Summary of Notifiable Infectious Diseases and Conditions - United States, 2015

Decoding the evolutionary history of ST30 Staphylococcus aureus: insights into a potentially silent MSSA bloodstream pathogen

Background

Staphylococcus aureus clonal complex 30 (CC30) is a historically significant pathogen affecting both hospital and community settings. The notable pandemic clones, phage-type 80/81 (PT80/81) and the Southwest Pacific clone (SWP) have spread internationally, contributing to significant morbidity and mortality. Despite their importance, research on the evolution of sequence type (ST) 30 has been limited, often focusing on a small number of strains or specific regions.

Methods

In this study, we analyzed over 500 ST30 genomes from diverse sources, including Brazilian strains sequenced by our team, using genomic, pangenomic, phylogenetic, and time-calibrated phylogenetic analyses.

Results

We traced key evolutionary events, estimating that the specialization of PT80/81 and SWP occurred after a divergence around 1868, forming a group of PT80/81-related strains and another group formed by SWP-related strains. Our findings highlight major events involving gene acquisition and loss, as well as mobile genetic elements (MGE). Notably, PT80/81 lost most lpl genes during diversification, which may have restricted the circulation of related strains. Contemporary strains-defined as those that emerged in the 21st century-predominantly cluster within a group divided into three subgroups, including Brazilian strains that acquired a novel pathogenicity island. Also clustering within the contemporary group, most toxic shock syndrome toxin-1 (TSST-1)-producing strains are methicillin-susceptible S. aureus (MSSA) that have gained additional virulence traits, including sea, which enhance their adaptability and virulence.

Conclusion

Our study revises the evolutionary history of ST30 S. aureus uncovering critical pathoadaptive events that may explain its success. Additionally, our findings emphasize a neglected issue: the high prevalence of MSSA in hospital infections, particularly the silent circulation of TSST-1 producing strains, capable of causing severe infections. Robust surveillance studies to monitor these strains are crucial.

HPV vaccine hesitancy in the United States

PURPOSE OF REVIEW

Human papillomavirus (HPV) is the most common STI and accounts for roughly 37 000 HPV-associated cancers annually in the United States. Despite documented safety and effectiveness of the HPV vaccine, vaccination rates should be higher. We summarize literature surrounding vaccine hesitancy, a main reason for suboptimal vaccine coverage. We aim to describe the complex factors that lead to hesitancy in order to support improvement of vaccination rates in our communities.

RECENT FINDINGS

Studies document sustained immunogenicity and effectiveness 10 years post HPV vaccination. Vaccine coverage was rising until 2022, when initiation declined. Primary reasons for hesitancy are: perceived lack of provider recommendation, a lack of parental knowledge and necessity especially if an adolescent is not sexually active, and safety concerns. The COVID-19 pandemic challenged access to care and exacerbated vaccine-related discourse. Studies of hesitant adopters reveal that social processes, including conversations with community members, have a substantial impact on decisions to vaccinate.

SUMMARY

We highlight recent literature behind parental hesitancy toward the HPV vaccine, focusing on concerns about its necessity and safety, exacerbated by medical mistrust and misinformation. We summarize findings of successful educational outreach and community-based interventions to improve vaccination rates in the postpandemic social media era.

Development of Etf-3-specific nanobodies to prevent Ehrlichia infection and LNP-mRNA delivery in cellular and murine models

Ehrlichia chaffeensis is an obligatory intracellular bacterium that infects monocytes and macrophages and causes human monocytic ehrlichiosis. Ehrlichia translocated factor-3 (Etf-3) is a type IV secretion system effector that binds host-cell ferritin light chain and induces ferritinophagy, thus increasing cellular labile iron pool for Ehrlichia proliferation. To further characterize roles of Etf-3 in Ehrlichia infection, we produced immune libraries of Etf-3-specific nanobodies (Nbs). Based on distinct complementarity-determining region 3 sequences, we identified 16 and 15 families of anti-Etf-3 Nbs that could specifically bind the N- and C-terminal halves of Etf-3, respectively. Transfection with plasmids encoding the anti-Etf-3 Nbs N48 and N51, but not N59, significantly inhibited E. chaffeensis infection in HEK293 cells. All three Nbs colocalized with Etf-3-GFP in co-transfected RF/6A cells, but N48 and N51 had significantly higher binding affinities for recombinant Etf-3. Etf-3-GFP transfection-induced ferritinophagy and endogenous ferritin degradation was abrogated in HEK293 cells co-transfected with N48 or N51, but not with N59. To efficiently express Nbs in the infected host-cell cytoplasm, lipid nanoparticles-encapsulated mRNAs (LNP-mRNAs) encoding N48, N51, or N59 were created for delivery into cells or mice. Incubation of HEK293 cells or inoculation of mice with LNP-mRNA-N48 or LNP-mRNA-N51 significantly inhibited E. chaffeensis infection compared to those with LNP-mRNA-N59 or without LNP-mRNA. Our results demonstrate that Etf-3-specific Nbs delivered via LNP-mRNAs can inhibit Etf-3 functions and Ehrlichia infection.

Public Health Impact of Introducing a Pentavalent Vaccine Against Invasive Meningococcal Disease in the United States

BACKGROUND

Invasive meningococcal disease (IMD) is primarily associated with five Neisseria meningitidis serogroups: A, B, C, W, or Y. In the United States (US), available vaccines protect against serogroups B (MenB), A, C, W, and Y (MenACWY), and A, B, C, W, and Y (MenABCWY). The Advisory Committee on Immunization Practices is re-evaluating the adolescent meningococcal vaccination schedule with varying recommendation formats. This analysis aimed to predict which schedule could avert the most IMD cases and have the most positive public health impact (PHI).

METHODS

An epidemiological model compared the 15-year PHI of vaccination schedules using MenB, MenACWY, and/or MenABCWY vaccines versus current US standard of care (SoC). Varying coverage rates reflected routine, shared clinical decision making, and risk-based recommendations. Sensitivity analyses assessed robustness of the results to different inputs/assumptions.

RESULTS

The most positive PHI compared with SoC was observed with one dose of MenACWY at 11 years of age and two doses of MenABCWY (6 months apart) at 16 years of age, assuming routine recommendation and coverage reflecting real-world uptake of MenACWY. This strategy resulted in 123 IMD cases averted (MenB: 59, MenACWY: 64), 17 deaths prevented, 574 life-years saved, and 757 quality-adjusted life-years gained versus SoC. Eliminating MenACWY vaccination at 11 years was found to result in an additional IMD burden.

CONCLUSION

A routinely recommended two-dose pentavalent vaccine, with doses administered 6 months apart at 16 years of age, alongside the routinely recommended MenACWY vaccine at 11 years of age, would improve the PHI and benefits of IMD vaccination to society.

Directional and Strain-Specific Interaction Between Lactobacillus plantarum and Staphylococcus aureus

The interaction between Lactobacillus plantarum and Staphylococcus aureus strains FRI-1169 and MN8, two original isolated strains from menstrual toxic shock syndrome (mTSS) cases, is a key focus for developing non-antibiotic strategies to control S. aureus-related infections. While the antagonistic effects of Lactobacilli species on S. aureus through mechanisms like organic acid and bacteriocin production are known, the molecular dynamics of these interactions remain underexplored. This study employs a proteomic approach to analyze the interactions between L. plantarum WCFS1 and S. aureus strains, FRI-1169 and MN8, during co-culture. We profiled differentially expressed proteins (DEPs) found in the spent media and cytosols of both bacteria, revealing distinct directional and strain-specific responses. The findings demonstrate that L. plantarum exerts a more pronounced effect on S. aureus, with more DEPs and upregulated proteins, while S. aureus showed fewer DEPs and more downregulated proteins. These strain-specific interactions highlight the complex metabolic and regulatory adjustments between these bacterial species. This research provides valuable insights into the molecular mechanisms of Lactobacillus-S. aureus antagonism and underscores the potential of proteomic analysis as a powerful tool for studying bacterial dynamics in co-culture systems.

Molecular Epidemiology of Ticks and Tick-Borne Pathogens in the Ta-Pa Mountain Area of Chongqing, China

To validate the prevalence and biodiversity of ticks and tick-borne pathogens in Chongqing, a total of 601 ticks were collected from dogs, cattle, and goats within the Ta-pa Mountain range in Chongqing, China. Five distinct tick species were identified, including Ixodes ovatus (1.66%, 10/601), I. acutitarsus (0.50%, 3/601), Haemaphysalis flava (10.32%, 62/601), Ha. hystricis (9.82%, 59/601), and Ha. longicornis (77.70%, 467/601). A suit of semi-nest PCR and nest PCR primers were custom-synthesized for the detection of tick-borne pathogens. The analysis yielded positive results for 7.15% Rickettsia (Candidatus R. principis, R. japonica, and R. raoultii), 3.49% Anaplasma (A. bovis and A. capra), 1.16% Ehrlichia, 1.83% Coxiella burnetii, and 3.49% protozoa (Theileria. capreoli, T. orientalis, T. luwenshuni, and Babesia sp.) in ticks. Notably, Ca. R. principis was identified for the first time in I. ovatus and Ha. longicornis. These findings underscore the significant prevalence and diversity of ticks and their associated pathogens within the Chongqing Ta-pa Mountain region. This study accordingly provides an extensive dataset that contributes to the epidemiological understanding and disease prevention strategies for tick-borne illnesses in the local area.

Campylobacteriosis Outbreak Linked to Municipal Water, Nebraska, USA, 20211

In September 2021, eight campylobacteriosis cases were identified in a town in Nebraska, USA. We assessed potential exposures for a case-control analysis. We conducted whole-genome sequencing on Campylobacter isolates from patients' stool specimens. We collected large-volume dead-end ultrafiltration water samples for Campylobacter and microbial source tracking testing at the Centers for Disease Control and Prevention. We identified 64 cases in 2 waves of illnesses. Untreated municipal tap water consumption was strongly associated with illness (wave 1 odds ratio 15.36; wave 2 odds ratio 16.11). Whole-genome sequencing of 12 isolates identified 2 distinct Campylobacter jejuni subtypes (1 subtype/wave). The town began water chlorination, after which water testing detected coliforms. One dead-end ultrafiltration sample yielded nonculturable Campylobacter and avian-specific fecal rRNA genomic material. Our investigation implicated contaminated, untreated, municipal water as the source. Results of microbial source tracking supported mitigation with continued water chlorination. No further campylobacteriosis cases attributable to water were reported.

Antimicrobial Resistance of Staphylococcus spp. from Human Specimens Submitted to Diagnostic Laboratories in South Africa, 2012-2017

Antimicrobial resistance (AMR) poses a significant worldwide health challenge associated with prolonged illnesses, increased healthcare costs, and high mortality rates. The present study examined the patterns and predictors of AMR among human Staphylococcus isolates obtained from diagnostic laboratories in South Africa between 2012 and 2017. This study examined data from 404 217 isolates, assessing resistance rates across different characteristics such as age, sample origin, Staphylococcus species, and study period. The highest resistance was observed against cloxacillin (70.3%), while the lowest resistance was against Colistin (0.1%). A significant (p < 0.05) decreasing trend in AMR was observed over the study period, while a significant increasing temporal trend (p < 0.05) was observed for multidrug resistance (MDR) over the same period. A significant (p < 0.05) association was observed between specimen type, species of organism, and year of isolation with AMR outcome. Significant (p < 0.05) associations were observed between specimen type and season with MDR. The observed high levels of AMR and a growing trend in MDR are concerning for public health. Clinicians should take these findings into account when deciding on therapeutic options. Continued monitoring of AMR among Staphylococcus spp. and judicious use of antimicrobials in human medicine should be promoted.

Analysis of Amblyomma americanum microRNAs in response to Ehrlichia chaffeensis infection and their potential role in vectorial capacity

Background

MicroRNAs (miRNAs) represent a subset of small noncoding RNAs and carry tremendous potential for regulating gene expression at the post-transcriptional level. They play pivotal roles in distinct cellular mechanisms including inhibition of bacterial, parasitic, and viral infections via immune response pathways. Intriguingly, pathogens have developed strategies to manipulate the host's miRNA profile, fostering environments conducive to successful infection. Therefore, changes in an arthropod host's miRNA profile in response to pathogen invasion could be critical in understanding host-pathogen dynamics. Additionally, this area of study could provide insights into discovering new targets for disease control and prevention. The main objective of the present study is to investigate the functional role of differentially expressed miRNAs upon Ehrlichia chaffeensis, a tick-borne pathogen, infection in tick vector, Amblyomma americanum.

Methods

Small RNA libraries from uninfected and E. chaffeensis-infected Am. americanum midgut and salivary gland tissues were prepared using the Illumina Truseq kit. Small RNA sequencing data was analyzed using miRDeep2 and sRNAtoolbox to identify novel and known miRNAs. The differentially expressed miRNAs were validated using a quantitative PCR assay. Furthermore, a miRNA inhibitor approach was used to determine the functional role of selected miRNA candidates.

Results

The sequencing of small RNA libraries generated >147 million raw reads in all four libraries and identified a total of >250 miRNAs across the four libraries. We identified 23 and 14 differentially expressed miRNAs in salivary glands, and midgut tissues infected with E. chaffeensis, respectively. Three differentially expressed miRNAs (miR-87, miR-750, and miR-275) were further characterized to determine their roles in pathogen infection. Inhibition of target miRNAs significantly decreased the E. chaffeensis load in tick tissues, which warrants more in-depth mechanistic studies.

Conclusions

The current study identified known and novel miRNAs and suggests that interfering with these miRNAs may impact the vectorial capacity of ticks to harbor Ehrlichia. This study identified several new miRNAs for future analysis of their functions in tick biology and tick-pathogen interaction studies.

Analysis of Amblyomma americanum microRNAs in response to Ehrlichia chaffeensis infection and their potential role in vectorial capacity

Background

MicroRNAs (miRNAs) represent a subset of small noncoding RNAs and carry tremendous potential for regulating gene expression at the post-transcriptional level. They play pivotal roles in distinct cellular mechanisms including inhibition of bacterial, parasitic, and viral infections via immune response pathways. Intriguingly, pathogens have developed strategies to manipulate the host's miRNA profile, fostering environments conducive to successful infection. Therefore, changes in an arthropod host's miRNA profile in response to pathogen invasion could be critical in understanding host-pathogen dynamics. Additionally, this area of study could provide insights into discovering new targets for disease control and prevention. The main objective of the present study is to investigate the functional role of differentially expressed miRNAs upon Ehrlichia chaffeensis, a tick-borne pathogen, infection in tick vector, Amblyomma americanum.

Methods

Small RNA libraries from uninfected and E. chaffeensis-infected Am. americanum midgut and salivary gland tissues were prepared using the Illumina Truseq kit. Small RNA sequencing data was analyzed using miRDeep2 and sRNAtoolbox to identify novel and known miRNAs. The differentially expressed miRNAs were validated using a quantitative PCR assay. Furthermore, a miRNA inhibitor approach was used to determine the functional role of selected miRNA candidates.

Results

The sequencing of small RNA libraries generated >147 million raw reads in all four libraries and identified a total of >250 miRNAs across the four libraries. We identified 23 and 14 differentially expressed miRNAs in salivary glands, and midgut tissues infected with E. chaffeensis, respectively. Three differentially expressed miRNAs (miR-87, miR-750, and miR-275) were further characterized to determine their roles in pathogen infection. Inhibition of target miRNAs significantly decreased the E. chaffeensis load in tick tissues, which warrants more in-depth mechanistic studies.

Conclusions

The current study identified known and novel miRNAs and suggests that interfering with these miRNAs may impact the vectorial capacity of ticks to harbor Ehrlichia. This study identified several new miRNAs for future analysis of their functions in tick biology and tick-pathogen interaction studies.

A Retrospective Descriptive Study of Staphylococcus Species Isolated from Canine Specimens Submitted to a Diagnostic Laboratory in South Africa, 2012-2017

There is a scarcity of published studies on the occurrence of Staphylococcus spp. Among dogs in South Africa. The objective of the study was to characterise the Staphylococcus spp. Isolated from dog samples submitted to a veterinary diagnostic laboratory in South Africa in terms of time, place, and person. This study utilised a dataset of 1627 positive Staphylococcus isolates obtained from a veterinary diagnostic laboratory in South Africa from 2012 to 2017. Out of the 1627 confirmed isolates, 10 different species of Staphylococcus were identified. Among these, 92.0% were classified as coagulase-positive staphylococci (CoPS), 6.0% were coagulase-negative staphylococci (CoNS), and 3.0% were coagulase-variable. Male dogs contributed just over half (53.2%) of the Staphylococcus isolates, while female dogs contributed the remaining 46.8%. The largest proportion of isolates (23.2%) were obtained from dogs aged ≥ 9 years, with the highest number of isolates originating from KwaZulu-Natal Province (45.0%) and the least from Northern Cape Province (0.1%). Out of the total samples included in the records, the majority (46.0%) were skin specimens. The number of Staphylococcus isolates recorded showed limited variation between the seasons (24.3% in autumn, 26.3% in winter, 26.0% in spring, and 24.0% in summer). This study highlighted the diversity of Staphylococcus spp. isolated from dogs, and the burden of staphylococcal carriage among dogs in South Africa. Further research is required to examine the factors that contribute to the observed discrepancies in the proportions of Staphylococcus spp. between the provinces.

Strategies for Improving Vaccine Communication and Uptake

Vaccines have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about the scope and impact of the problem, the facts surrounding common vaccination concerns, and the latest evidence regarding effective communication techniques for the vaccine conversation. After reading this clinical report, readers can expect to: Understand concepts and underlying determinants of vaccine uptake and vaccine hesitancy.Understand the relationship between vaccine hesitancy and costs of preventable medical care.Recognize and address specific concerns (eg, vaccine safety) with caregivers when hesitancy is present.

A rapid multiplex loop-mediated isothermal amplification (mLAMP) assay for detection of Entamoeba histolytica and Giardia duodenalis

We developed a rapid multiplex loop-mediated isothermal amplification (mLAMP) assay for two common intestinal parasites-Entamoeba histolytica and Giardia duodenalis, where early detection may be helpful. The mLAMP assay was optimized for the detection of DNA of E. histolytica (18S rRNA gene) and G. duodenalis (Elongation factor 1 alpha gene) from standard strains by using six specific primers FIP (forward inner primer), BIP (backward inner primer), F3 (forward outer primer), B3 (backward outer primer), loopF (forward loop primer), and loopB (backward loop primer) for each gene target. The amplification time was 16-26 min for E. histolytica and 10-15 min for G. duodenalis, and the parasites could be distinguished based on melting-curve analysis for specific annealing temperatures (Tm) of 84°C-86°C and 88°C-90°C for E. histolytica and G. duodenalis, respectively. The analytical sensitivity was one fg, and no cross-reactivity with other intestinal pathogens was observed. Thus, the mLAMP assay could detect and clearly distinguish E. histolytica and G. duodenalis with a rapid turnaround time and excellent analytical sensitivity and specificity.

Combined metabolomics and transcriptomics analysis reveals the mechanism of antibiotic resistance of Salmonella enterica serovar Typhimurium after acidic stress

Drug-resistant Salmonella is widely distributed in the meat production chain, endangering food safety and public health. Acidification of meat products during processing can induce acid stress, which may alter antibiotic resistance. Our study investigated the effects of acid stress on the antibiotic resistance and metabolic profile of Salmonella Typhimurium, and explored the underlying mechanisms using metabolomic and transcriptomic analysis. We found that acid-stressed 14028s was more sensitive to small molecule hydrophobic antibiotics (SMHA) while more resistant to meropenem (MERO). Metabolomic analysis revealed that enhanced sensitivity to SMHA was correlated with increased purine metabolism and tricarboxylic acid cycle. Transcriptomic analysis revealed the downregulation of chemotaxis-related genes, which are also associated with SMHA sensitivity. We also found a significant downregulation of the ompF gene, which encodes a major outer membrane protein OmpF of Salmonella. The decreased expression of OmpF porin hindered the influx of MERO, leading to enhanced resistance of the bacteria to the drug. Our findings contribute to greatly improve the understanding of the relationship between Salmonella metabolism, gene expression, and changes in drug resistance after acid stress, while providing a structural framework for exploring the relationship between bacterial stress responses and antibiotic resistance.

Lymphocytic Choriomeningitis Virus in Person Living with HIV, Connecticut, USA, 2021

Lymphocytic choriomeningitis virus is an underreported cause of miscarriage and neurologic disease. Surveillance remains challenging because of nonspecific symptomatology, inconsistent case reporting, and difficulties with diagnostic testing. We describe a case of acute lymphocytic choriomeningitis virus disease in a person living with HIV in Connecticut, USA, identified by using quantitative reverse transcription PCR.

Impact of the COVID-19 pandemic on the epidemiology of other communicable diseases in Japan

OBJECTIVES

To elucidate the impact of the COVID-19 pandemic on the epidemiology of other infectious diseases.

DESIGN

We investigated the epidemiology of 36 communicable diseases during 2015-2021 in Japan and compared the number of cases in each disease between the prepandemic (2015-2019) and intrapandemic (2020-2021) periods. Relationships between the incidence of the infectious diseases and the COVID-19 pandemic were also investigated.

RESULTS

Of 36 communicable diseases, the number of cases in the 27 diseases (75%) mainly caused by pathogens transmitted by droplet or contact was lower intrapandemic than prepandemic, and the cases of 21 diseases (58%) continued to decrease intrapandemic. The number of cases of six diseases (17%) was higher intrapandemic than prepandemic, and the cases of two diseases (5.6%), Japanese spotted fever and syphilis, continued to increase intrapandemic. Time trend analyses revealed a positive correlation between case numbers of communicable diseases and the COVID-19 pandemic, whereas the case numbers of hand-foot-and-mouth disease and respiratory syncytial virus infection rebounded in 2021 after decreasing in 2020.

CONCLUSION

The COVID-19 pandemic has greatly impacted the epidemiology of communicable diseases, suggesting that countermeasures against COVID-19 and lifestyle changes might be involved in these epidemiological changes.

Sexual health indicators for the United States: Measuring progress and documenting public health needs

Introduction

Today, we are facing increased and continued adverse sexual health outcomes in the United States, including high post-COVID-19 pandemic rates of sexually transmitted infections (STIs). For the past 20 years, there have been calls for a national health strategy and a more comprehensive sexual health approach to address the myriad of persistent sexual health problems in this country. Employing a sexual health approach requires shifting from a longstanding, stigmatizing focus on morbidity toward a holistic and integrated focus on health rather than disease. While strategies are being implemented by multisectoral stakeholders, it is also important to establish a core set of indicators that broadly describe the state of sexual health in the U.S. and allow for measurement across time. The development of a comprehensive scorecard with key sexual health indicators has been proposed by other entities (e.g., Public Health England, World Health Organization), but such an attempt has not been made in the U.S.

Methods

A review of national U.S. surveys and surveillance systems with items related to sexual health was conducted for years 2010-2022 to develop an inventory of existing data that yield national estimates for potential indicators of sexual health.

Results

We selected 23 sexual health indicators in four broad domains including: (1) knowledge; communication and attitudes (five indicators); (2) behaviors and relationships (four indicators); (3) service access and utilization (seven indicators); and (4) adverse health outcomes (seven indicators). Recent data for each indicator are provided.

Discussion

A growing body of evidence shows the positive effects of moving away from a morbidity focus toward an integrated, health-promoting approach to sexual health. Yet, not much has been done in terms of how we implement this national shift. We argue that measurement and monitoring are key to future change. We envision these core sexual health indicators would be published in the form of an index that is publicly available and updated frequently. These sexual health indicators could be used for ongoing monitoring, and to guide related research, programming, and policy development to help promote sexual health in coming years.

Prostatitis as initial manifestation of Chlamydia psittaci pneumonia diagnosed by metagenome next-generation sequencing: A case report

Chlamydia psittaci (C. psittaci) pneumonia is a zoonotic infectious disease caused by C. psittaci, which is often underdiagnosed. The application of metagenomic next-generation sequencing (mNGS) provides an unbiased method for the detection of unknown pathogens. A 46-year-old man received empirical treatment with piperacillin-tazobactam and moxifloxacin after an initial diagnosis of prostatitis and pneumonia. However, he experienced recurrent symptoms and a cough, and a chest computed tomography (CT) showed aggravated pulmonary inflammation. Upon further questioning, the patient recalled a history of contact with pigeons, and a bronchoscope alveolar lavage fluid analysis with mNGS suggested C. psittaci infection. Following treatment with doxycycline, the patient's symptoms were rapidly alleviated, and chest CT showed pulmonary lesions absorption. The patient was followed up for 1 month without any discomfort. This case highlights that initial manifestations of C. psittaci pneumonia may present with atypical symptoms such as prostatitis. Furthermore, mNGS can be a useful tool for the detection of rare or unknown pathogens such as C. psittaci.

Why the American Academy of Pediatrics recommends initiating HPV vaccine at age 9

The American Academy of Pediatrics (AAP) recommends starting the human papillomavirus (HPV) vaccine series between 9 and 12 years, at an age that the provider deems optimal for acceptance and completion of the vaccination series. This recommendation differs from the Advisory Committee on Immunization Practices (ACIP), which recommends HPV vaccination be initiated at age 11 or 12 years, stating the series can be started at age 9 years. This commentary discusses the reasoning behind AAP's decision to differ from ACIP, as the AAP and ACIP schedules are essentially harmonized for all other vaccines. Reasons include recognition that (1) vaccination uptake is suboptimal; (2) offering vaccination earlier offers provider's flexibility in introducing the vaccine; (3) initiating the vaccine at age 9 or 10 may be preferable for parents or adolescents who do not want to receive ≥3 concomitant vaccines at age 11 or 12; (4) earlier initiation may disentangle HPV recommendations from discussions of sexuality; (5) earlier recommendation might alleviate HPV vaccine hesitancy "fatigue;" (6) the immune response is robust at younger ages with no evidence of waning protection; and (7) there is a dearth of evidence supporting starting the recommendation at age 11 or 12 within the "adolescent immunization platform."

An electronic medical record-based intervention to improve hepatitis A vaccination rates in the emergency department during a regional outbreak

Background

In response to the severe hepatitis A outbreak that occurred in Michigan between August 2016 and September 2019, our multihospital health system implemented an electronic medical record (EMR)-based vaccination intervention across its nine emergency departments (EDs). The objectives were to explore the impact of this intervention on increasing vaccination rates among high-risk individuals and to assess the barriers to use of a computerised vaccine reminder system.

Methods

All patients who were 18 years or older were screened using an electronic nursing questionnaire. If a patient was at high risk based on the questionnaire, an electronic best practice advisory (BPA) would trigger and give the physician or advanced practice provider the option to order the hepatitis A vaccine. We explored the vaccination rates in the 24-month preintervention and the 18-month intervention periods. We then administered a survey to physicians, advanced practice providers and nurses evaluating their perceptions and barriers to use of the EMR intervention.

Results

During the preintervention period, 49 vaccines were ordered (5.5 per 100 000 patient visits) and 32 were administered (3.6 per 100 000 patient visits). During the intervention period, 574 865 patient visits (74.3%) were screened. 2494 vaccines (322 per 100 000 patient visits) were ordered, and 1205 vaccines (155 per 100 000 patients visits) were administered. Physicians and advanced practice providers were initially compliant with the BPA’s use, but compliance declined over time. Surveys revealed that the major barrier to use was lack of time.

Conclusions

EMR screening tools and BPAs can be used in the ED as an effective strategy to vaccinate high-risk individuals. This may be translatable to outbreaks of other vaccine-preventable illnesses like influenza, measles or SARS-CoV-2. Providing ongoing education about the public health initiative and giving feedback to physicians, advanced practice providers and nurses about tool compliance are needed to sustain the improvement over time.

Geographical distribution and space-time clustering of human illnesses with major Salmonella serotypes in Florida, USA, 2017-2018

Nontyphoidal salmonellosis is the leading reported foodborne illness in Florida. Although the diversity of Salmonella serotypes circulating in Florida has been identified, the geographical characteristics of the major serotypes are poorly described. Here we examined the geospatial patterns of 803 whole-genome sequenced Salmonella isolates within seven major serotypes (Enteritidis, Newport, Javiana, Sandiego, Braenderup, Typhimurium and I 4,[5],12:i:-) with the metadata obtained from Florida Department of Health during 2017-2018. Geographically, the distribution of incidence rates varied distinctively between serotypes. Illnesses with Enteritidis and Newport serotypes were widespread in Florida. The incidence rate for Javiana was relatively higher in the north compared to the south. Typhimurium was concentrated in the northwest, while I 4,[5],12:i:-, the monophasic variant of Typhimurium was limited to the south. We also evaluated space-time clustering of isolates at the zip code level using scan statistic models. Space-time clusters were detected for each major serotype during 2017-2018. The multinomial scan statistic found the risk of illness with Javiana was higher in the north and southwest in the fall of 2017 compared to other major serotypes. This serotype-specific clustering analysis will assist in further unpacking the associations between distinct reservoirs and illnesses with major serotypes in Florida.

Worldwide Evolution of Vaccinable and Nonvaccinable Viral Skin Infections: Google Trends Analysis

BACKGROUND

Most common viral skin infections are not reportable conditions. Studying the population dynamics of these viral epidemics using traditional field methods is costly and time-consuming, especially over wide geographical areas.

OBJECTIVE

This study aimed to explore the evolution, seasonality, and distribution of vaccinable and nonvaccinable viral skin infections through an analysis of Google Trends.

METHODS

Worldwide search trends from January 2004 through May 2021 for viral skin infections were extracted from Google Trends, quantified, and analyzed.

RESULTS

Time series decomposition showed that the total search term volume for warts; zoster; roseola; measles; hand, foot, and mouth disease (HFMD); varicella; and rubella increased worldwide over the study period, whereas the interest for Pityriasis rosea and herpes simplex decreased. Internet searches for HFMD, varicella, and measles exhibited the highest seasonal patterns. The interest for measles and rubella was more pronounced in African countries, whereas the interest for HFMD and roseola was more pronounced in East Asia.

CONCLUSIONS

Harnessing data generated by web searches may increase the efficacy of traditional surveillance systems and strengthens the suspicion that the incidence of some vaccinable viral skin infections such as varicella, measles, and rubella may be globally increasing, whereas the incidence of common nonvaccinable skin infections remains stable.

Impact of Routine Childhood Immunization in Reducing Vaccine-Preventable Diseases in the United States

BACKGROUND AND OBJECTIVES

Current routine immunizations for children aged ≤10 years in the United States in 2019 cover 14 vaccine-preventable diseases. We characterize the public-health impact of vaccination by providing updated estimates of disease incidence with and without universally recommended pediatric vaccines.

METHODS

Prevaccine disease incidence was obtained from published data or calculated using annual case estimates from the prevaccine period and United States population estimates during the same period. Vaccine-era incidence was calculated as the average incidence over the most recent 5 years of available surveillance data or obtained from published estimates (if surveillance data were not available). We adjusted for underreporting and calculated the percent reduction in overall and age-specific incidence for each disease. We multiplied prevaccine and vaccine-era incidence rates by 2019 United States population estimates to calculate annual number of cases averted by vaccination.

RESULTS

Routine immunization reduced the incidence of all targeted diseases, leading to reductions in incidence ranging from 17% (influenza) to 100% (diphtheria, Haemophilus influenzae type b, measles, mumps, polio, and rubella). For the 2019 United States population of 328 million people, these reductions equate to >24 million cases of vaccine-preventable disease averted. Vaccine-era disease incidence estimates remained highest for influenza (13 412 per 100 000) and Streptococcus pneumoniae-related acute otitis media (2756 per 100 000).

CONCLUSIONS

Routine childhood immunization in the United States continues to yield considerable sustained reductions in incidence across all targeted diseases. Efforts to maintain and improve vaccination coverage are necessary to continue experiencing low incidence levels of vaccine-preventable diseases.

Increasing Incidence of Spotted Fever Group Rickettsioses in the United States, 2010-2018

Spotted fever group Rickettsia species are intracellular bacteria transmitted by tick or mite vectors and that cause human diseases referred to as spotted fever group rickettsioses, or spotted fevers. In the United States, the most recognized and commonly reported spotted fevers are Rocky Mountain spotted fever (RMSF) (Rickettsia rickettsii), Rickettsia parkeri rickettsiosis, Pacific Coast tick fever (Rickettsia species 364D), and rickettsialpox (Rickettsia akari). In this study, we summarize and evaluate surveillance data on spotted fever cases reported to the Centers for Disease Control and Prevention (CDC) through the National Notifiable Diseases Surveillance System from 2010 to 2018. During this period, there were 36,632 reported cases of spotted fevers with 95.83% (N = 35,104) reported as meeting the case definition as probable and 4.17% (N = 1528) reported as meeting the case definition as confirmed. The average national incidence of total cases, both probable and confirmed, was 12.77 cases per million persons per year. The highest statewide incidence was in Arkansas, with 256.84 per million per year, whereas the lowest incidence occurred in California, with 0.32 per million per year (note that spotted fevers were not notifiable in Hawaii and Alaska). Cases of spotted fevers were reported more frequently among males by gender, White by race, and non-Hispanic by ethnicity. The incidence of spotted fevers increased significantly from 2010 to 2018, but it is uncertain how many of the reported cases were RMSF and how many developed from more moderate spotted fevers. Improvement of the ability to differentiate between spotted fever group Rickettsia species is needed.

The "Biological Weapons" of Ehrlichia chaffeensis: Novel Molecules and Mechanisms to Subjugate Host Cells

Ehrlichia chaffeensis is an obligatory intracellular bacterium that causes human monocytic ehrlichiosis, an emerging, potentially fatal tick-borne infectious disease. The bacterium enters human cells via the binding of its unique outer-membrane invasin EtpE to the cognate receptor DNase X on the host-cell plasma membrane; this triggers actin polymerization and filopodia formation at the site of E. chaffeensis binding, and blocks activation of phagocyte NADPH oxidase that catalyzes the generation of microbicidal reactive oxygen species. Subsequently, the bacterium replicates by hijacking/dysregulating host-cell functions using Type IV secretion effectors. For example, the Ehrlichia translocated factor (Etf)-1 enters mitochondria and inhibits mitochondria-mediated apoptosis of host cells. Etf-1 also induces autophagy mediated by the small GTPase RAB5, the result being the liberation of catabolites for proliferation inside host cells. Moreover, Etf-2 competes with the RAB5 GTPase-activating protein, for binding to RAB5-GTP on the surface of E. chaffeensis inclusions, which blocks GTP hydrolysis and consequently prevents the fusion of inclusions with host-cell lysosomes. Etf-3 binds ferritin light chain to induce ferritinophagy to obtain intracellular iron. To enable E. chaffeensis to rapidly adapt to the host environment and proliferate, the bacterium must acquire host membrane cholesterol and glycerophospholipids for the purpose of producing large amounts of its own membrane. Future studies on the arsenal of unique Ehrlichia molecules and their interplay with host-cell components will undoubtedly advance our understanding of the molecular mechanisms of obligatory intracellular infection and may identify hitherto unrecognized signaling pathways of human hosts. Such data could be exploited for development of treatment and control measures for ehrlichiosis as well as other ailments that potentially could involve the same host-cell signaling pathways that are appropriated by E. chaffeensis.

An Automated Syphilis Serology Record Search and Review Algorithm to Prioritize Investigations by Health Departments

BACKGROUND

Reactive syphilis serologies are investigated by health departments to determine if they represent new infection, reinfection, or treatment failure. Serologies prioritized for investigation based on nontreponemal test titer and age (using a "reactor grid") undergo manual record search and review. We developed a computerized algorithm that automates the record search and review.

METHODS

We developed and tested the algorithm using a Florida Department of Health data set containing serologies reported January 2016 to December 2018 and previous records linked to each individual. The algorithm was based on the syphilis case definition, which requires (except primary cases with signs and symptoms) (1) a positive treponemal test result and a newly positive nontreponemal test result or (2) a 4-fold increase in nontreponemal test titer. Two additional steps were added to avoid missing cases. New York City Department of Health and Mental Hygiene validated this algorithm.

RESULTS

The algorithm closed more investigations (49.9%) than the reactor grid (27.0%). The algorithm opened 99.4% of the individuals investigated and labeled as cases by the health department; it missed 75 cases. Many investigations opened by the algorithm were closed by the reactor grid; we could not assess how many would have been cases. In New York City, the algorithm closed 70.9% of investigations, likely because more individuals had previous test in the database (88.2%) compared with Florida (56.5%).

CONCLUSIONS

The automated algorithm successfully searched and reviewed records to help identify cases of syphilis. We estimate the algorithm would have saved Florida 590 workdays for 3 years.

Prevalence of Risk and Protective Factors for Tick Exposure and Tick-Borne Disease Among Residents of Indiana

OBJECTIVE

To determine the prevalence of risk and protective factors for tick exposure and tick-borne disease (TBD) based on gender and living in urban or rural areas (urbanicity) among a cross section of Indiana adults.

METHODS

Data were collected from 3003 adults (81% response rate) spread across all 92 Indiana counties. Study participants were recruited from existing online panels maintained by Qualtrics. We calculated prevalence ratio (PR) and 95% confidence interval (CI) of 8 primary outcomes for 2 different exposures: (1) gender (male/female) and (2) urbanicity.

RESULTS

Female participants were 10% less likely to find a tick on themselves than male participants (PR = 0.90; 95% CI, 0.74-0.99) and significantly more likely to worry about their health and safety because of ticks, whereas males avoided the outdoors less because of worry about ticks. Female participants were significantly more likely to adopt various personal protective measures, specifically because of concern for ticks. Female participants were also less likely to have been told by a health care provider that they have a TBD (PR = 0.53; 95% CI, 0.38-0.75). Rural participants were significantly more likely to report seeing a tick at their residential property (PR = 2.40; 95% CI, 2.11-2.76), report finding ticks on themselves (PR = 1.90; 95% CI, 1.68-2.23), and report finding a tick on a child at their residential property within the past 6 months than urban dwellers (PR = 1.37; 95% CI, 1.06-1.77). In addition, we found that 62% of participants have very high trust in government sources of information on TBD and tick prevention.

CONCLUSIONS

In Indiana, the area around people's residences may constitute an important source of tick exposure for humans. Being exposed to ticks is most prevalent in those living in rural areas of Indiana. Finally, risk factors for TBD are higher among males than among females.

Choosing Wisely For Critical Care: The Next Five

OBJECTIVES

To formulate new "Choosing Wisely" for Critical Care recommendations that identify best practices to avoid waste and promote value while providing critical care.

DATA SOURCES

Semistructured narrative literature review and quantitative survey assessments.

STUDY SELECTION

English language publications that examined critical care practices in relation to reducing cost or waste.

DATA EXTRACTION

Practices assessed to add no value to critical care were grouped by category. Taskforce assessment, modified Delphi consensus building, and quantitative survey analysis identified eight novel recommendations to avoid wasteful critical care practices. These were submitted to the Society of Critical Care Medicine membership for evaluation and ranking.

DATA SYNTHESIS

Results from the quantitative Society of Critical Care Medicine membership survey identified the top scoring five of eight recommendations. These five highest ranked recommendations established Society of Critical Care Medicine's Next Five "Choosing" Wisely for Critical Care practices.

CONCLUSIONS

Five new recommendations to reduce waste and enhance value in the practice of critical care address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care. These recommendations supplement the initial critical care recommendations from the "Choosing Wisely" campaign.

Human-tick encounters as a measure of tickborne disease risk in lyme disease endemic areas

Entomological measures have long served as proxies for human risk of Lyme disease (LD) and other tickborne diseases (TBDs) in endemic areas of the United States, despite conflicting results regarding the correlation between these measures and human disease outcomes. Using data from a previous TBD intervention study in Connecticut, Maryland and New York, we evaluated whether human-tick encounters can serve as an accurate proxy for risk of TBDs in areas where LD and other Ixodes scapularis-transmitted infections are common. Among 2,590 households consisting of 4,210 individuals, experiencing a tick encounter was associated with an increased risk of both self-reported (RR = 3.17, 95% CI: 2.05, 4.91) and verified TBD (RR = 2.60, 95% CI: 1.39, 4.84) at the household level. Household characteristics associated with experiencing any tick encounter were residence in Connecticut (aOR = 1.86, 95% CI: 1.38, 2.51) or New York (aOR = 1.66, 95% CI: 1.25, 2.22), head of household having a graduate level education (aOR = 1.46, 95% CI: 1.04, 2.08), owning a pet (aOR = 1.80, 95% CI: 1.46, 2.23) and a property size of 2 acres or larger (aOR = 2.30, 95% CI: 1.42, 3.70). Results for individual characteristics were similar to those for households. Future prevention studies in LD endemic areas should consider using human-tick encounters as a robust proxy for TBD risk.

Cost-benefit analysis of vaccination against four preventable diseases in older adults: Impact of an aging population

OBJECTIVE

This exploratory study estimates the economic value of the current vaccination program and increased coverage against four preventable diseases in older adults in the United States (US).

METHODS

A population-based, age-structured economic model was used to conduct a cost-benefit analysis of vaccination against influenza, pertussis, herpes zoster, and pneumococcal disease among US adults aged 50 years and older, accounting for aging of the population. The model used separate decision trees for each disease to project the discounted number of vaccinated individuals, number of disease cases, and direct medical and indirect costs (2018 US$) over a 30-year period. Benefit-cost ratios (BCRs) and net present values were calculated for two primary analyses comparing current vaccination coverage versus no vaccination and comparing increased coverage versus current coverage. Key parameter values were varied in deterministic sensitivity analyses.

RESULTS

Current adult vaccination coverage (vs. no vaccination) is estimated to result in nearly 65 million averted disease cases, $185 billion averted costs of cases, and $136 billion in incremental vaccination costs over a 30-year period from a societal perspective (BCR = 1.4). Increased vaccination coverage (vs. current coverage) is associated with over 33 million additional averted disease cases, $96 billion additional averted costs of cases, and nearly $83 billion in incremental vaccination costs, resulting in a societal BCR of 1.2 over 30 years. Deterministic sensitivity analyses demonstrated that results were most sensitive to disease incidence, vaccine efficacy, and productivity costs for time required for vaccination.

CONCLUSIONS

Study results highlight the economic value of vaccination programs for older adults in the US and indicate that efforts to further increase vaccination coverage may be warranted and economically justifiable.

Melioidosis in a Resident of Texas with No Recent Travel History, United States

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.

An intracellular nanobody targeting T4SS effector inhibits Ehrlichia infection

Infection with obligatory intracellular bacteria is difficult to treat, as intracellular targets and delivery methods of therapeutics are not well known. Ehrlichia translocated factor-1 (Etf-1), a type IV secretion system (T4SS) effector, is a primary virulence factor for an obligatory intracellular bacterium, Ehrlichia chaffeensis In this study, we developed Etf-1-specific nanobodies (Nbs) by immunizing a llama to determine if intracellular Nbs block Etf-1 functions and Ehrlichia infection. Of 24 distinct anti-Etf-1 Nbs, NbD7 blocked mitochondrial localization of Etf-1-GFP in cotransfected cells. NbD7 and control Nb (NbD3) bound to different regions of Etf-1. Size-exclusion chromatography showed that the NbD7 and Etf-1 complex was more stable than the NbD3 and Etf-1 complex. Intracellular expression of NbD7 inhibited three activities of Etf-1 and E. chaffeensis: up-regulation of mitochondrial manganese superoxide dismutase, reduction of intracellular reactive oxygen species, and inhibition of cellular apoptosis. Consequently, intracellular NbD7 inhibited Ehrlichia infection, whereas NbD3 did not. To safely and effectively deliver Nbs into the host cell cytoplasm, NbD7 was conjugated to cyclized cell-permeable peptide 12 (CPP12-NbD7). CPP12-NbD7 effectively entered mammalian cells and abrogated the blockade of cellular apoptosis caused by E. chaffeensis and inhibited infection by E. chaffeensis in cell culture and in a severe combined-immunodeficiency mouse model. Our results demonstrate the development of an Nb that interferes with T4SS effector functions and intracellular pathogen infection, along with an intracellular delivery method for this Nb. This strategy should overcome current barriers to advance mechanistic research and develop therapies complementary or alternative to the current broad-spectrum antibiotic.

Trends in the incidence and mortality of legionellosis in Japan: a nationwide observational study, 1999-2017

This study examined temporal trend, seasonality, and geographical variations of legionellosis incidence and mortality in Japan. This nationwide observational study used the Japanese Vital Statistics and Infectious Diseases Weekly Report (1999-2017) data to calculate legionellosis crude and age-adjusted incidence and mortality rates per 100,000 population by age and sex. Incidence was compared among the 4 seasons and regional incidence among 47 prefectures. Of 13,613 (11,194 men) people with legionellosis in Japan, 725 (569 men) were fatal. Increasing incidence trend occurred from 0.0004 (1999) to 1.37 (2017) per 100,000 population. People aged ≥ 70 years accounted for 43.1% overall; men's age-adjusted incidence rate was consistently approximately five times higher than for women. Significantly higher incidence occurred in summer than in winter (p = 0.013). Geographically, highest incidence (≥ 2.0 per 100,000 population) occurred in Hokuriku District, with increasing trends in Hokkaido and middle-part of Japan. Estimated fatality rates decreased consistently at 5.9% (95% confidence interval: - 8.1, - 3.5) annually, from 1999 to 2017, with no trend change point. Increasing legionellosis incidence occurred in Japan during 1999-2017, with declining estimated fatality rates. In this aging society and warming world, disease clinical burden may further deteriorate in future due to increasing incidence trends.

Using Data Surveillance to Understand the Rising Incidence of Babesiosis in the United States, 2011-2018

Babesiosis is a tick-borne disease that is caused by intraerythrocytic protozoan parasites of the genus Babesia. Common symptoms of babesiosis are generally characterized as nonspecific flu-like symptoms, such as fever or chills. Human infections are reported to the Centers for Disease Control and Prevention (CDC) through the National Notifiable Diseases Surveillance System (NNDSS). This study summarizes data of Babesia infections reported to the CDC by the NNDSS from 2011 to 2018. In total, there were 14,159 reported cases of babesiosis, and the incidence rate was 5.55 cases per million persons per year, displaying an increasing trend during the study period. The demographic group most affected was middle-aged and elderly white males. Infections were most abundant in the New England and the Mid-Atlantic regions of the United States. Our study provides useful results for a basic understanding of incidence, spatial and temporal distribution, and severity of babesiosis.

Trends in Morbidity, Mortality, and Cost of Hospitalizations Associated With Infectious Disease Sequelae of the Opioid Epidemic

BACKGROUND

Increases in fatal drug poisonings and hepatitis C infections associated with the opioid epidemic are relatively well defined, because passive surveillance systems for these conditions exist. Less described is the association between the opioid epidemic and skin, soft-tissue, and venous infections (SSTVIs), endocarditis, sepsis, and osteomyelitis.

METHODS

Michigan hospitalizations between 2016 and 2018 that included an International Classification of Diseases, Tenth Revision, Clinical Modification, code indicating substance use were examined for codes indicative of infectious conditions associated with injecting drugs. Trends in these hospitalizations were examined, as were demographic characteristics, discharge disposition, payer, and cost data.

RESULTS

Among hospitalized patients with a substance use diagnosis code, endocarditis, osteomyelitis, sepsis, and SSTVI hospitalizations increased by 33%, 35%, 24%, and 12%, respectively between 2016 and 2018. During this time frame, 1257 patients died or were discharged to hospice. All SSTVI hospitalizations resulted in >$1.3 billion in healthcare costs. Public insurance accounted for more than two-thirds of all hospitalization costs.

CONCLUSIONS

This study describes a method for performing surveillance for infection-related sequelae of injection drug use. Endocarditis, osteomyelitis, sepsis, and SSTVI hospitalizations have increased year over year between 2016 and 2018. These hospitalizations result in significant morbidity, mortality, and healthcare costs and should be a focus of future surveillance and prevention efforts.

Spatial Epidemiology of Salmonellosis in Florida, 2009-2018

Non-typhoidal Salmonella enterica infections cause a high disease burden in the United States with an estimated 1.2 million illnesses annually. The state of Florida consistently has a relatively high incidence compared to other states in the United States. Nevertheless, studies regarding the epidemiology of nontyphoidal salmonellosis and its spatial and temporal patterns in Florida were rarely reported. We examined the spatial and temporal patterns of 62,947 salmonellosis cases reported to FL Health Charts between 2009 and 2018. Dominant serotypes circulating in Florida were also explored using whole genome sequencing (WGS) based serotype-prediction for 2,507 Salmonella isolates sequenced by the Florida Department of Health during 2017 and 2018. The representativeness of laboratory-sequenced isolates for reported cases was determined by regression modeling. The annual incidence rate of salmonellosis decreased from 36.0 per 100,000 population in 2009 to 27.8 per 100,000 in 2016, and gradually increased in 2017 and 2018. Increased use of culture-independent testing did not fully explain this increase. The highest incidence rate was observed in children, contributing 40.9% of total reported cases during this period. A seasonal pattern was observed with the incidence peaking in September and October, later than the national average pattern. Over these 10 years, the Northeast and Northwest regions of the state had higher reported incidence rates, while reported rates in the Southeast and South were gradually increasing over time. Serotypes were predicted based on WGS data in the EnteroBase platform. The top-five most prevalent serotypes in Florida during 2017–2018 were Enteritidis, Newport, Javiana, Sandiego and Braenderup. The highest percentage of isolates was from children under 5 years of age (41.4%), and stool (84.7%) was the major source of samples. A zero-inflated negative binomial regression model showed that the reported case number was a strong predictor for the number of lab-sequenced isolates in individual counties, and the geospatial distribution of sequenced isolates was not biased by other factors such as age group. The spatial and temporal patterns identified in this study along with the prevalence of different serotypes will be helpful for the development of efficient prevention and control strategies for salmonellosis in Florida.

Age- and risk factor-based serologic screening for Hepatitis C virus among an Urban, high-risk population

Hepatitis C virus (HCV) screening among individuals born between 1945 and 1965 (ie birth cohort) may augment risk factor-based screening. We assessed HCV seropositivity among injection drug users (IDUs) and birth cohort members from New York City. We assessed HCV risk factors and seropositivity in 7722 participants from community health, HIV prevention, syringe exchange and drug treatment programmes. A total of 26.6% were HCV seropositive, 55.8% were born between 1945 and 1965, and 82.2% had ever injected drugs. Among all participants, HCV seropositivity was higher among IDUs compared to non-IDUs (60.5% versus 7.7%, odds ratio (OR) = 18.5, 95% confidence interval (CI) [16.2, 21.1], P < .0001) and among birth cohort members compared to non-birth cohort members (31.3% versus 22.3%, OR = 1.6, 95%CI [1.4, 1.8], P < .0001). Within the birth cohort, HCV seroprevalence among IDUs was 68.5% versus 11.8%, OR = 16.2, 95%CI [13.7, 19.3]. After adjustment, HCV seroprevalence was higher in IDUs, previously incarcerated, whites (<42 years) and 'other races' (versus blacks), HIV-infected, those who snorted heroin, those with liver disease history, and those who had sex with an HCV-seropositive partner. HCV seroprevalence among IDU, birth cohort members, was considerably higher than among the general population. In this high-risk, urban population, the association between IDU and HCV seropositivity was approximately ten times that between birth cohort membership and HCV seropositivity.

Increasing Incidence of Anaplasmosis in the United States, 2012 Through 2016

Anaplasmosis is a tick-borne disease that is primarily caused by the rickettsial bacterium Anaplasma phagocytophilum. Anaplasmosis is a febrile disease with common symptoms, including headaches, fever, and lethargy, but it can cause serious organ failure and even death if left untreated. Human infections are reported annually to the Centers for Disease Control and Prevention (CDC) through the National Notifiable Diseases Surveillance System (NNDSS). This report analyzed the cases of anaplasmosis reported by the NNDSS from 2012 to 2016. In total, there were 15,778 reported A. phagocytophilum infections, and the incidence rate was 7.27 cases per million persons per year, with the number of reported cases increasing each year. The demographic group most affected was middle-aged and elderly white males. Infections were most abundant in the coastal northeast and northern midwest regions. Our study provides useful results for a basic understanding of incidence, distribution, and severity of A. phagocytophilum infections.

Implementation of Legionella Prevention Policy in Health Care Facilities: The United States Veterans Health Administration Experience

CONTEXT

The Veterans Health Administration requires implementation of Legionella prevention policy in potable water systems at Department of Veterans Affairs (VA) medical facilities across the United States and territories.

PROGRAM

The Veterans Health Administration Central Office program offices with expertise in engineering and clinical aspects of Legionella prevention policy have provided joint, structured on-site assistance to VA medical facilities for consultation on policy implementation. Site visits included review of facility documentation and data, discussions with staff, touring of buildings, and development of recommendations.

IMPLEMENTATION

Information obtained from on-site consultative assistance provided to VA medical facilities from December 2012 through January 2018 was reviewed to identify engineering and clinical challenges and lessons from implementation of Legionella prevention policy in VA health care buildings. Fifteen consultative site visits were conducted during this period regarding implementation of Legionella prevention and validation of effectiveness.

EVALUATION

It was found that implementation of Legionella prevention policy in potable water systems was complex and practices varied for each building. Common implementation challenges included capability of applying engineering controls, water stagnation, and assessment of health care association of Legionella cases. Process challenges included routine verification of actions, methods for assessing environmental validation data, and documentation of requirements. It was found that consistent and data-driven implementation of policy is crucial for an effective program.

DISCUSSION

Guidance and standards documents in the community for Legionella prevention in building water systems are often general in nature, but implementation requires specific decisions and routine assessments and modifications to optimize outcomes. This real-world review of challenges and lessons from a large health care system with a detailed primary Legionella prevention policy informs future development of guidance and policy, both within and external to VA, and can provide insight to other health care facilities planning to implement practices for water safety.

How to Understand "Herd Immunity" in COVID-19 Pandemic

The COVID-19 pandemic has been a global threat. Through rapid and effective surveillance and control, the newly confirmed patients have been fluctuated at a very low level and imported case explained most of them through March, 2020 to the present, indicating China's response has achieved a stage victory. By contrast, the epidemic of COVID-19 in other countries out of China is bursting. Different countries are adopting varied response strategy in terms of their public health system to prevent the spread. Herd immunity has been a hot topic since the outbreak of COVID-19 pandemic. Can it be a possible strategy to combat COVID-19? To fully interpret the knowledge regarding the term upon the background of COVID-19-related health crisis, we aim to systematically review the definition, describe the effective measures of acquiring herd immunity, and discuss its feasibility in COVID-19 prevention. Findings from this review would promote and strengthen the international cooperation and joint efforts when confronting with COVID-19.

How to Understand "Herd Immunity" in COVID-19 Pandemic

The COVID-19 pandemic has been a global threat. Through rapid and effective surveillance and control, the newly confirmed patients have been fluctuated at a very low level and imported case explained most of them through March, 2020 to the present, indicating China’s response has achieved a stage victory. By contrast, the epidemic of COVID-19 in other countries out of China is bursting. Different countries are adopting varied response strategy in terms of their public health system to prevent the spread. Herd immunity has been a hot topic since the outbreak of COVID-19 pandemic. Can it be a possible strategy to combat COVID-19? To fully interpret the knowledge regarding the term upon the background of COVID-19-related health crisis, we aim to systematically review the definition, describe the effective measures of acquiring herd immunity, and discuss its feasibility in COVID-19 prevention. Findings from this review would promote and strengthen the international cooperation and joint efforts when confronting with COVID-19.

Shigellosis Among Gay and Bisexual Men: A Qualitative Assessment to Examine Knowledge, Attitudes, and Practices

BACKGROUND

Shigellosis is a highly contagious enteric bacterial disease transmitted through the fecal-oral route. It is primarily transmitted through person-to-person contact and via contaminated food and water. Outbreaks of shigellosis among men who have sex with men (MSM) attributed to sexual person-to-person contact have been reported. These outbreaks are of concern because they are often caused by multidrug-resistant strains of Shigella. Little is known about shigellosis-related knowledge, attitudes, and practices among gay, bisexual, and other MSM.

METHODS

Six focus groups were conducted among self-identified gay or bisexual men in Atlanta, GA, in Fall 2017. Participants were asked about shigellosis-related knowledge, attitudes, and practices. Focus groups were audio recorded, and the transcribed audio was analyzed using inductive and deductive thematic coding.

RESULTS

Among the 24 focus group participants, most perceived that diarrheal illness was caused by contaminated food. Knowledge of shigellosis and Shigella was low, with most never having heard of the disease or bacteria. Participants did not perceive shigellosis to be a serious health concern, especially when compared with HIV; however, they did perceive gay and bisexual men to be at risk of Shigella infection. Participants reported mixed intentions to change sexual behaviors to prevent shigellosis or talk with sexual partners about diarrhea.

CONCLUSIONS

Health communication and education efforts could be used to increase knowledge about shigellosis and shift perceptions about the severity of shigellosis among gay, bisexual, and other MSM. Additional work is needed to identify effective ways to promote shigellosis-related prevention behaviors among gay, bisexual, and other MSM.

Transmission of Eastern Equine Encephalitis Virus From an Organ Donor to 3 Transplant Recipients

BACKGROUND

In fall 2017, 3 solid organ transplant (SOT) recipients from a common donor developed encephalitis within 1 week of transplantation, prompting suspicion of transplant-transmitted infection. Eastern equine encephalitis virus (EEEV) infection was identified during testing of endomyocardial tissue from the heart recipient.

METHODS

We reviewed medical records of the organ donor and transplant recipients and tested serum, whole blood, cerebrospinal fluid, and tissue from the donor and recipients for evidence of EEEV infection by multiple assays. We investigated blood transfusion as a possible source of organ donor infection by testing remaining components and serum specimens from blood donors. We reviewed data from the pretransplant organ donor evaluation and local EEEV surveillance.

RESULTS

We found laboratory evidence of recent EEEV infection in all organ recipients and the common donor. Serum collected from the organ donor upon hospital admission tested negative, but subsequent samples obtained prior to organ recovery were positive for EEEV RNA. There was no evidence of EEEV infection among donors of the 8 blood products transfused into the organ donor or in products derived from these donations. Veterinary and mosquito surveillance showed recent EEEV activity in counties nearby the organ donor's county of residence. Neuroinvasive EEEV infection directly contributed to the death of 1 organ recipient and likely contributed to death in another.

CONCLUSIONS

Our investigation demonstrated EEEV transmission through SOT. Mosquito-borne transmission of EEEV to the organ donor was the likely source of infection. Clinicians should be aware of EEEV as a cause of transplant-associated encephalitis.

Impact of population aging on the burden of vaccine-preventable diseases among older adults in the United States

Despite vaccination recommendations, the burden of vaccine-preventable diseases remains high in older adults in the United States (US), contributing to substantial morbidity, mortality, and health care resource use and costs. To adequately plan for health care resource needs and to help inform vaccination policies, burden of disease projections that account for population aging over the coming decades are needed. As a first step, this exploratory study projects the burden of influenza, pertussis, herpes zoster, and pneumococcal disease in adults aged 50 y and older in the US, using a population-based modeling framework with separate decision trees for each vaccine-preventable disease. The model uses projected population estimates from the US Census Bureau to account for changes in the US population over time and then calculates expected numbers of cases and associated costs for each disease, keeping current estimates of age-specific disease incidence, vaccine coverage, and efficacy constant over time. This approach was used to focus the exploratory analysis on the burden of disease that may be expected due to population changes alone, assuming that all else remains unchanged. Due to population growth and the shifting age distribution over the next 30 y, the annual societal economic burden for the four vaccine-preventable diseases is projected to increase from approximately $35 billion to $49 billion, resulting in cumulative costs of approximately $1.3 trillion, as well as more than 1 million disease-related deaths. Given such notable burden, further efforts to increase vaccination coverage and effectiveness in older adults are needed.

Infectious Disease Research in the Era of Big Data

Infectious disease research spans scales from the molecular to the global—from specific mechanisms of pathogen drug resistance, virulence, and replication to the movement of people, animals, and pathogens around the world. All of these research areas have been impacted by the recent growth of large-scale data sources and data analytics. Some of these advances rely on data or analytic methods that are common to most biomedical data science, while others leverage the unique nature of infectious disease, namely its communicability. This review outlines major research progress in the past few years and highlights some remaining opportunities, focusing on data or methodological approaches particular to infectious disease.

Trends in Legionnaires' Disease-Associated Hospitalizations, United States, 2006-2010

Background

Legionella pneumophila is a waterborne cause of both healthcare-associated and community-acquired pneumonia. Legionella pneumophila serogroup 1 is responsible for 80% of infections. There is currently limited published disease burden data on Legionnaires’ disease-associated hospitalization in the United States.

Methods

In this study, we estimated the annual incidence of Legionnaires’ disease-associated hospitalizations in United States and identified demographic, temporal, and regional characteristics of individuals hospitalized for Legionnaires’ disease. A retrospective study was conducted using the National Hospital Discharge Survey (NHDS) data from 2006 to 2010. The NHDS is a nationally representative US survey, which includes estimates of inpatient stays in short-stay hospitals in the United States, excluding federal, military, and Veterans Administration hospitals. All discharges assigned with the Legionnaires’ disease International Classification of Diseases 9th Clinical Modification discharge diagnostic code (482.84) were included in this study.

Results

We observed the annual incidence and number of Legionnaires’ disease-associated hospitalizations (per 100 000 population) in the United States by year, age, sex, race, and region. Over a 5-year period, 14 574 individuals experienced Legionnaires’ disease-associated hospitalizations in the United States The annual population-adjusted incidence (per 100 000 population) of Legionnaires’ disease-associated hospitalizations was 5.37 (95% confidence interval [CI], 5.12–5.64) in 2006, 7.06 (95% CI, 6.80–7.40) in 2007, 8.77 (95% CI, 8.44–9.11) in 2008, 17.07 (95% CI, 16.62–17.54) in 2009, and 9.66 (95% CI, 9.32–10.01) in 2010. A summer peak of Legionnaires’ disease-associated hospitalizations occurred from June through September in 2006, 2007, 2008, and 2010.

Conclusions

Legionnaires’ disease-associated hospitalizations significantly increased over the 5-year study period. The increasing disease burden of Legionnaires’ disease suggests that large segments of the US population are at risk for exposure to this waterborne pathogen.