Research opportunities for the primary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report

Primary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) encompasses the timely diagnosis and adequate treatment of the superficial group A Streptococcus (GAS) infections pharyngitis and impetigo. GAS is the only known inciting agent in the pathophysiology of the disease. However, sufficient evidence indicates that the uptake and delivery of primary prevention approaches in RHD-endemic regions are significantly suboptimal. This report presents expert deliberations on priority research and implementation opportunities for primary prevention of ARF/RHD that were developed as part of a workshop convened by the US National Heart, Lung, and Blood Institute in November 2021. The opportunities identified by the Primary Prevention Working Group encompass epidemiological, laboratory, clinical, implementation and dissemination research domains and are anchored on five pillars including: (A) to gain a better understanding of superficial GAS infection epidemiology to guide programmes and policies; (B) to improve diagnosis of superficial GAS infections in RHD endemic settings; (C) to develop scalable and sustainable models for delivery of primary prevention; (D) to understand potential downstream effects of the scale-up of primary prevention and (E) to develop and conduct economic evaluations of primary prevention strategies in RHD endemic settings. In view of the multisectoral stakeholders in primary prevention strategies, we emphasise the need for community co-design and government engagement, especially in the implementation and dissemination research arena. We present these opportunities as a reference point for research organisations and sponsors who aim to contribute to the increasing momentum towards the global control and prevention of RHD.

Time to negative throat culture following initiation of antibiotics for pharyngeal group A Streptococcus: a systematic review and meta-analysis up to October 2021 to inform public health control measures

BackgroundPublic health guidance recommending isolation of individuals with group A streptococcal (GAS) infection or carriage for 12-24 h from antibiotic initiation to prevent onward transmission requires a strong evidence base.AimTo estimate the pooled proportion of individuals who remain GAS culture-positive at set intervals after initiation of antibiotics through a systematic literature review (PROSPERO CRD42021290364) and meta-analysis.MethodsWe searched Ovid MEDLINE (1946-), EMBASE (1974-) and Cochrane library. We included interventional or observational studies with ≥ 10 participants reporting rates of GAS throat culture positivity during antibiotic treatment for culture-confirmed GAS pharyngitis, scarlet fever and asymptomatic pharyngeal GAS carriage. We did not apply age, language or geographical restrictions.ResultsOf 5,058 unique records, 43 were included (37 randomised controlled studies, three non-randomised controlled trials and three before-and-after studies). The proportion of individuals remaining culture-positive on day 1, day 2 and days 3-9 were 6.9% (95% CI: 2.7-16.8%), 5.4% (95% CI: 2.1-13.3%) and 2.6% (95% CI: 1.6-4.2%). For penicillins and cephalosporins, day 1 positivity was 6.5% (95% CI: 2.5-16.1%) and 1.6% (95% CI: 0.04-42.9%), respectively. Overall, for 9.1% (95% CI: 7.3-11.3), throat swabs collected after completion of therapy were GAS culture-positive. Only six studies had low risk of bias.ConclusionsOur review provides evidence that antibiotics for pharyngeal GAS achieve a high rate of culture conversion within 24 h but highlights the need for further research given methodological limitations of published studies and imprecision of pooled estimates. Further evidence is needed for non-beta-lactam antibiotics and asymptomatic individuals.

Standardization of Epidemiological Surveillance of Group A Streptococcal Cellulitis

Cellulitis is an acute bacterial infection of the dermis and subcutaneous tissue usually found complicating a wound, ulcer, or dermatosis. This article provides guidelines for the surveillance of cellulitis. The primary objectives of cellulitis surveillance are to (1) monitor trends in rates of infection, (2) describe the demographic and clinical characteristics of patients with cellulitis, (3) estimate the frequency of complications, and (4) describe the risk factors associated with primary and recurrent cellulitis. This article includes case definitions for clinical cellulitis and group A streptococcal cellulitis, based on clinical and laboratory evidence, and case classifications for an initial and recurrent case. It is expected that surveillance for cellulitis will be for all-cause cellulitis, rather than specifically for Strep A cellulitis. Considerations of the type of surveillance are also presented, including identification of data sources and surveillance type. Minimal surveillance necessary for cellulitis is facility-based, passive surveillance. Prospective, active, facility-based surveillance is recommended for estimates of pathogen-specific cellulitis burden. Participant eligibility, surveillance population, and additional surveillance considerations such as active follow-up of cases, the use of International Classification of Disease diagnosis codes, and microbiological sampling of cases are discussed. Finally, the core data elements to be collected on case report forms are presented.

Standardization of Epidemiological Surveillance of Group A Streptococcal Pharyngitis

Pharyngitis, more commonly known as sore throat, is caused by viral and/or bacterial infections. Group A Streptococcus (Strep A) is the most common bacterial cause of pharyngitis. Strep A pharyngitis is an acute, self-limiting disease but if undertreated can lead to suppurative complications, nonsuppurative poststreptococcal immune-mediated diseases, and toxigenic presentations. We present a standardized surveillance protocol, including case definitions for pharyngitis and Strep A pharyngitis, as well as case classifications that can be used to differentiate between suspected, probable, and confirmed cases. We discuss the current tests used to detect Strep A among persons with pharyngitis, including throat culture and point-of-care tests. The type of surveillance methodology depends on the resources available and the objectives of surveillance. Active surveillance and laboratory confirmation is the preferred method for case detection. Participant eligibility, the surveillance population and additional considerations for surveillance of pharyngitis are addressed, including baseline sampling, community engagement, frequency of screening and season. Finally, we discuss the core elements of case report forms for pharyngitis and provide guidance for the recording of severity and pain associated with the course of an episode.

Standardization of Epidemiological Surveillance of Acute Poststreptococcal Glomerulonephritis

Acute poststreptococcal glomerulonephritis (APSGN) is an immune complex-induced glomerulonephritis that develops as a sequela of streptococcal infections. This article provides guidelines for the surveillance of APSGN due to group A Streptococcus (Strep A). The primary objectives of APSGN surveillance are to monitor trends in age- and sex-specific incidence, describe the demographic and clinical characteristics of patients with APSGN, document accompanying risk factors, then monitor trends in frequency of complications, illness duration, hospitalization rates, and mortality.

This document provides surveillance case definitions for APSGN, including clinical and subclinical APSGN based on clinical and laboratory evidence. It also details case classifications that can be used to differentiate between confirmed and probable cases, and it discusses the current investigations used to provide evidence of antecedent Strep A infection.

The type of surveillance recommended depends on the burden of APSGN in the community and the objectives of surveillance. Strategies for minimal surveillance and enhanced surveillance of APSGN are provided. Furthermore, a discussion covers the surveillance population and additional APSGN-specific surveillance considerations such as contact testing, active follow up of cases and contacts, frequency of reporting, surveillance visits, period of surveillance, and community engagement. Finally, the document presents core data elements to be collected on case report forms, along with guidance for documenting the course and severity of APSGN.

Standardization of Epidemiological Surveillance of Group A Streptococcal Impetigo

Impetigo is a highly contagious bacterial infection of the superficial layer of skin. Impetigo is caused by group A Streptococcus (Strep A) and Staphylococcus aureus, alone or in combination, with the former predominating in many tropical climates. Strep A impetigo occurs mainly in early childhood, and the burden varies worldwide. It is an acute, self-limited disease, but many children experience frequent recurrences that make it a chronic illness in some endemic settings. We present a standardized surveillance protocol including case definitions for impetigo including both active (purulent, crusted) and resolving (flat, dry) phases and discuss the current tests used to detect Strep A among persons with impetigo. Case classifications that can be applied are detailed, including differentiating between incident (new) and prevalent (existing) cases of Strep A impetigo. The type of surveillance methodology depends on the burden of impetigo in the community. Active surveillance and laboratory confirmation is the preferred method for case detection, particularly in endemic settings. Participant eligibility, surveillance population and additional considerations for surveillance of impetigo, including examination of lesions, use of photographs to document lesions, and staff training requirements (including cultural awareness), are addressed. Finally, the core elements of case report forms for impetigo are presented and guidance for recording the course and severity of impetigo provided.

A systematic framework for prioritising burden of disease data required for vaccine development and implementation: the case for group A streptococcal diseases

Vaccine development and implementation decisions need to be guided by accurate and robust burden of disease data. We developed an innovative systematic framework outlining the properties of such data that are needed to advance vaccine development and evaluation, and prioritize research and surveillance activities. We focus on 4 objectives—advocacy, regulatory oversight and licensure, policy and post-licensure evaluation, and post-licensure financing—and identify key stakeholders and specific requirements for burden of disease data aligned with each objective. We apply this framework to group A Streptococcus, a pathogen with an underrecognized global burden, and give specific examples pertinent to 8 clinical endpoints. This dynamic framework can be adapted for any disease with a vaccine in development and can be updated as vaccine candidates progress through clinical trials. This framework will also help with research and innovation priority setting of the Immunization Agenda 2030 (IA2030) and accelerate development of future vaccines.

The Global Landscape of Pediatric Bacterial Meningitis Data Reported to the World Health Organization-Coordinated Invasive Bacterial Vaccine-Preventable Disease Surveillance Network, 2014-2019

BACKGROUND

The World Health Organization (WHO) coordinates the Global Invasive Bacterial Vaccine-Preventable Diseases (IB-VPD) Surveillance Network to support vaccine introduction decisions and use. The network was established to strengthen surveillance and laboratory confirmation of meningitis caused by Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis.

METHODS

Sentinel hospitals report cases of children <5 years of age hospitalized for suspected meningitis. Laboratories report confirmatory testing results and strain characterization tested by polymerase chain reaction. In 2019, the network included 123 laboratories that follow validated, standardized testing and reporting strategies.

RESULTS

From 2014 through 2019, >137 000 suspected meningitis cases were reported by 58 participating countries, with 44.6% (n = 61 386) reported from countries in the WHO African Region. More than half (56.6%, n = 77 873) were among children <1 year of age, and 4.0% (n = 4010) died among those with reported disease outcome. Among suspected meningitis cases, 8.6% (n = 11 798) were classified as probable bacterial meningitis. One of 3 bacterial pathogens was identified in 30.3% (n = 3576) of these cases, namely S. pneumoniae (n = 2177 [60.9%]), H. influenzae (n = 633 [17.7%]), and N. meningitidis (n = 766 [21.4%]). Among confirmed bacterial meningitis cases with outcome reported, 11.0% died; case fatality ratio varied by pathogen (S. pneumoniae, 12.2%; H. influenzae, 6.1%; N. meningitidis, 11.0%). Among the 277 children who died with confirmed bacterial meningitis, 189 (68.2%) had confirmed S. pneumoniae. The proportion of pneumococcal cases with pneumococcal conjugate vaccine (PCV) serotypes decreased as the number of countries implementing PCV increased, from 77.8% (n = 273) to 47.5% (n = 248). Of 397 H. influenzae specimens serotyped, 49.1% (n = 195) were type b. Predominant N. meningitidis serogroups varied by region.

CONCLUSIONS

This multitier, global surveillance network has supported countries in detecting and serotyping the 3 principal invasive bacterial pathogens that cause pediatric meningitis. Streptococcus pneumoniae was the most common bacterial pathogen detected globally despite the growing number of countries that have nationally introduced PCV. The large proportions of deaths due to S. pneumoniae reflect the high proportion of meningitis cases caused by this pathogen. This global network demonstrated a strong correlation between PCV introduction status and reduction in the proportion of pneumococcal meningitis infections caused by vaccine serotypes. Maintaining case-based, active surveillance with laboratory confirmation for prioritized vaccine-preventable diseases remains a critical component of the global agenda in public health.The World Health Organization (WHO)-coordinated Invasive Bacterial Vaccine-Preventable Disease (IB-VPD) Surveillance Network reported data from 2014 to 2019, contributing to the estimates of the disease burden and serotypes of pediatric meningitis caused by Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis.

Comparison of common acute respiratory infection case definitions for identification of hospitalized influenza cases at a population-based surveillance site in Egypt

Background

Multiple case definitions are used to identify hospitalized patients with community-acquired acute respiratory infections (ARI). We evaluated several commonly used hospitalized ARI case definitions to identify influenza cases.

Methods

The study included all patients from a population-based surveillance site in Damanhour, Egypt hospitalized for a broad set of criteria consistent with community acquired ARIs. Naso- and oropharyngeal (NP/OP) swabs were tested for influenza using RT-PCR. Sensitivity, specificity and PPV for influenza identification was compared between the 2014 WHO Severe Acute Respiratory Infection (SARI) definition (fever ≥38°C and cough with onset within 10 days), the 2011 WHO SARI definition (fever ≥38°C and cough with onset within 7 days), the 2006 PAHO SARI definition, the International Emerging Infections Program (IEIP) pneumonia case definition, and the International Management of Childhood Illness (IMCI) case definitions for moderate and severe pneumonia.

Results

From June 2009-December 2012, 5768 NP/OP swabs were obtained from 6113 hospitalized ARI patients; 799 (13.9%) were influenza positive. The 2014 WHO SARI case definition captured the greatest number of ARI patients, influenza positive patients and ARI deaths compared to the other case definitions examined. Sensitivity for influenza detection was highest for the 2014 WHO SARI definition with 88.6%, compared to the 2011 WHO SARI (78.2%) the 2006 PAHO SARI (15.8%) the IEIP pneumonia (61.0%) and the IMCI moderate and severe pneumonia (33.8% and 38.9%) case definitions (IMCI applies to <5 only).

Conclusions

Our results support use of the 2014 WHO SARI definition for identifying influenza positive hospitalized SARI cases as it captures the highest proportion of ARI deaths and influenza positive cases. Routine use of this case definition for hospital-based surveillance will provide a solid, globally comparable foundation on which to build needed response efforts for novel pandemic viruses.

1467. Association between Pathogen Load in the Upper Respiratory Tract and Severe Acute Respiratory Infections in Guatemalan Adults: Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis, Streptococcus pneumoniae, Klebsiella pneumoniae

Background

The causal attribution of bacterial pathogens to severe acute respiratory infections (SARI) is challenging because many bacteria are frequently detected in the upper respiratory tract of asymptomatic persons. Quantification of pathogen load may help differentiate asymptomatic pathogen carriage from clinically significant infection. We aimed to determine whether real-time PCR (rt-PCR) cycle threshold (Ct) values, as a proxy for bacterial load, differ between adults with SARI and asymptomatic adults.

Methods

Adults with SARI (acute onset of fever and cough, requiring hospitalization) were frequency matched to asymptomatic adults (enrolled from trauma and orthopedic inpatient wards) by age group, catchment area, and enrollment date at three surveillance sites in Guatemala. Nasopharyngeal and oropharyngeal specimens were collected from all participants and tested for pathogens using rt-PCR. Using the Wilcoxon rank sum test, we compared the distributions and median Ct values between ill and asymptomatic adults in whom Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis, Streptococcus pneumoniae, and Klebsiella pneumoniae were detected.

Results

Between October 2013 and October 2015, 304 adults with SARI and 174 asymptomatic adults were enrolled (Table). M. catarrhalis, S. aureus, and S. pneumoniae were detected with similar frequency in both groups. H. influenzae and K. pneumoniae were detected more frequently in asymptomatic adults. We found the greatest difference in Ct value distributions between ill (median Ct=30.8) and asymptomatic adults (median Ct=35.6) with S. pneumoniae detections (p< 0.01) (Figure). Median Ct values of H. influenzae (29.3 vs 31.1, p=0.04) and M. catarrhalis (29.2 vs 31.5, p=0.05) were also lower among adults with SARI.

Frequency of select bacterial pathogen detection among adults with SARI and among asymptomatic adults, Guatemala, 2013-2015

Distributions of Ct values among adults with SARI and asymptomatic adults in whom a given bacterial pathogen was detected

Conclusion

Pathogen loads of S. pneumoniae, H. influenzae, and M. catarrhalis were higher among adults with SARI than among asymptomatic adults, suggesting that Ct values may provide insight into SARI etiology for some pathogens, despite the similar frequency of detection among both ill and asymptomatic adults. Future work will normalize Ct values to account for variation in testing and analysis and explore the use of Ct values to estimate population attributable fractions of respiratory infections.

Disclosures

All Authors: No reported disclosures

Risk for Invasive Streptococcal Infections among Adults Experiencing Homelessness, Anchorage, Alaska, USA, 2002-2015

The risk for invasive streptococcal infection has not been clearly quantified among persons experiencing homelessness (PEH). We compared the incidence of detected cases of invasive group A Streptococcus infection, group B Streptococcus infection, and Streptococcus pneumoniae (pneumococcal) infection among PEH with that among the general population in Anchorage, Alaska, USA, during 2002–2015. We used data from the Centers for Disease Control and Prevention’s Arctic Investigations Program surveillance system, the US Census, and the Anchorage Point-in-Time count (a yearly census of PEH). We detected a disproportionately high incidence of invasive streptococcal disease in Anchorage among PEH. Compared with the general population, PEH were 53.3 times as likely to have invasive group A Streptococcus infection, 6.9 times as likely to have invasive group B Streptococcus infection, and 36.3 times as likely to have invasive pneumococcal infection. Infection control in shelters, pneumococcal vaccination, and infection monitoring could help protect the health of this vulnerable group.

Evaluation of pneumococcal meningitis clusters in Burkina Faso and implications for potential reactive vaccination

•

From 2011 to 2017, Burkina Faso had 20 pneumococcal meningitis clusters of ≥ 5 cases per district/week.

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Clusters had a maximum weekly incidence of 7 cases and a maximum duration of 4 weeks.

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Most clusters occurred prior to 13-valent pneumococcal conjugate vaccine introduction.

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Clusters were caused by a mixture of serotypes, with serotype 1 being most common.

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Due to the limited cluster size and duration, there were no clear indications for reactive vaccination.

Background

To better understand how to prevent and respond to pneumococcal meningitis outbreaks in the meningitis belt, we retrospectively examined Burkina Faso’s case-based meningitis surveillance data for pneumococcal meningitis clusters and assessed potential usefulness of response strategies.

Methods

Demographic and clinical information, and cerebrospinal fluid laboratory results for meningitis cases were collected through nationwide surveillance. Pneumococcal cases were confirmed by culture, polymerase chain reaction (PCR), or latex agglutination; strains were serotyped using PCR. We reviewed data from 2011 to 2017 to identify and describe clusters of ≥ 5 confirmed pneumococcal meningitis cases per week in a single district. We assessed whether identified clusters met the 2016 WHO provisional pneumococcal meningitis outbreak definition: a district with a weekly incidence of >5 suspected meningitis cases/100,000 persons, >60% of confirmed meningitis cases caused by Streptococcus pneumoniae, and >10 confirmed pneumococcal meningitis cases.

Results

Twenty pneumococcal meningitis clusters were identified, with a maximum weekly incidence of 7 cases and a maximum duration of 4 weeks. Most identified clusters (15/20; 75%) occurred before nationwide introduction of 13-valent pneumococcal conjugate vaccine (PCV13) in October 2013. Most cases were due to serotype 1 (74%), 10% were due to PCV13 serotypes besides serotype 1, and 8 clusters had >1 serotype. While 6 identified clusters had a weekly incidence of >5 suspected cases/100,000 and all 20 clusters had >60% of confirmed meningitis cases due to S. pneumoniae, no cluster had >10 confirmed pneumococcal meningitis cases in a single week.

Conclusions

Following PCV13 introduction, pneumococcal meningitis clusters were rarely detected, and none met the WHO provisional pneumococcal outbreak definition. Due to the limited cluster size and duration, there were no clear instances where reactive vaccination could have been useful. More data are needed to inform potential response strategies.

Impact of 13-Valent Pneumococcal Conjugate Vaccine on Pneumococcal Meningitis, Burkina Faso, 2016-2017

BACKGROUND

In 2013, Burkina Faso introduced 13-valent pneumococcal conjugate vaccine (PCV13) into the routine childhood immunization program, to be administered to children at 8, 12, and 16 weeks of age. We evaluated the impact of PCV13 on pneumococcal meningitis.

METHODS

Using nationwide surveillance, we gathered demographic/clinical information and cerebrospinal fluid (CSF) results for meningitis cases. Pneumococcal cases were confirmed by culture, polymerase chain reaction (PCR), or latex agglutination; strains were serotyped using PCR. We compared annual incidence (cases per 100 000) 4 years after PCV13's introduction (2017) to average pre-PCV13 incidence (2011-2013). We adjusted incidence for age and proportion of cases with CSF tested at national laboratories.

RESULTS

In 2017, pneumococcal meningitis incidence was 2.7 overall and 10.5 (<1 year), 3.8 (1-4 years), 3.5 (5-14 years), and 1.4 (≥15 years) by age group. Compared to 2011-2013, PCV13-serotype incidence was significantly lower among all age groups, with the greatest decline among children aged <1 year (77%; 95% confidence interval [CI], 65%-84%). Among all ages, the drop in incidence was larger for PCV13 serotypes excluding serotype 1 (79%; 95% CI, 72%-84%) than for serotype 1 (52%; 95% CI, 44%-59%); incidence of non-PCV13 serotypes also declined (53%; 95% CI, 37%-65%). In 2017, 45% of serotyped cases among all ages were serotype 1 and 12% were other PCV13 serotypes.

CONCLUSIONS

In Burkina Faso, meningitis caused by PCV13 serotypes continues to decrease, especially among young children. However, the concurrent decline in non-PCV13 serotypes and short pre-PCV13 observation period complicate evaluation of PCV13's impact. Efforts to improve control of serotype 1, such as switching from a 3 + 0 schedule to a 2 + 1 schedule, may improve overall control of pneumococcal meningitis in this setting.

Characteristics of Intracranial Group A Streptococcal Infections in US Children, 1997-2014

BACKGROUND

Few data on intracranial group A Streptococcus (GAS) infection in children are available. Here, we describe the demographic, clinical, and diagnostic characteristics of 91 children with intracranial GAS infection.

METHODS

Cases of intracranial GAS infection in persons ≤18 years of age reported between 1997 and 2014 were identified by the Centers for Disease Control and Prevention's population- and laboratory-based Active Bacterial Core surveillance (ABCs) system. Medical charts were abstracted using a active, standardized case report form. All available isolates were emm typed. US census data were used to calculate rates.

RESULTS

ABCs identified 2596 children with invasive GAS infection over an 18-year period; 91 (3.5%) had an intracranial infection. Intracranial infections were most frequent during the winter months and among children aged <1 year. The average annual incidence was 0.07 cases per 100000 children. For 83 patients for whom information for further classification was available, the principal clinical presentations included meningitis (35 [42%]), intracranial infection after otitis media, mastoiditis, or sinusitis (34 [41%]), and ventriculoperitoneal shunt infection (14 [17%]). Seven (8%) of these infections progressed to streptococcal toxic shock syndrome. The overall case fatality rate was 15%. GAS emm types 1 (31% of available isolates) and 12 (13% of available isolates) were most common.

CONCLUSIONS

Pediatric intracranial (GAS) infections are uncommon but often severe. Risk factors for intracranial GAS infection include the presence of a ventriculoperitoneal shunt and contiguous infections in the middle ear or sinuses.

1625. Risk of Invasive Group A Streptococcus, Group B Streptococcus, and Streptococcus pneumoniae Infection Among Adults Experiencing Homelessness—Anchorage, Alaska, 2002–2015

Background

People experiencing homelessness (PEH) have an increased risk of infectious disease. However, for many infections, this increased risk has not been clearly quantified. For example, the risk of invasive streptococcal infection has not been established among PEH in the United States.

Methods

We compared the incidence of detected cases of invasive group A Streptococcus (GAS) infection, group B Streptococcus (GBS) infection, and Streptococcus pneumoniae (pneumococcal) infection among adult PEH to that in the general adult population in Anchorage, Alaska from 2005 through 2015 using data from the CDC Arctic Investigations Program surveillance system, the US census, and the Anchorage Point in Time count (PIT [a yearly census of PEH]).

Results

During 2005–2015, the PIT counted a mean number of 970 adults (minimum 795, maximum 1486) in Anchorage who were homeless, which accounted for 0.4% of the total population. Compared with the general population, PEH were 53 times as likely to have invasive GAS infection (95% CI 47–61), 7 times as likely to have invasive GBS infection (95% CI 6, 8), and 36 times as likely to have invasive pneumococcal infection (95% CI 33, 40). Of all invasive GAS cases in Anchorage over the time period, 19% occurred within the homeless population, while 3% of invasive GBS cases and 14% of invasive pneumococcal cases were within the homeless population. Additionally, the predominant subtypes of GAS and pneumococcus differed among PEH compared with the general population.

Conclusion

A disproportionate burden of invasive streptococcal disease in Anchorage was detected among PEH, indicating a need for further focus on this high-risk group.

Disclosures

All authors: No reported disclosures.

1891. Invasive Group A Streptococcus Infections Among Residents of Multiple Nursing Homes—Denver, Colorado, 2017–2018

Background

Older adults residing in nursing homes (NH) are at increased risk for invasive group A Streptococcus (GAS) infections due to advanced age, presence of wounds, and comorbidities; approximately one-third of infected patients die. Beginning in 2015, increasing numbers of GAS infections in NH residents and several NH clusters were reported from the Denver metropolitan area. Colorado Department of Public Health and Environment (CDPHE) and CDC investigated to characterize cases and assess if outbreaks resulted from interfacility transmission.

Methods

We reviewed data from Active Bacterial Core surveillance (ABCs) in the 5-county Denver area from January 2017 to June 2018. We defined a case as isolation of GAS from a normally sterile site in an NH resident. GAS isolates underwent whole-genome sequencing (WGS) at CDC’s Streptococcus Laboratory to determine emm types for genotyping. Among isolates with the same emm type, pairwise single-nucleotide polymorphism (SNP) distances were calculated using Nucmer software. In October 2018, a CDPHE-CDC team assessed infection control at NHs with cases of the most common emm type.

Results

Over 18 months, among >100 NHs in the Denver area, ≥1 GAS case was identified in 29 NHs, with 6 having ≥3 cases. During this period, 68 cases in NH residents were identified. WGS identified 17 emm types among isolates from these cases; most common was emm11.10 (34%, n = 22), a rare subtype in ABCs. All emm11.10 isolates had nearly identical genomes (average pairwise SNP distance: 3.2), and were isolated from 10 NHs, with 2 NHs having ≥ 4 cases. Multiple infection control lapses were noted during site visits to 8 NHs.

Conclusion

Multiple outbreaks due to GAS were noted in 5-county Denver area NHs in 2017–2018. WGS of surveillance isolates identified a rarely seen emm subtype 11.10 from multiple facilities with temporal and genomic clustering suggesting interfacility GAS transmission.

Disclosures

All Authors: No reported Disclosures.

1890. Missed Clinical Opportunities to Prevent Infections and Treat Substance Use Disorder (SUD) in People Who Inject Drugs (PWID)

Background

The age-adjusted rate of drug overdose deaths in the United States tripled from 1999 to 2016. Public health surveillance data indicate that an increasing proportion of infections due to bacterial and fungal pathogens is associated with injection drug use (IDU). We describe healthcare encounters (HCEs) of PWID as potential opportunities to prevent infections related to IDU by identifying risks and treating SUD, including with medication-assisted treatment (MAT) for opioid use disorder.

Methods

At six hospitals in western New York, we abstracted medical records from hospital admissions and emergency department (ED) visits for PWID (i.e., IDU in the preceding year) who had positive cultures for Staphylococcus aureus (any clinical specimen, April–July 2017), group A Streptococcus (invasive specimens, all of 2017) or Candida spp. (blood specimens, all of 2017). We reviewed hospital admission and ED records for 1 year preceding the positive culture to identify visits during which opportunities to prevent infection and treat SUD by addressing SUD and IDU were missed.

Results

We identified 99 PWID with positive cultures. The median age was 33 years (range 19–68) and 61 were female. Sixty-nine had a skin and soft-tissue infection, 44 had a bloodstream infection, and 20 had both. Thirty-one PWID left against medical advice during a hospital admission or an ED visit. Seventy-nine PWID were hospitalized, of whom 4 died. Ninety-five used opioids and 71 used cocaine in the preceding year. Seventy-five PWID had an HCE in the 12 months prior to the index visit, with a median of two HCE per person (interquartile range 1–4); 53 of PWID had a previous HCE for infection and 28 for opioid overdose. SUD was documented during a prior HCE at the same hospital for 61 PWID, but only 10 (16%) were offered MAT during any prior HCE and for 24 (39%) there was no documentation that any form of treatment for SUD was offered.

Conclusion

In this cohort, PWID frequently had one or more healthcare encounters documented at the same hospital in the year prior to a serious bacterial or fungal infection. These prior HCEs were often for infections or overdose that signaled the need for MAT, demonstrating that there are critical missed opportunities to identify risks, prevent infection, and treat SUD.

Disclosures

All Authors: No reported Disclosures.

Emergent Invasive Group A Streptococcus dysgalactiae subsp. equisimilis, United States, 2015-2018

The term group A Streptococcus is considered synonymous for the species Streptococcus pyogenes. We describe an emergent invasive S. dysgalactiae subspecies equisimilis lineage that obtained the group A antigen through a single ancestral recombination event between a group C S. dysgalactiae subsp. equisimilis strain and a group A S. pyogenes strain.

Capsule-Negative emm Types Are an Increasing Cause of Pediatric Group A Streptococcal Infections at a Large Pediatric Hospital in Texas

BACKGROUND

Bacterial infections caused by group A Streptococcus (GAS) are common in childhood. Few study reports have provided data on pediatric-specific trends in the epidemiology and bacterial strain characteristics of GAS infections.

METHODS

We prospectively collected GAS isolates from the clinical microbiology laboratory at Texas Children's Hospital between July 1, 2013, and June 30, 2017. Patient characteristics and GAS disease categories were determined through chart review. GAS isolates were obtained from patients in either the inpatient or outpatient setting, and cases were defined as pharyngeal disease, skin and soft-tissue infection (SSTI), or invasive disease on the basis of predefined criteria. All isolates were emm typed to determine trends over time.

RESULTS

We identified 930 cases over the 4-year period, including 432 (46.4%) pharyngeal, 235 (25.3%) SSTI, and 263 (28.3%) invasive disease types. The most frequently encountered emm types were emm1 (21.4%), emm12 (15.7%), emm89 (14.6%), emm4 (9.2%), and emm3 (8.2%). We observed significant changes over the 4-year period in the relative frequency of infections caused by emm1 (-17.7%; P = .046), emm4 (8.7%; P = .023), or emm6 (-7.9%; P = .024). Using bioinformatic analyses and targeted gene sequencing, we also discovered that all GAS emm28 and emm87 types harbored mutations that rendered them incapable of producing capsule. The relative frequency of GAS disease cases caused by capsule-negative GAS emm types (emm4, emm22, emm28, emm87, and emm89) increased over the 4-year period (32.2%-44.4%), although the difference was statistically significant for only nonpharyngeal disease types (27.1%-43.9%; P = .038).

CONCLUSIONS

Our data suggest an evolving epidemiology of GAS in the Houston pediatric population characterized by an increase in the frequency of capsule-negative emm types.

LB9. Rising High Rate of Invasive Group A Streptococcus Infections Among Persons Experiencing Homelessness in San Francisco, 2010–2017

Background

Rates of invasive group A Streptococcus (iGAS) disease in the United States have risen since 2014; reasons remain unclear. Outbreaks of iGAS infection among persons experiencing homelessness (PEH) and persons who inject drugs in Europe, Canada, and the United States have been described. Using active, population-based surveillance data from California’s Emerging Infections Program, we describe incidence trends and characteristics of iGAS infection among PEH and persons not experiencing homelessness (PNEH) in San Francisco (SF) County during 2010–2017.

Methods

We defined an iGAS case as infection with GAS isolated from a normally sterile site (e.g., blood) in an SF resident. We calculated annual iGAS disease incidence rates (cases per 100,000 population) for PEH and PNEH using denominators from SF’s Department of Homelessness and Supportive Housing and the State of California Department of Finance. Demographic, clinical, and exposure characteristics of PEH and PNEH were compared by chi-square or t-test.

Results

We identified 673 iGAS cases in SF during 2010–2017. Among these, 34% (229/673) were among PEH. Annual iGAS incidence among PEH rose from ~300 (2010–2014) to 547 (95% CI: 379–714) per 100,000 in 2017 (P &lt; 0.001, Cochran-Armitage trend test); rates peaked at 758 (95% CI: 561–955) in 2016. Annual iGAS incidence in PNEH rose from a mean of 5 in 2010–2013 to 9.3 (95% CI: 7.3–11.4) per 100,000 in 2017 (P &lt; 0.001). Annual iGAS incidence in PEH was 42–72 times that in PNEH. PEH with iGAS infections were significantly younger and more likely to be male, white, and uninsured or enrolled in Medicaid (P &lt; 0.05 for each) compared with PNEH with iGAS disease. Case fatality ratios, ICU admission, infection type, and length of hospital stay did not differ significantly. Smoking, current injection drug use, current alcohol abuse, and AIDS diagnosis were significantly more common among PEH with iGAS. Obesity, diabetes, and cancer were significantly more common among PNEH with iGAS.

Conclusion

In San Francisco, iGAS rates among both PEH and PNEH have risen significantly. Incidence of iGAS is strikingly higher in PEH than in PNEH and exposures differed between PEH and PNEH with iGAS. This information could inform development of disease control and prevention strategies.

Disclosures

All authors: No reported disclosures.

Early impact of 13-valent pneumococcal conjugate vaccine on pneumococcal meningitis-Burkina Faso, 2014-2015

OBJECTIVES

We evaluate early impact of 13-valent pneumococcal conjugate vaccine (PCV13) on pneumococcal meningitis in Burkina Faso.

METHODS

Nationwide surveillance gathered demographic/clinical information and cerebrospinal fluid (CSF) results for meningitis cases. Pneumococcal cases were confirmed by culture, polymerase chain reaction (PCR), or latex agglutination, and strains serotyped using PCR. We compared incidence (cases per 100,000) in the early post-PCV13 period (2014 and 2015) to average pre-PCV13 incidence (2011-2013).

RESULTS

In 2015, age-specific pneumococcal meningitis incidences were 8.7 (<1 year), 2.4 (1-4 years), 6.5 (5-14 years), and 2.6 (≥15 years). Compared to 2011-2013, PCV13-serotype incidence among all ages decreased by 32% (95%CI: 23%-39%), with significant decreases among children aged <1 year (76%; 95%CI: 64%-84%) and 1-4 years (58%, 95%CI: 40%-71%). Among all ages, incidence of PCV13 serotypes besides serotype 1 decreased (68%; 95%CI: 59%-75%), but serotype 1 incidence did not. Incidence of non-PCV13 serotypes also decreased (47%; 95%CI: 29%-60%). Among children aged <1 year, serotypes 12F/12A/12B/44/46 (17%), 1 (12%), and 5 (10%) predominated.

CONCLUSIONS

Following PCV13 introduction, PCV13-serotype meningitis incidence in young children significantly decreased. PCV13 impact on serotype 1 and disease in older children and adults requires continued monitoring.

Pneumococcal carriage and antibiotic susceptibility patterns from two cross-sectional colonization surveys among children aged <5 years prior to the introduction of 10-valent pneumococcal conjugate vaccine - Kenya, 2009-2010

Background

Pneumococci are spread by persons with nasopharyngeal colonization, a necessary precursor to invasive disease. Pneumococcal conjugate vaccines can prevent colonization with vaccine serotype strains. In 2011, Kenya became one of the first African countries to introduce the 10-valent pneumococcal conjugate vaccine (PCV10) into its national immunization program. Serial cross-sectional colonization surveys were conducted to assess baseline pneumococcal colonization, antibiotic resistance patterns, and factors associated with resistance.

Methods

Annual surveys were conducted in one urban and one rural site during 2009 and 2010 among children aged <5 years. To reflect differences in vaccine target population, recruitment was age-stratified in Kibera, whereas a simple random sample of children was drawn in Lwak. Nasopharyngeal swabs were collected from eligible children. Pneumococci were isolated and serotyped. Antibiotic susceptibility testing was performed using the 2009 isolates. Antibiotic nonsusceptibility was defined as intermediate susceptibility or resistance to ≥1 antibiotics (i.e., penicillin, chloramphenicol, levofloxacin, erythromycin, tetracycline, cotrimoxazole, and clindamycin); multidrug resistance (MDR) was defined as nonsusceptibility to ≥3 antibiotics. Weighted analysis was conducted when appropriate. Modified Poisson regression was used to calculate factors associated with antibiotic nonsusceptibility.

Results

Of 1,087 enrolled (Kibera: 740, Lwak: 347), 90.0% of these were colonized with pneumococci, and 37.3% were colonized with PCV10 serotypes. There were no differences by survey site or year. Of 657 (of 730; 90%) isolates tested for antibiotic susceptibility, nonsusceptibility to cotrimoxazole and penicillin was found in 98.6 and 81.9% of isolates, respectively. MDR was found in 15.9% of isolates and most often involved nonsusceptibility to cotrimoxazole and penicillin; 40.4% of MDR isolates were PCV10 serotypes. In the multivariable model, PCV10 serotypes were independently associated with penicillin nonsusceptibility (Prevalence Ratio: 1.2, 95% CI 1.1–1.3), but not with MDR.

Conclusions

Before PCV10 introduction, nearly all Kenyan children aged <5 years were colonized with pneumococci, and PCV10 serotype colonization was common. PCV10 serotypes were associated with penicillin nonsusceptibility. Given that colonization with PCV10 serotypes is associated with greater risk for invasive disease than colonization with other serotypes, successful PCV10 introduction in Kenya is likely to have a substantial impact in reducing vaccine-type pneumococcal disease and drug-resistant pneumococcal infection.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-2103-0) contains supplementary material, which is available to authorized users.

Nationwide Trends in Bacterial Meningitis before the Introduction of 13-Valent Pneumococcal Conjugate Vaccine-Burkina Faso, 2011-2013

BACKGROUND

Following introduction of Haemophilus influenzae type b vaccine in 2006 and serogroup A meningococcal conjugate vaccine in 2010, Streptococcus pneumoniae (Sp) became the leading cause of bacterial meningitis in Burkina Faso. We describe bacterial meningitis epidemiology, focusing on pneumococcal meningitis, before 13-valent pneumococcal conjugate vaccine (PCV13) introduction in the pediatric routine immunization program in October 2013.

METHODS

Nationwide population-based meningitis surveillance collects case-level demographic and clinical information and cerebrospinal fluid (CSF) laboratory results. Sp infections are confirmed by culture, real-time polymerase chain reaction (rt-PCR), or latex agglutination, and CSF serotyped using real-time and conventional PCR. We calculated incidence rates in cases per 100,000 persons, adjusting for age and proportion of cases with CSF tested at national reference laboratories, and case fatality ratios (CFR).

RESULTS

During 2011-2013, 1,528 pneumococcal meningitis cases were reported. Average annual adjusted incidence rates were 26.9 (<1 year), 5.4 (1-4 years), 7.2 (5-14 years), and 3.0 (≥15 years). Overall CFR was 23% and highest among children aged <1 year (32%) and adults ≥30 years (30%). Of 1,528 cases, 1,036 (68%) were serotyped: 71% were PCV13-associated serotypes, 14% were non-PCV13-associated serotypes, and 15% were non-typeable by PCR. Serotypes 1 (45%) and 12F/12A/12B/44/46 (8%) were most common. Among children aged <1 year, serotypes 5 (15%), 6A/6B (13%) and 1 (12%) predominated.

CONCLUSIONS

In Burkina Faso, the highest morbidity and mortality due to pneumococcal meningitis occurred among children aged <1 year. The majority of cases were due to PCV13-associated serotypes; introduction of PCV13 should substantially decrease this burden.

A Cluster of Group A Streptococcal Infections in a Skilled Nursing Facility-the Potential Role of Healthcare Worker Presenteeism

OBJECTIVES

To determine the extent of a group A streptococcus (GAS) cluster (2 residents with invasive GAS (invasive case-patients), 2 carriers) caused by a single strain (T antigen type 2 and M protein gene subtype 2.0 (T2, emm 2.0)), evaluate factors contributing to transmission, and provide recommendations for disease control.

DESIGN

Cross-sectional analysis and retrospective review.

SETTING

Skilled nursing facility (SNF).

PARTICIPANTS

SNF residents and staff.

MEASUREMENTS

The initial cluster was identified through laboratory notification and screening of SNF residents with wounds. Laboratory and SNF administrative records were subsequently reviewed to identify additional residents with GAS, oropharyngeal and wound (if present) swabs were collected from SNF staff and residents to examine GAS colonization, staff were surveyed to assess infection control practices and risk factors for GAS colonization, epidemiologic links between case-patients and persons colonized with GAS were determined, and facility infection control practices were assessed.

RESULTS

No additional invasive case-patients were identified. Oropharyngeal swabs obtained from all 167 SNF residents were negative; one wound swab grew GAS that was the same as the outbreak strain (T2, emm 2.0). The outbreak strain was not identified in any of the 162 staff members. One of six staff members diagnosed with GAS pharyngitis worked while ill and had direct contact with invasive case-patients within a few weeks before their onset of symptoms. Additional minor breaches in infection control were noted.

CONCLUSION

Sick healthcare workers may have introduced GAS into the SNF, with propagation by infection control lapses. "Presenteeism," or working while ill, may introduce and transmit GAS to vulnerable in SNF populations. Identification of an invasive GAS case-patient should trigger a prompt response by facilities to prevent further transmission and workplace culture, and policies should be in place to discourage presenteeism in healthcare settings.

Notes from the Field: Fatal Infection Associated with Equine Exposure - King County, Washington, 2016

On March 17, 2016, Public Health-Seattle & King County in Washington was notified of two persons who received a diagnosis of Streptococcus equi subspecies zooepidemicus (S. zooepidemicus) infections. S. zooepidemicus is a zoonotic pathogen that rarely causes human illness and is usually associated with consuming unpasteurized dairy products or with direct horse contact (1). In horses, S. zooepidemicus is a commensal bacterium that can cause respiratory, wound, and uterine infections (2). The health department investigated to determine the magnitude of the outbreak, identify risk factors, and offer recommendations.

High Streptococcus pneumoniae colonization prevalence among HIV-infected Kenyan parents in the year before pneumococcal conjugate vaccine introduction

BACKGROUND

Streptococcus pneumoniae is a leading cause of pneumonia, meningitis and sepsis in developing countries, particularly among children and HIV-infected persons. Pneumococcal oropharyngeal (OP) or nasopharyngeal (NP) colonization is a precursor to development of invasive disease. New conjugate vaccines hold promise for reducing colonization and disease.

METHODS

Prior to introduction of 10-valent pneumococcal conjugate vaccine (PCV10), we conducted a cross-sectional survey among HIV-infected parents of children <5 years old in rural Kenya. Other parents living with an HIV-infected adult were also enrolled. After broth enrichment, NP and OP swabs were cultured for pneumococcus. Serotypes were identified by Quellung. Antimicrobial susceptibility was performed using broth microdilution.

RESULTS

We enrolled 973 parents; 549 (56.4%) were HIV-infected, 153 (15.7%) were HIV-uninfected and 271 (27.9%) had unknown HIV status. Among HIV-infected parents, the median age was 32 years (range 15-74) and 374/549 (68%) were mothers. Pneumococci were isolated from 237/549 (43.2%) HIV-infected parents and 41/153 (26.8%) HIV-non-infected parents (p = 0.0003). Colonization with PCV10 serotypes was not significantly more frequent in HIV-infected (12.9%) than HIV-uninfected parents (11.8%; p = 0.70). Among HIV-infected parents, cooking site separate from sleeping area and CD4 count >250 were protective (OR = 0.6; 95% CI 0.4, 0.9 and OR = 0.5; 95% CI 0.2, 0.9, respectively); other associations were not identified. Among 309 isolates tested from all parents, 255 (80.4%) were penicillin non-susceptible (MIC ≥0.12 μg/ml).

CONCLUSIONS

Prevalence of pneumococcal colonization is high among HIV-infected parents in rural Kenya. If young children are the pneumococcal reservoir for this population, PCV10 introduction may reduce vaccine-type colonization and disease among HIV-infected parents through indirect protection.

Notes from the Field: Group A Streptococcal Pharyngitis Misdiagnoses at a Rural Urgent-Care Clinic--Wyoming, March 2015

Group A Streptococcus (GAS) is the most common bacterial cause of pharyngitis, implicated in 20%-30% of pediatric and 5%-15% of adult health care visits for sore throat (1). Along with the sudden onset of throat pain, GAS pharyngitis symptoms include fever, headache, and bilateral tender cervical lymphadenopathy (1,2). Accurate diagnosis and management of GAS pharyngitis is critical for limiting antibiotic overuse and preventing rheumatic fever (2), but distinguishing between GAS and viral pharyngitis clinically is challenging (1). Guidelines for diagnosis and management of GAS pharyngitis have been published by the Infectious Diseases Society of America (IDSA)* (1). IDSA recommends that patients with sore throat be tested for GAS to distinguish between GAS and viral pharyngitis; however, IDSA emphasizes the use of selective testing based on clinical symptoms and signs to avoid identifying GAS carriers rather than acute GAS infections (1). Therefore, testing for GAS usually is not recommended for the following: patients with sore throat and accompanying symptoms (e.g., cough, rhinorrhea) that strongly suggest a viral etiology; children aged <3 years, because acute rheumatic fever is extremely rare in this age group; and asymptomatic household contacts of patients with GAS pharyngitis (1). IDSA recommends penicillin or amoxicillin as the treatment of choice based on effectiveness and narrow spectrum of activity. To date, penicillin-resistant GAS has never been documented (1).

The Impact of Obesity and Diabetes on the Risk of Disease and Death due to Invasive Group A Streptococcus Infections in Adults

BACKGROUND

Invasive group A Streptococcus (iGAS) infections cause significant morbidity and mortality worldwide. We analyzed whether obesity and diabetes were associated with iGAS infections and worse outcomes among an adult US population.

METHODS

We determined the incidence of iGAS infections using 2010-2012 cases in adults aged ≥ 18 years from Active Bacterial Core surveillance (ABCs), a population-based surveillance system, as the numerator. For the denominator, we used ABCs catchment area population estimates from the 2011 to 2012 Behavioral Risk Factor Surveillance System (BRFSS) survey. The relative risk (RR) of iGAS was determined by obesity and diabetes status after adjusting for age group, gender, race, and other underlying conditions through binomial logistic regression. Multivariable logistic regression was used to determine whether obesity or diabetes was associated with increased odds of death due to iGAS compared to normal weight and nondiabetic patients, respectively.

RESULTS

Between 2010 and 2012, 2927 iGAS cases were identified. Diabetes was associated with an increased risk of iGAS in all racial groups (adjusted risk ratio [aRR] ranged from 2.71 to 5.08). Grade 3 obesity (body mass index [BMI] ≥ 40) was associated with an increased risk of iGAS for whites (aRR = 3.47; 95% confidence interval [CI], 3.00-4.01). Grades 1-2 (BMI = 30.0-<40.0) and grade 3 obesity were associated with an increased odds of death (odds ratio [OR] = 1.55, [95% CI, 1.05, 2.29] and OR = 1.62 [95% CI, 1.01, 2.61], respectively) when compared to normal weight patients.

CONCLUSIONS

These results may help target vaccines against GAS that are currently under development. Efforts to develop enhanced treatment regimens for iGAS may improve prognoses for obese patients.

Twenty Years of Active Bacterial Core Surveillance

Active Bacterial Core surveillance (ABCs) was established in 1995 as part of the Centers for Disease Control and Prevention Emerging Infections Program (EIP) network to assess the extent of invasive bacterial infections of public health importance. ABCs is distinctive among surveillance systems because of its large, population-based, geographically diverse catchment area; active laboratory-based identification of cases to ensure complete case capture; detailed collection of epidemiologic information paired with laboratory isolates; infrastructure that allows for more in-depth investigations; and sustained commitment of public health, academic, and clinical partners to maintain the system. ABCs has directly affected public health policies and practices through the development and evaluation of vaccines and other prevention strategies, the monitoring of antimicrobial drug resistance, and the response to public health emergencies and other emerging infections.

Acute rheumatic fever and rheumatic heart disease among children--American Samoa, 2011-2012

Acute rheumatic fever is a nonsuppurative, immune-mediated consequence of group A streptococcal pharyngitis (strep throat). Recurrent or severe acute rheumatic fever can cause permanent cardiac valve damage and rheumatic heart disease, which increases the risk for cardiac conditions (e.g., infective endocarditis, stroke, and congestive heart failure). Antibiotics can prevent acute rheumatic fever if administered no more than 9 days after symptom onset. Long-term benzathine penicillin G (BPG) injections are effective in preventing recurrent acute rheumatic fever attacks and are recommended to be administered every 3-4 weeks for 10 years or until age 21 years to children who receive a diagnosis of acute rheumatic fever. During August 2013, in response to anecdotal reports of increasing rates of acute rheumatic fever and rheumatic heart disease, CDC collaborated with the American Samoa Department of Health and the Lyndon B. Johnson Tropical Medical Center (the only hospital in American Samoa) to quantify the number of cases of pediatric acute rheumatic fever and rheumatic heart disease in American Samoa and to assess the potential roles of missed pharyngitis diagnosis, lack of timely prophylaxis prescription, and compliance with prescribed BPG prophylaxis. Using data from medical records, acute rheumatic fever incidence was calculated as 1.1 and 1.5 cases per 1,000 children aged ≤18 years in 2011 and 2012, respectively; 49% of those with acute rheumatic fever subsequently received a diagnosis of rheumatic heart disease. Noncompliance with recommended prophylaxis with BPG after physician-diagnosed acute rheumatic fever was noted for 22 (34%) of 65 patients. Rheumatic heart disease point prevalence was 3.2 cases per 1,000 children in August 2013. Establishment of a coordinated acute rheumatic fever and rheumatic heart disease control program in American Samoa, likely would improve diagnosis, treatment, and patient compliance with BPG prophylaxis.

Clinical inquiries regarding Ebola virus disease received by CDC--United States, July 9-November 15, 2014

Since early 2014, there have been more than 6,000 reported deaths from Ebola virus disease (Ebola), mostly in Guinea, Liberia, and Sierra Leone. On July 9, 2014, CDC activated its Emergency Operations Center for the Ebola outbreak response and formalized the consultation service it had been providing to assist state and local public health officials and health care providers evaluate persons in the United States thought to be at risk for Ebola. During July 9-November 15, CDC responded to clinical inquiries from public health officials and health care providers from 49 states and the District of Columbia regarding 650 persons thought to be at risk. Among these, 118 (18%) had initial signs or symptoms consistent with Ebola and epidemiologic risk factors placing them at risk for infection, thereby meeting the definition of persons under investigation (PUIs). Testing was not always performed for PUIs because alternative diagnoses were made or symptoms resolved. In total, 61 (9%) persons were tested for Ebola virus, and four, all of whom met PUI criteria, had laboratory-confirmed Ebola. Overall, 490 (75%) inquiries concerned persons who had neither traveled to an Ebola-affected country nor had contact with an Ebola patient. Appropriate medical evaluation and treatment for other conditions were noted in some instances to have been delayed while a person was undergoing evaluation for Ebola. Evaluating and managing persons who might have Ebola is one component of the overall approach to domestic surveillance, the goal of which is to rapidly identify and isolate Ebola patients so that they receive appropriate medical care and secondary transmission is prevented. Health care providers should remain vigilant and consult their local and state health departments and CDC when assessing ill travelers from Ebola-affected countries. Most of these persons do not have Ebola; prompt diagnostic assessments, laboratory testing, and provision of appropriate care for other conditions are essential for appropriate patient care and reflect hospital preparedness.

Global invasive bacterial vaccine-preventable diseases surveillance--2008-2014

Meningitis and pneumonia are leading causes of morbidity and mortality in children globally infected with Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis, and Haemophilus influenzae causing a large proportion of disease. Vaccines are available to prevent many of the common types of these infections. S. pneumoniae was estimated to have caused 11% of deaths in children aged <5 years globally in the pre-pneumococcal conjugate vaccine (PCV) era. Since 2007, the World Health Organization (WHO) has recommended inclusion of PCV in childhood immunization programs worldwide, especially in countries with high child mortality. As of November 26, 2014, a total of 112 (58%) of all 194 WHO member states and 44 (58%) of the 76 member states ever eligible for support from Gavi, the Vaccine Alliance (Gavi), have introduced PCV. Invasive pneumococcal disease (IPD) surveillance that includes data on serotypes, along with meningitis and pneumonia syndromic surveillance, provides important data to guide decisions to introduce PCV and monitor its impact.

Invasive group A Streptococcus infections associated with liposuction surgery at outpatient facilities not subject to state or federal regulation

IMPORTANCE

Liposuction is one of the most common cosmetic surgery procedures in the United States. Tumescent liposuction, in which crystalloid fluids, lidocaine, and epinephrine are infused subcutaneously before cannula-assisted aspiration of fat, can be performed without intravenous or general anesthesia, often at outpatient facilities. However, some of these facilities are not subject to state or federal regulation and may not adhere to appropriate infection control practices.

OBJECTIVE

To describe an outbreak of severe group A Streptococcus (GAS) infections among persons undergoing tumescent liposuction at 2 outpatient cosmetic surgery facilities not subject to state or federal regulation.

DESIGN

Outbreak investigation (including cohort analysis of at-risk patients), interviews using a standardized questionnaire, medical record review, facility assessment, and laboratory analysis of GAS isolates.

SETTING AND PARTICIPANTS

Patients undergoing liposuction at 2 outpatient facilities, one in Maryland and the other in Pennsylvania, between July 1 and September 14, 2012.

MAIN OUTCOMES AND MEASURES

Confirmed invasive GAS infections (isolation of GAS from a normally sterile site or wound of a patient with necrotizing fasciitis or streptococcal toxic shock syndrome), suspected GAS infections (inflamed surgical site and either purulent discharge or fever and chills in a patient with no alternative diagnosis), postsurgical symptoms and patient-reported experiences related to his or her procedure, and emm types, T-antigen types, and antimicrobial susceptibility of GAS isolates.

RESULTS

We identified 4 confirmed cases and 9 suspected cases, including 1 death (overall attack rate, 20% [13 of 66]). One instance of likely secondary GAS transmission to a household member occurred. All confirmed case patients had necrotizing fasciitis and had undergone surgical debridement. Procedures linked to illness were performed by a single surgical team that traveled between the 2 locations; 2 team members (1 of whom reported recent cellulitis) were colonized with a GAS strain that was indistinguishable by laboratory analysis of the isolates from the case patients. Facility assessments and patient reports indicated substandard infection control, including errors in equipment sterilization and infection prevention training.

CONCLUSIONS AND RELEVANCE

This outbreak of severe GAS infections was likely caused by transmission from colonized health care workers to patients during liposuction procedures. Additional oversight of outpatient cosmetic surgery facilities is needed to assure that they maintain appropriate infection control practices and other patient protections.

Incidence and clinical features of respiratory syncytial virus infections in a population-based surveillance site in the Nile Delta Region

BACKGROUND

Most reports about respiratory syncytial virus (RSV) in developing countries rely on sentinel surveillance, from which population incidence is difficult to infer. We used the proportion of RSV infections from population-based surveillance with data from a healthcare utilization survey to produce estimates of RSV incidence in Damanhour district, Egypt.

METHODS

We conducted population-based surveillance in 3 hospitals (2009-2012) and 3 outpatient clinics (2011-2012) in Damanhour district. Nasopharyngeal and oropharyngeal specimens from hospitalized patients with acute respiratory illness and outpatients with influenza-like illness were tested by real-time reverse transcriptase polymerase chain reaction for RSV. We also conducted a healthcare utilization survey in 2011-2012 to determine the proportion of individuals who sought care for respiratory illness.

RESULTS

Among 5342 hospitalized patients and 771 outpatients, 12% and 5% tested positive for RSV, respectively. The incidence of RSV-associated hospitalization and outpatient visits was estimated at 24 and 608 (per 100 000 person-years), respectively. Children aged <1 year experienced the highest incidence of RSV-associated hospitalizations (1745/100 000 person-years).

CONCLUSIONS

This study demonstrates the utility of combining a healthcare utilization survey and population-based surveillance data to estimate disease incidence. Estimating incidence and outcomes of RSV disease is critical to establish the burden of RSV in Egypt.

Investigation of a prolonged Group A Streptococcal outbreak among residents of a skilled nursing facility, Georgia, 2009-2012

BACKGROUND

Group A Streptococcus (GAS) is an important bacterial cause of life-threatening illness among the elderly. Public health officials investigated a protracted GAS outbreak in a skilled nursing facility in Georgia housing patients requiring 24-hour nursing or rehabilitation, to prevent additional cases.

METHODS

We defined a case as illness in a skilled nursing facility resident with onset after January 2009 with GAS isolated from a usually sterile (invasive) or nonsterile site (noninvasive). Cases were "recurrent" if >1 month elapsed between episodes. We evaluated infection control practices, performed a GAS carriage study, emm-typed available GAS isolates, and conducted a case-control study of risk factors for infection.

RESULTS

Three investigations, spanning 36 months, identified 19 residents with a total of 24 GAS infections: 15 invasive (3 recurrent) and 9 noninvasive (2 recurrent) episodes. All invasive cases required hospitalization; 4 patients died. Seven residents were GAS carriers. All invasive cases and resident carrier isolates were type emm 11.0. We observed hand hygiene lapses, inadequate infection documentation, and more frequent wound care staff turnover on wing A versus wing B. Risk factors associated with infection in multivariable analysis included living on wing A (odds ratio [OR], 3.4; 95% confidence interval [CI], .9-16.4) and having an indwelling line (OR, 5.6; 95% CI, 1.2-36.4). Cases ceased following facility-wide chemoprophylaxis in July 2012.

CONCLUSIONS

Staff turnover, compromised skin integrity in residents, a suboptimal infection control program, and lack of awareness of infections likely contributed to continued GAS transmission. In widespread, prolonged GAS outbreaks in skilled nursing facilities, facility-wide chemoprophylaxis may be necessary to prevent sustained person-to-person transmission.

Bacterial meningitis surveillance in the Eastern Mediterranean region, 2005-2010: successes and challenges of a regional network

OBJECTIVE

To describe epidemiology of bacterial meningitis in the World Health Organization Eastern Mediterranean Region countries and assist in introduction of new bacterial vaccines.

STUDY DESIGN

A laboratory-based sentinel surveillance was established in 2004, and up to 10 countries joined the network until 2010. Personnel at participating hospitals and national public health laboratories received training in surveillance and laboratory methods and used standard clinical and laboratory-confirmed case definitions.

RESULTS

Over 22,000 suspected cases of meningitis were reported among children ≤5 years old and >6600 among children >5 years old. In children ≤5 years old, 921 of 13,125 probable cases (7.0%) were culture-confirmed. The most commonly isolated pathogens were S pneumoniae (27% of confirmed cases), N meningitidis (22%), and H influenzae (10%). Among culture-confirmed case-patients with known outcome, case-fatality rate was 7.0% and 12.2% among children ≤5 years old and those >5 years old, respectively. Declining numbers of Haemophilus influenzae type b meningitis cases within 2 years post-Haemophilus influenzae type b conjugate vaccine introduction were observed in Pakistan.

CONCLUSIONS

Bacterial meningitis continues to cause significant morbidity and mortality in the Eastern Mediterranean Region. Surveillance networks for bacterial meningitis ensure that all sites are using standardized methodologies. Surveillance data are useful to monitor impact of various interventions including vaccines, but maintaining data quality requires consistent reporting and regular technical support.

Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America

The guideline is intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and management, and recommendations are provided regarding antibiotic choices and dosing. Penicillin or amoxicillin remain the treatments of choice, and recommendations are made for the penicillin-allergic patient, which now include clindamycin.

Investigation of a Chlamydia pneumoniae outbreak in a Federal correctional facility in Texas

BACKGROUND

Chlamydia pneumoniae illness is poorly characterized, particularly as a sole causative pathogen. We investigated a C. pneumoniae outbreak at a federal correctional facility.

METHODS

We identified inmates with acute respiratory illness (ARI) from 1 November 2009 to 24 February 2010 through clinic self-referral and active case finding. We tested oropharyngeal and/or nasopharyngeal swabs for C. pneumoniae by real-time polymerase chain reaction (qPCR) and serum samples by microimmunofluorescence. Cases were inmates with ARI and radiologically confirmed pneumonia, positive qPCR, or serological evidence of recent infection. Swabs from 7 acutely ill inmates were tested for 18 respiratory pathogens using qPCR TaqMan Array Cards (TACs). Follow-up swabs from case patients were collected for up to 8 weeks.

RESULTS

Among 33 self-referred and 226 randomly selected inmates, 52 (20.1%) met the case definition; pneumonia was confirmed in 4 by radiology only, in 9 by qPCR only, in 17 by serology only, and in 22 by both qPCR and serology. The prison attack rate was 10.4% (95% confidence interval, 7.0%-13.8%). White inmates and residents of housing unit Y were at highest risk. TAC testing detected C. pneumoniae in 4 (57%) inmates; no other causative pathogens were identified. Among 40 inmates followed prospectively, C. pneumoniae was detected for up to 8 weeks. Thirteen (52%) of 25 inmates treated with azithromycin continued to be qPCR positive >2 weeks after treatment.

CONCLUSIONS

Chlamydia pneumoniae was the causative pathogen of this outbreak. Higher risk among certain groups suggests that social interaction contributed to transmission. Persistence of C. pneumoniae in the oropharynx creates challenges for outbreak control measures.

Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America

The guideline is intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and management, and recommendations are provided regarding antibiotic choices and dosing. Penicillin or amoxicillin remain the treatments of choice, and recommendations are made for the penicillin-allergic patient, which now include clindamycin.

Genomic analysis of emm59 group A Streptococcus invasive strains, United States

Genomic analysis of type emm59 group A Streptococcus invasive strains isolated in the United States discovered higher than anticipated genetic heterogeneity among strains and identified a heretofore unrecognized monoclonal cluster of invasive infections in the San Francisco Bay area. Heightened monitoring for a potential shift in the epidemic behavior of emm59 group A Streptococcus is warranted.

Outbreak of bacterial meningitis among patients undergoing myelography at an outpatient radiology clinic

PURPOSE

To investigate an outbreak of bacterial meningitis at an outpatient radiology clinic (clinic A) and to determine the source and implement measures to prevent additional infections.

METHODS

A case was defined as bacterial meningitis in a patient undergoing myelography at clinic A from October 11 to 25, 2010. Patients who underwent myelography and other procedures at clinic A during that period were interviewed, medical records were reviewed, and infection prevention practices were assessed. Case-patient cerebrospinal fluid (CSF) specimens, oral specimens from health care personnel (HCP), and opened iohexol vials were tested for bacteria. Bacterial isolates were compared using pulsed-field gel electrophoresis. A culture-negative CSF specimen was tested using a real-time polymerase chain reaction assay.

RESULTS

Three cases were identified among 35 clinic A patients who underwent procedures from October 11 to 25, 2010. All case-patients required hospitalization, 2 in an intensive care unit. Case-patients had myelography performed by the same radiology physician assistant and technician on October 25; all patients who underwent myelography on October 25 were affected. HCP did not wear facemasks and reused single-dose iohexol vials for multiple patients. Streptococcus salivarius (a bacteria commonly found in oral flora) was detected in the CSF of 2 case-patients (1 by culture, 1 using real-time polymerase chain reaction) and in HCP oral specimens; 1 opened iohexol vial contained Staphylococcus epidermidis. Pulsed-field gel electrophoresis profiles from the case-patient S salivarius and the radiology physician assistant were indistinguishable.

CONCLUSIONS

Bacterial meningitis likely occurred because HCP performing myelography did not wear facemasks; lapses in injection practices may have contributed to transmission. Targeted education regarding mask use and safe injection practices is needed among radiology HCP.

Putting surveillance data into context: the role of health care utilization surveys in understanding population burden of pneumonia in developing countries

Background: Surveillance is essential to estimating the global burden of pneumonia, yet differences in surveillance methodology and health care-seeking behaviors limit inter-country comparisons.

Methods: Results were compared from community surveys measuring health care-seeking for pneumonia defined as: (1) cough and difficulty breathing for ⩾2 days; or, (2) provider-diagnosed pneumonia. Surveys were conducted in six sites in Guatemala, Kenya and Thailand; these sites also conduct, active, hospital- and population-based disease surveillance for pneumonia.

Results: Frequency of self-reported pneumonia during the preceding year ranged from 1.1% (Thailand) to 6.3% (Guatemala) and was highest in children aged <5 years and in urban sites. The proportion of persons with pneumonia who sought hospital-based medical services ranged from 12% (Guatemala, Kenya) to 80% (Thailand) and was highest in children <5 years of age. Hospitals and private provider offices were the most common places where persons with pneumonia sought health care. The most commonly cited reasons for not seeking health care were: (a) mild illness; (b) already recovering; and (3) cost of treatment.

Conclusions: Health care-seeking patterns varied widely across countries. Using results from standardized health care utilization surveys to adjust facility-based surveillance estimates of pneumonia allows for more accurate and comparable estimates.

Population-based study of invasive disease due to beta-hemolytic streptococci of groups other than A and B

BACKGROUND

Beta-hemolytic streptococci of groups other than A and B (NABS) are increasingly recognized as causes of clinically significant disease, but precise information about this heterogeneous group is lacking. We report the incidence of NABS infection and describe the epidemiologic and clinical characteristics.

METHODS

Active, population-based surveillance for invasive NABS was performed over a 2-year period in the 8-county metropolitan Atlanta, Georgia, area and the 3-county San Francisco Bay, California, area. Clinical records were reviewed, and available isolates were sent to the Centers for Disease Control and Prevention (Atlanta) for additional microbiologic characterization. Incidences were calculated using year-appropriate US Census Bureau data.

RESULTS

A total of 489 cases of invasive NABS infection were identified (3.2 cases per 100,000 population). The median age of patients was 55 years; 64% of patients were males, and 87% had underlying diseases. The incidence was higher among black persons than white persons (4.0 vs. 2.5 cases per 100,000 population; P < .01) and increased with age among all races. Infections were community acquired in 416 cases (85%). Among the 450 patients (94%) with NABS infection who were hospitalized, 55 (12%) died. Of 266 isolates (54%) speciated at the Centers for Disease Control and Prevention, 212 (80%) were Streptococcus dysgalactiae subspecies equisimilis; 46 (17%) were members of the Streptococcus anginosus group. S. dysgalactiae subspecies equisimilis primarily presented as skin and soft-tissue infection in older patients, whereas individuals with invasive S. anginosus group infections were more likely to be younger patients with intra-abdominal infections.

CONCLUSIONS

NABS comprise multiple distinct species that cause a significant number of community-acquired invasive infections. Clinical manifestations differ by species. Thus, speciation of invasive NABS may be warranted in clinical settings.

Invasive group a streptococcal disease in nursing homes, Minnesota, 1995-2006

Nursing home residents are at high risk for invasive GAS disease; clusters are common.

Nursing home residents are at high risk for invasive group A streptococcal (GAS) disease, and clusters of cases in nursing homes are common.To characterize the epidemiologic features of invasive GAS disease in nursing homes, we conducted active, statewide, population- and laboratory-based surveillance in Minnesota from April 1995 through 2006. Of 1,858 invasive GAS disease cases, 134 (7%) occurred in nursing home residents; 34 of these cases were identified as part of 13 clusters. Recognizing cases of GAS disease in nursing homes posed challenges. Measures to ensure identification of case-patients as residents of specific nursing homes need to be included in standard guidelines for the prevention and control of invasive GAS disease in this setting.