estimating equations, we evaluated associations between recent opioid misuse, individual ACEs, and cumulative number of ACEs. We calculated population attributable fractions (PAF) to determine the proportion of adolescents' recent opioid misuse attributable to ACEs. RESULTS: Nearly one in 50 adolescents reported opioid misuse within 30 days (1.9%); approximately 60% of youth experienced >/=1 ACE; 10.2% experienced >/=5 ACEs. Cumulative ACE exposure demonstrated a significant graded relationship with opioid misuse. Compared with youth with zero ACEs, youth with 1 ACE (adjusted odds ratio [AOR]: 1.9, 95% confidence interval [CI]: 0.93.9), 2 ACEs (AOR: 3.8, CI: 1.97.9), 3 ACEs (AOR: 3.7, CI: 2.26.5), 4 ACEs (AOR: 5.8, CI: 3.111.2), and >/=5 ACEs (AOR: 15.3, CI: 8.826.6) had higher odds of recent opioid misuse. The population attributable fraction of recent opioid misuse associated with experiencing >/=1 ACE was 71.6% (CI: 59.8-83.5). CONCLUSIONS: There was a significant graded relationship between number of ACEs and recent opioid misuse among adolescents. Over 70% of recent adolescent opioid misuse in our study population was attributable to ACEs. Efforts to decrease opioid misuse could include programmatic, policy, and clinical practice interventions to prevent and mitigate the negative effects of ACEs.

On July 24, 2017, the Ohio Department of Health (ODH) was notified of a positive rabies test result from a domestic cat in Summit County, a county considered free from terrestrial rabies. Oral rabies vaccination (ORV) of raccoons, in the form of consumable bait, is conducted each year along the Ohio-Pennsylvania border to prevent the westward expansion of the raccoon rabies virus variant (RVV). In the United States, several distinct rabies virus variants exist; raccoon RVV is enzootic along the eastern parts of the United States (from Florida to Maine), including several counties in northeast Ohio (1). Animal rabies vaccination is protective against all rabies virus variants. The rabid cat (cat A) was located west of the ORV barrier, raising concern that it had acquired the infection from a raccoon and suggesting a possible breach in the ORV barrier (Figure 1). ODH initiated an investigation to identify persons and animals exposed to the rabid cat during its viral shedding period and collaborated with CDC to determine the likely origin of the virus (Figure 2). Public health investigators later discovered that the cat originated in North Carolina. Phylogenetic analysis confirmed that the virus was most similar to the raccoon RVV that circulates in North Carolina (Figure 3); therefore, this ORV breach was likely the result of human-mediated movement of a rabid animal rather than natural expansion of the raccoon rabies virus enzootic area. This report summarizes the investigation and highlights the importance of owner compliance regarding rabies vaccination.

Campylobacter causes an estimated 1.3 million diarrheal illnesses in the United States annually (1). In August 2017, the Florida Department of Health notified CDC of six Campylobacter jejuni infections linked to company A, a national pet store chain based in Ohio. CDC examined whole-genome sequencing (WGS) data and identified six isolates from company A puppies in Florida that were highly related to an isolate from a company A customer in Ohio. This information prompted a multistate investigation by local and state health and agriculture departments and CDC to identify the outbreak source and prevent additional illness. Health officials from six states visited pet stores to collect puppy fecal samples, antibiotic records, and traceback information. Nationally, 118 persons, including 29 pet store employees, in 18 states were identified with illness onset during January 5, 2016-February 4, 2018. In total, six pet store companies were linked to the outbreak. Outbreak isolates were resistant by antibiotic susceptibility testing to all antibiotics commonly used to treat Campylobacter infections, including macrolides and quinolones. Store record reviews revealed that among 149 investigated puppies, 142 (95%) received one or more courses of antibiotics, raising concern that antibiotic use might have led to development of resistance. Public health authorities issued infection prevention recommendations to affected pet stores and recommendations for testing puppies to veterinarians. This outbreak demonstrates that puppies can be a source of multidrug-resistant Campylobacter infections in humans, warranting a closer look at antimicrobial use in the commercial dog industry.

We quantified measles transmissibility during a measles outbreak in Ohio in 2014 to evaluate the impact of public health responses. Case incidence and the serial interval (time between symptom onset in primary and secondary cases) were used to assess trends in the effective reproduction number R (average number of secondary cases generated per case). A mathematical model was parameterized by early R values to determine outbreak size and duration if containment measures had not been initiated, and the impact of vaccination. As containment started, we found a fourfold decline in R (~4 to 1) over 2 weeks, and maintenance of R < 1 as control measures continued. Under a conservative scenario, the model estimated 8,472 cases (90% confidence interval [CI]: 8,447, 8,489) over 195 days (90% CI: 179, 223) without control efforts, and 715 cases (90% CI: 103, 1,338) over 128 days (90% CI: 117, 139) when including vaccination; 7,757 fewer cases (90% CI: 7,130, 8,365) and 67 fewer outbreak days (90% CI: 48, 98) were attributed to vaccination. Vaccination may not account entirely for transmission reductions, suggesting changes in community behavior (social distancing) and other control efforts (isolation, quarantining) are important. Our findings highlight the benefits of measles outbreak response and of understanding behavior change dynamics.

Infection with La Crosse virus can cause meningoencephalitis, but it is not known to cause acute flaccid paralysis (AFP). During 2008-2014, nine confirmed or probable La Crosse virus disease cases with possible AFP were reported in Ohio, USA. After an epidemiologic and clinical investigation, we determined no patients truly had AFP.

An essential element of Ebola control involves monitoring and movement restrictions for people who come into contact with an Ebola patient while the patient is infectious. Although procedures can vary by local regulations, monitoring and movement restrictions for Ebola contacts normally last for 21 days after the last exposure to the infectious patient. Contact monitoring and movement restrictions allow for early identification of disease to prevent further transmission.1 However, movement restrictions also limit a contact’s ability to meet some of his or her own daily living needs. Ensuring that measures and processes are in place to provide for these needs is an important component of implementing movement restrictions. Stigmatization of contacts because of community fears creates an additional need for supports.2 A previous report of a related Ebola investigation in Texas described the needs of Ebola contacts, including basic needs for food, financial assistance, and education. In that investigation, health officials found that meeting the needs of Ebola contacts was essential to successful contact monitoring.3 | Providing for the daily needs of people whose movement is restricted during an outbreak response is not new to public health. This need was noted during the typhus and cholera epidemics in New York City in 18924 and during the severe acute respiratory syndrome epidemic in Taiwan and Canada in 2013, where affected individuals experienced uncomfortable surroundings, discrimination, uncertainty, and a need for family support.5,6 We discuss the importance of preparing for such daily needs and how the Ebola experience in Ohio adds to the Texas report to inform future situations in which movement restrictions are needed.

On August 3, 2016, the Ohio Department of Health Laboratory reported to CDC that a respiratory specimen collected on July 28 from a male aged 13 years who attended an agricultural fair in Ohio during July 22-29, 2016, and subsequently developed a respiratory illness, tested positive by real-time reverse transcription-polymerase chain reaction (rRT-PCR) for influenza A(H3N2) variant* (H3N2v). The respiratory specimen was collected as part of routine influenza surveillance activities. The next day, CDC was notified of a child aged 9 years who was a swine exhibitor at an agricultural fair in Michigan who became ill on July 29, 2016, and tested positive for H3N2v virus at the Michigan Department of Health and Human Services Laboratory. Investigations by Michigan and Ohio health authorities identified 18 human infections linked to swine exhibits at agricultural fairs. To minimize transmission of influenza viruses from infected swine to visitors, agricultural fair organizers should consider prevention measures such as shortening the time swine are on the fairgrounds, isolating ill swine, maintaining a veterinarian on call, providing handwashing stations, and prohibiting food and beverages in animal barns. Persons at high risk for influenza-associated complications should be discouraged from entering swine barns.

Background Although measles was eliminated in the United States in 2000, importations of the virus continue to cause outbreaks. We describe the epidemiologic features of an outbreak of measles that originated from two unvaccinated Amish men in whom measles was incubating at the time of their return to the United States from the Philippines and explore the effect of public health responses on limiting the spread of measles. Methods We performed descriptive analyses of data on demographic characteristics, clinical and laboratory evaluations, and vaccination coverage. Results From March 24, 2014, through July 23, 2014, a total of 383 outbreak-related cases of measles were reported in nine counties in Ohio. The median age of case patients was 15 years (range, <1 to 53); a total of 178 of the case patients (46%) were female, and 340 (89%) were unvaccinated. Transmission took place primarily within households (68% of cases). The virus strain was genotype D9, which was circulating in the Philippines at the time of the reporting period. Measles-mumps-rubella (MMR) vaccination coverage with at least a single dose was estimated to be 14% in affected Amish households and more than 88% in the general (non-Amish) Ohio community. Containment efforts included isolation of case patients, quarantine of susceptible persons, and administration of the MMR vaccine to more than 10,000 persons. The spread of measles was limited almost exclusively to the Amish community (accounting for 99% of case patients) and affected only approximately 1% of the estimated 32,630 Amish persons in the settlement. Conclusions The key epidemiologic features of a measles outbreak in the Amish community in Ohio were transmission primarily within households, the small proportion of Amish people affected, and the large number of people in the Amish community who sought vaccination. As a result of targeted containment efforts, and high baseline coverage in the general community, there was limited spread beyond the Amish community. (Funded by the Ohio Department of Health and the Centers for Disease Control and Prevention.).

BACKGROUND: In 2012, one third of cases in a multi-state outbreak of variant influenza A(H3N2) virus [(H3N2)v] occurred in Ohio. We conducted an investigation of (H3N2)v cases associated with agricultural Fair A in Ohio. METHODS: We surveyed Fair A swine exhibitors and their household members. Confirmed cases had influenza-like illness (ILI) and a positive laboratory test for (H3N2)v virus and probable cases had ILI. We calculated attack rates. We determined risk factors for infection using multivariable log-binomial regression. RESULTS: We identified a total of 20 confirmed and 94 probable cases associated with Fair A. Among 114 cases, the median age was 10 years, there were no hospitalizations or deaths, and 85% had swine exposure. In the exhibitor household cohort of 359 persons (83 households), we identified 6 confirmed (2%) and 40 probable (11%) cases. Age <10 years was a significant risk factor (p<0.01) for illness. One instance of likely human-to-human transmission was identified. CONCLUSIONS: In this (H3N2)v outbreak, no evidence of sustained human-to-human (H3N2)v transmission was found. Our risk factor analysis contributed to the development of recommendations that those at increased risk of influenza complications, including children aged <5 years, avoid swine barns at fairs during the 2012 fair season.

BACKGROUND: Variant influenza virus infections are rare but may have pandemic potential if person-to-person transmission is efficient. We describe the epidemiology of a multistate outbreak of an influenza A(H3N2) variant virus (H3N2v) first identified in 2011. METHODS: We identified laboratory-confirmed cases of H3N2v and used a standard case report form to characterize illness and exposures. We considered illness to result from person-to-person H3N2v transmission if swine contact was not identified within 4 days prior to illness onset. RESULTS: From 9 July to 7 September 2012, we identified 306 cases of H3N2v in 10 states. The median age of all patients was 7 years. Commonly reported signs and symptoms included fever (98%), cough (85%), and fatigue (83%). Sixteen patients (5.2%) were hospitalized, and 1 fatal case was identified. The majority of those infected reported agricultural fair attendance (93%) and/or contact with swine (95%) prior to illness. We identified 15 cases of possible person-to-person transmission of H3N2v. Viruses recovered from patients were 93%-100% identical and similar to viruses recovered from previous cases of H3N2v. All H3N2v viruses examined were susceptible to oseltamivir and zanamivir and resistant to adamantane antiviral medications. CONCLUSIONS: In a large outbreak of variant influenza, the majority of infected persons reported exposures, suggesting that swine contact at an agricultural fair was a risk for H3N2v infection. We identified limited person-to-person H3N2v virus transmission, but found no evidence of efficient or sustained person-to-person transmission. Fair managers and attendees should be aware of the risk of swine-to-human transmission of influenza viruses in these settings.

Two women in labor received intrapartum spinal anesthesia from the same anesthesiologist approximately one hour apart. Within 15 hours both patients developed Streptococcus salivarius meningitis and one patient died. Blood and CSF from both patients and tongue swab specimens from the anesthesiologist yielded isolates of an indistinguishable S. salivarius strain.