Use of Inactivated Polio Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2023

Poliovirus can cause poliomyelitis and lifelong paralysis. Although wild poliovirus types 2 and 3 have been eradicated, wild poliovirus type 1 and vaccine-derived polioviruses are still circulating in multiple countries worldwide. In 2022, a case of paralytic polio caused by vaccine-derived poliovirus type 2 was identified in an unvaccinated young adult in New York. This case and subsequent detection of community transmission underscored the ongoing risk for importation of poliovirus into the United States and risk for poliomyelitis among unvaccinated persons. However, previous Advisory Committee on Immunization Practices (ACIP) recommendations for adult polio vaccination were limited to adults known to be at increased risk for exposure. During October 2022-June 2023, the ACIP Polio Vaccine Work Group reviewed data on poliovirus surveillance and epidemiology, safety and effectiveness of inactivated poliovirus vaccine (IPV), and other considerations outlined in the ACIP Evidence to Recommendations Framework. On June 21, 2023, ACIP voted to recommend that all U.S. adults aged ≥18 years who are known or suspected to be unvaccinated or incompletely vaccinated against polio complete a primary polio vaccination series with IPV. This report summarizes evidence considered for this recommendation and provides clinical guidance for the use of IPV in adults.

Duration of Enterovirus D68 RNA Shedding in the Upper Respiratory Tract and Transmission among Household Contacts, Colorado, USA

Enterovirus D68 (EV-D68) causes cyclical outbreaks of respiratory disease and acute flaccid myelitis. EV-D68 is primarily transmitted through the respiratory route, but the duration of shedding in the respiratory tract is unknown. We prospectively enrolled 9 hospitalized children with EV-D68 respiratory infection and 16 household contacts to determine EV-D68 RNA shedding dynamics in the upper respiratory tract through serial midturbinate specimen collections and daily symptom diaries. Five (31.3%) household contacts, including 3 adults, were EV-D68-positive. The median duration of EV-D68 RNA shedding in the upper respiratory tract was 12 (range 7-15) days from symptom onset. The most common symptoms were nasal congestion (100%), cough (92.9%), difficulty breathing (78.6%), and wheezing (57.1%). The median illness duration was 20 (range 11-24) days. Understanding the duration of RNA shedding can inform the expected rate and timing of EV-D68 detection in associated acute flaccid myelitis cases and help guide public health measures.

Poliovirus outbreak in New York State, August 2022: qualitative assessment of immediate public health responses and priorities for improving vaccine coverage

In 2022, a case of paralysis was reported in an unvaccinated adult in Rockland County (RC), New York. Genetically linked detections of vaccine-derived poliovirus type 2 (VDPV2) were reported in multiple New York counties, England, Israel, and Canada. The aims of this qualitative study were to: i) review immediate public health responses in New York to assess the challenges in addressing gaps in vaccination coverage; ii) inform a longer-term strategy to improving vaccination coverage in under-vaccinated communities, and iii) collect data to support comparative evaluations of transnational poliovirus outbreaks. Twenty-three semi-structured interviews were conducted with public health professionals, healthcare professionals, and community partners. Results indicate that i) addressing suboptimal vaccination coverage in RC remains a significant challenge after recent disease outbreaks; ii) the poliovirus outbreak was not unexpected and effort should be invested to engage mothers, the key decision-makers on childhood vaccination; iii) healthcare providers (especially paediatricians) received technical support during the outbreak, and may require resources and guidance to effectively contribute to longer-term vaccine engagement strategies; vi) data systems strengthening is required to help track under-vaccinated children. Public health departments should prioritize long-term investments in appropriate communication strategies, countering misinformation, and promoting the importance of the routine immunization schedule.

Polio eradication: Addressing the hurdles on the last mile

1988, the World Health Assembly committed to eradicate poliomyelitis, a viral disease that can cause permanent paralysis. Today, only type 1 of the three wild poliovirus types remains circulating in limited geographic areas following widespread use of different poliovirus vaccines. While we are close to zero new cases of wild polio, it is a fragile situation, and there are many remaining and new hurdles to overcome. Here, experts discuss how to address them.

Wastewater Testing and Detection of Poliovirus Type 2 Genetically Linked to Virus Isolated from a Paralytic Polio Case - New York, March 9-October 11, 2022

In July 2022, a case of paralytic poliomyelitis resulting from infection with vaccine-derived poliovirus (VDPV) type 2 (VDPV2)§ was confirmed in an unvaccinated adult resident of Rockland County, New York (1). As of August 10, 2022, poliovirus type 2 (PV2)¶ genetically linked to this VDPV2 had been detected in wastewater** in Rockland County and neighboring Orange County (1). This report describes the results of additional poliovirus testing of wastewater samples collected during March 9-October 11, 2022, and tested as of October 20, 2022, from 48 sewersheds (the community area served by a wastewater collection system) serving parts of Rockland County and 12 surrounding counties. Among 1,076 wastewater samples collected, 89 (8.3%) from 10 sewersheds tested positive for PV2. As part of a broad epidemiologic investigation, wastewater testing can provide information about where poliovirus might be circulating in a community in which a paralytic case has been identified; however, the most important public health actions for preventing paralytic poliomyelitis in the United States remain ongoing case detection through national acute flaccid myelitis (AFM) surveillance†† and improving vaccination coverage in undervaccinated communities. Although most persons in the United States are sufficiently immunized, unvaccinated or undervaccinated persons living or working in Kings, Orange, Queens, Rockland, or Sullivan counties, New York should complete the polio vaccination series as soon as possible.

Enhanced contact investigations for nine early travel-related cases of SARS-CoV-2 in the United States

Coronavirus disease 2019 (COVID-19), the respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China and has since become pandemic. In response to the first cases identified in the United States, close contacts of confirmed COVID-19 cases were investigated to enable early identification and isolation of additional cases and to learn more about risk factors for transmission. Close contacts of nine early travel-related cases in the United States were identified and monitored daily for development of symptoms (active monitoring). Selected close contacts (including those with exposures categorized as higher risk) were targeted for collection of additional exposure information and respiratory samples. Respiratory samples were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction at the Centers for Disease Control and Prevention. Four hundred four close contacts were actively monitored in the jurisdictions that managed the travel-related cases. Three hundred thirty-eight of the 404 close contacts provided at least basic exposure information, of whom 159 close contacts had ≥1 set of respiratory samples collected and tested. Across all actively monitored close contacts, two additional symptomatic COVID-19 cases (i.e., secondary cases) were identified; both secondary cases were in spouses of travel-associated case patients. When considering only household members, all of whom had ≥1 respiratory sample tested for SARS-CoV-2, the secondary attack rate (i.e., the number of secondary cases as a proportion of total close contacts) was 13% (95% CI: 4-38%). The results from these contact tracing investigations suggest that household members, especially significant others, of COVID-19 cases are at highest risk of becoming infected. The importance of personal protective equipment for healthcare workers is also underlined. Isolation of persons with COVID-19, in combination with quarantine of exposed close contacts and practice of everyday preventive behaviors, is important to mitigate spread of COVID-19.

Enhanced contact investigations for nine early travel-related cases of SARS-CoV-2 in the United States

Coronavirus disease 2019 (COVID-19), the respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China and has since become pandemic. In response to the first cases identified in the United States, close contacts of confirmed COVID-19 cases were investigated to enable early identification and isolation of additional cases and to learn more about risk factors for transmission. Close contacts of nine early travel-related cases in the United States were identified and monitored daily for development of symptoms (active monitoring). Selected close contacts (including those with exposures categorized as higher risk) were targeted for collection of additional exposure information and respiratory samples. Respiratory samples were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction at the Centers for Disease Control and Prevention. Four hundred four close contacts were actively monitored in the jurisdictions that managed the travel-related cases. Three hundred thirty-eight of the 404 close contacts provided at least basic exposure information, of whom 159 close contacts had ≥1 set of respiratory samples collected and tested. Across all actively monitored close contacts, two additional symptomatic COVID-19 cases (i.e., secondary cases) were identified; both secondary cases were in spouses of travel-associated case patients. When considering only household members, all of whom had ≥1 respiratory sample tested for SARS-CoV-2, the secondary attack rate (i.e., the number of secondary cases as a proportion of total close contacts) was 13% (95% CI: 4-38%). The results from these contact tracing investigations suggest that household members, especially significant others, of COVID-19 cases are at highest risk of becoming infected. The importance of personal protective equipment for healthcare workers is also underlined. Isolation of persons with COVID-19, in combination with quarantine of exposed close contacts and practice of everyday preventive behaviors, is important to mitigate spread of COVID-19.

Adverse Events Among Young Adults Following a Third Dose of Measles-Mumps-Rubella Vaccine

BACKGROUND

A third measles-mumps-rubella vaccine (MMR) dose (MMR3) is recommended in the United States for persons at increased risk for mumps during outbreaks. MMR3 is also likely given to persons who might have received 2 doses of MMR but lack documentation. Since MMR3 safety data are limited, we describe adverse events in persons receiving MMR3 in a nonoutbreak setting.

METHODS

Young adults with 2 documented MMR doses were administered MMR3. From 2 weeks before until 4 weeks after MMR3 receipt, participants reported daily on 11 solicited, common symptoms potentially associated with MMR. Weekly rate differences in post- vs prevaccination (baseline) were evaluated by Poisson regression. Baseline rates were subtracted from postvaccination rates of significantly different symptoms to estimate the number and percentage of participants with excess risk for symptoms post-MMR3. Descriptive analyses were performed for 3 postvaccination injection-site symptoms.

RESULTS

The 662 participants were aged 18-28 years (median = 20 years); 56% were women. Headache, joint problems, diarrhea, and lymphadenopathy rates were significantly higher postvaccination vs baseline. We estimate that 119 participants (18%) reported more symptoms after MMR3 than prevaccination. By symptom, 13%, 10%, 8%, and 6% experienced increased symptoms of headache, joint problems, diarrhea, and lymphadenopathy, respectively, after MMR3. The median onset was Days 3-6 postvaccination; the median duration was 1-2 days. One healthcare visit for a potential vaccination-related symptom (urticaria) was reported. Injection-site symptoms were reported by 163 participants (25%); the median duration was 1-2 days.

CONCLUSIONS

Reported systemic and local events were mild and transient. MMR3 is safe and tolerable among young adults.

Vital Signs: Clinical Characteristics of Patients with Confirmed Acute Flaccid Myelitis, United States, 2018

Background

Acute flaccid myelitis (AFM) is a serious neurologic syndrome that affects mostly children and is characterized by the acute onset of limb weakness or paralysis. Since U.S. surveillance for AFM began in 2014, reported cases have peaked biennially. This report describes the clinical characteristics of AFM patients during 2018, the most recent peak year.

Methods

Medical records from persons meeting AFM clinical criterion (acute onset of flaccid limb weakness) were submitted to CDC. Patients with confirmed AFM met the clinical criterion and had magnetic resonance imaging indicating spinal cord lesions largely restricted to gray matter and spanning one or more vertebral segments. Symptoms, physical findings, test and imaging results, and hospitalization data were abstracted and described.

Results

Among 238 patients with confirmed AFM during 2018, median age was 5.3 years. Among the 238 patients, 205 (86%) had onset during August–November. Most (92%) had prodromal fever, respiratory illness, or both beginning a median of 6 days before weakness onset. In addition to weakness, common symptoms at clinical evaluation were gait difficulty (52%), neck or back pain (47%), fever (35%), and limb pain (34%). Among 211 who were outpatients when weakness began, most (76%) sought medical care within 1 day, and 64% first sought treatment at an emergency department. Overall, 98% of patients were hospitalized, 54% were admitted to an intensive care unit, and 23% required endotracheal intubation and mechanical ventilation.

Conclusion

Clinicians should suspect AFM in children with acute flaccid limb weakness, especially during August–November and when accompanied by neck or back pain and a recent history of febrile respiratory illness. Increasing awareness in frontline settings such as emergency departments should aid rapid recognition and hospitalization for AFM.

Clinical and virologic characteristics of the first 12 patients with coronavirus disease 2019 (COVID-19) in the United States

Data on the detailed clinical progression of COVID-19 in conjunction with epidemiological and virological characteristics are limited. In this case series, we describe the first 12 US patients confirmed to have COVID-19 from 20 January to 5 February 2020, including 4 patients described previously^1-3. Respiratory, stool, serum and urine specimens were submitted for SARS-CoV-2 real-time reverse-transcription polymerase chain reaction (rRT-PCR) testing, viral culture and whole genome sequencing. Median age was 53 years (range: 21-68); 8 patients were male. Common symptoms at illness onset were cough (n = 8) and fever (n = 7). Patients had mild to moderately severe illness; seven were hospitalized and demonstrated clinical or laboratory signs of worsening during the second week of illness. No patients required mechanical ventilation and all recovered. All had SARS-CoV-2 RNA detected in respiratory specimens, typically for 2-3 weeks after illness onset. Lowest real-time PCR with reverse transcription cycle threshold values in the upper respiratory tract were often detected in the first week and SARS-CoV-2 was cultured from early respiratory specimens. These data provide insight into the natural history of SARS-CoV-2. Although infectiousness is unclear, highest viral RNA levels were identified in the first week of illness. Clinicians should anticipate that some patients may worsen in the second week of illness.

Gas Chromatographic Determination of Deoxynivalenol in Wheat with Electron Capture Detection: Collaborative Study

Ten laboratories participated in a collaborative study of a method for the determination of deoxynivalenol in wheat by gas chromatography with electron capture detection. Each laboratory analyzed 6 samples in duplicate. Each collaborator received samples spiked at the 100.3, 501.3, and 1002.6 ng/g levels; a control sample; and 2 naturally contaminated samples. The average recovery (outliers excluded) for the spiked samples was 92.2%. The mean repeatability and reproducibility, respectively, were 32.2 and 41.3% for the spiked samples and 30.9 and 47.6% for the naturally contaminated samples. The method was adopted official first action.

Clinical characteristics of enterovirus A71 neurological disease during an outbreak in children in Colorado, USA, in 2018: an observational cohort study

BACKGROUND

In May, 2018, Children's Hospital Colorado noted an outbreak of enterovirus A71 (EV-A71) neurological disease. We aimed to characterise the clinical features of EV-A71 neurological disease during this outbreak.

METHODS

In this retrospective observational cohort study, children (younger than 18 years) who presented to Children's Hospital Colorado (Aurora, CO, USA) between March 1 and November 30, 2018, with neurological disease (defined by non-mutually exclusive criteria, including meningitis, encephalitis, acute flaccid myelitis, and seizures) and enterovirus detected from any biological specimen were eligible for study inclusion. The clinical characteristics of children with neurological disease associated with EV-A71 were compared with those of children with neurological disease associated with other enteroviruses during the same period. To explore the differences in clinical presentation of acute flaccid myelitis, we also used a subgroup analysis to compare clinical findings in children with EV-A71-associated acute flaccid myelitis during the study period with these findings in those with enterovirus D68 (EV-D68)-associated acute flaccid myelitis at the same hospital between 2013 and 2018.

FINDINGS

Between March 10 and Nov 10, 2018, 74 children presenting to Children's Hospital Colorado were found to have enterovirus neurological disease; EV-A71 was identified in 43 (58%) of these children. The median age of the children with EV-A71 neurological disease was 22·7 months (IQR 4·0-31·9), and most of these children were male (34 [79%] children). 40 (93%) children with EV-A71 neurological disease had findings suggestive of meningitis, 31 (72%) children showed evidence of encephalitis, and ten (23%) children met our case definition of acute flaccid myelitis. All children with EV-A71 disease had fever and 18 (42%) children had hand, foot, or mouth lesions at or before neurological onset. Children with EV-A71 disease were best differentiated from those with other enteroviruses (n=31) by the neurological findings of myoclonus, ataxia, weakness, and autonomic instability. Of the specimens collected from children with EV-A71, this enterovirus was detected in 94% of rectal, 79% of oropharyngeal, 56% of nasopharyngeal, and 20% of cerebrospinal fluid specimens. 39 (93%) of 42 children with EV-A71 neurological disease who could be followed up showed complete recovery by 1-2 months. Compared with children with EV-D68-associated acute flaccid myelitis, children with EV-A71-associated acute flaccid myelitis were younger, showed neurological onset earlier after prodromal symptom onset, had milder weakness, showed more rapid improvement, and were more likely to completely recover.

INTERPRETATION

This outbreak of EV-A71 neurological disease, the largest reported in the Americas, was characterised by fever, myoclonus, ataxia, weakness, autonomic instability, and full recovery in most patients. Because EV-A71 epidemiology outside of Asia remains difficult to predict, identification of future outbreaks will be aided by prompt recognition of these distinct clinical findings, testing of non-sterile and sterile site specimens, and enhanced enterovirus surveillance.

FUNDING

None.

1723. Mumps Attack Rates Following Administration of a Third Dose of MMR Vaccine to School-Aged Children, Arkansas, 2016–2017

Background

During the 2016–2017 school year, the largest mumps outbreak in the United States since 2006 occurred in Arkansas with nearly 3,000 cases. As part of outbreak response, a third dose of measles–mumps–rubella vaccine (MMR3) was offered at 27 schools with mumps attack rates ≥5 cases/1,000 students. We compared attack rates after vaccination clinics among students who received MMR3 and students with 2 MMR vaccine doses.

Methods

We obtained information on school enrollment and student immunization status from school registries, and mumps case status from Arkansas’s National Electronic Disease Surveillance System database. We included students aged 6–21 years who had previously received ≥2 doses of MMR vaccine. We used Arkansas’s Immunization Information System to identify students who received MMR3.

We included schools with at least 1 mumps case after their vaccination clinic. We calculated mumps attack rates by 2- and 3-dose MMR vaccine recipients. Observation time started 14 days after each clinic to allow for development of an immune response to MMR3, and continued to the end of the 2016–2017 school year. Observation time varied by school as schools held clinics on different dates.

Results

A total of 18 schools (10 elementary, 8 middle/junior high) with 10,275 students who had previously received ≥2 doses of MMR (85% of total enrolled) met inclusion criteria. Median number of students per school was 553. Median student age was 11 years (range, 6–18) and 1,525 students received MMR3. MMR3 uptake varied by school (median, 12%; range, 2–33%; interquartile range, 7–22%). A total of 12 mumps cases occurred among MMR3 recipients and 122 cases among 2-dose recipients. School-specific attack rates ranged from 0 to 23 cases/1,000 students among 3-dose recipients, and 2–41 cases/1,000 students among 2-dose recipients. Mumps attack rates within each school were lower for 3-dose recipients vs. 2-dose recipients in all but one school (P < .05). The differences in attack rates between 2- and 2-dose recipients ranged from −5 to 23 cases/1,000 students (median, 5/1,000).

Conclusion

Mumps attack rates were lower in 3-dose vs. 2-dose MMR vaccine recipients after MMR3 vaccination clinics, supporting a benefit of MMR3 for persons in outbreak settings. Further analysis is needed to determine impact of MMR3 on duration and size of mumps outbreaks.

Disclosures

All authors: No reported disclosures.

660. Are US Clinicians Thinking Measles in the Post-elimination Era? Surveillance for Measles-Like Illness in a Commercially Insured US Population

Background

In September 2016, the Americas was the first region to eliminate measles, a highly contagious, vaccine-preventable disease that can lead to complications and death. To maintain elimination, the Pan American Health Organization (PAHO) suggested a minimum rate of suspected measles investigations (≥2 per 100,000 population) be conducted annually. However, measles-like illness (MLI) investigations conducted by US clinicians are not tracked by the measles surveillance program in the United States. To ensure the US meets PAHO standards, we estimated the rate of MLI investigations using a large insurance claims database.

Methods

We used the 2009–2016 Truven Health MarketScan^® Databases to identify MLI and MLI investigations. MLI were defined using International Classification of Diseases (ICD)-9/10 diagnostic codes in two ways: a priori, using the Council of State and Territorial Epidemiologists (CSTE) measles case definition or empirically, using ICD codes on insurance claims with a measles diagnostic code. MLI investigations were defined as MLI occurring up to 5 days prior to a measles diagnostic code or billing code for measles serology testing. We computed annual rates of MLI investigations per 100,000 population.

Results

We identified ~35.5 million MLI using the a priori definition. Of these, 24,010 had a measles serology code within 5 days; median age was 30 and 51% were aged 18–34 years. Using the empirical definition we identified ~46 million MLI. Of these, 29,940 were coupled with a measles serology code; median age was 31 and 50% were aged 18–34 years. The median annual rates for MLI investigations were 3.2 (a priori) and 4.3 (empirical) per 100,000 population.

Conclusion

Maintaining measles elimination requires continued vigilance by clinicians and high-quality case-based surveillance. The estimated rates of MLI investigations in this US population exceeded the PAHO standard, suggesting that the quality of US measles surveillance is robust.

Disclosures

All authors: No reported disclosures.

Modifiable risk factors for typhoid intestinal perforations during a large outbreak of typhoid fever, Kampala Uganda, 2015

Background

Between January and June, 2015, a large typhoid fever outbreak occurred in Kampala, Uganda, with 10,230 suspected cases. During the outbreak, area surgeons reported a surge in cases of typhoid intestinal perforation (TIP), a complication of typhoid fever. We conducted an investigation to characterize TIP cases and identify modifiable risk factors for TIP.

Methods

We defined a TIP case as a physician-diagnosed typhoid patient with non-traumatic terminal ileum perforation. We identified cases by reviewing medical records at all five major hospitals in Kampala from 2013 to 2015. In a matched case-control study, we compared potential risk factors among TIP cases and controls; controls were typhoid patients diagnosed by TUBEX TF, culture, or physician but without TIP, identified from the outbreak line-list and matched to cases by age, sex and residence. Cases and controls were interviewed using a standard questionnaire from 1st -23rd December 2015. We used conditional logistic regression to assess risk factors for TIP and control for confounding.

Results

Of the 88 TIP cases identified during 2013–2015, 77% (68/88) occurred between January and June, 2015; TIPs sharply increased in January and peaked in March, coincident with the typhoid outbreak. The estimated risk of TIP was 6.6 per 1000 suspected typhoid infections (68/10,230). The case-fatality rate was 10% (7/68). Cases sought care later than controls; Compared with 29% (13/45) of TIP cases and 63% (86/137) of controls who sought treatment within 3 days of onset, 42% (19/45) of cases and 32% (44/137) of controls sought treatment 4–9 days after illness onset (OR_adj = 2.2, 95%CI = 0.83–5.8), while 29% (13/45) of cases and 5.1% (7/137) of controls sought treatment ≥10 days after onset (OR_adj = 11, 95%CI = 1.9–61). 68% (96/141) of cases and 23% (23/100) of controls had got treatment before being treated at the treatment centre (OR_adj = 9.0, 95%CI = 1.1–78).

Conclusion

Delay in seeking treatment increased the risk of TIPs. For future outbreaks, we recommended aggressive community case-finding, and informational campaigns in affected communities and among local healthcare providers to increase awareness of the need for early and appropriate treatment.

A large and persistent outbreak of typhoid fever caused by consuming contaminated water and street-vended beverages: Kampala, Uganda, January - June 2015

Background

On 6 February 2015, Kampala city authorities alerted the Ugandan Ministry of Health of a “strange disease” that killed one person and sickened dozens. We conducted an epidemiologic investigation to identify the nature of the disease, mode of transmission, and risk factors to inform timely and effective control measures.

Methods

We defined a suspected case as onset of fever (≥37.5 °C) for more than 3 days with abdominal pain, headache, negative malaria test or failed anti-malaria treatment, and at least 2 of the following: diarrhea, nausea or vomiting, constipation, fatigue. A probable case was defined as a suspected case with a positive TUBEX® TF test. A confirmed case had blood culture yielding Salmonella Typhi. We conducted a case-control study to compare exposures of 33 suspected case-patients and 78 controls, and tested water and juice samples.

Results

From 17 February–12 June, we identified 10,230 suspected, 1038 probable, and 51 confirmed cases. Approximately 22.58% (7/31) of case-patients and 2.56% (2/78) of controls drank water sold in small plastic bags (OR_M-H = 8.90; 95%CI = 1.60–49.00); 54.54% (18/33) of case-patients and 19.23% (15/78) of controls consumed locally-made drinks (OR_M-H = 4.60; 95%CI: 1.90–11.00). All isolates were susceptible to ciprofloxacin and ceftriaxone. Water and juice samples exhibited evidence of fecal contamination.

Conclusion

Contaminated water and street-vended beverages were likely vehicles of this outbreak. At our recommendation authorities closed unsafe water sources and supplied safe water to affected areas.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-4002-0) contains supplementary material, which is available to authorized users.

Evaluation of Knowledge and Practices Regarding Cholera, Water Treatment, Hygiene, and Sanitation Before and After an Oral Cholera Vaccination Campaign-Haiti, 2013-2014

In 2013, the Government of Haiti implemented its first oral cholera vaccine (OCV) campaign in Petite Anse, an urban setting, and Cerca Carvajal, a rural commune. We conducted and compared responses to two independent cross-sectional knowledge and practices household surveys pre- (N = 297) and post- (N = 302) OCV campaign in Petite Anse. No significant differences in knowledge about causes, symptoms, and prevention of cholera were noted. Compared with precampaign respondents, fewer postcampaign respondents reported treating (66% versus 27%, P < 0.001) and covering (96% versus 89%, P = 0.02) their drinking water. Compared with precampaign, postcampaign survey household observations showed increased availability of soap (16.2% versus 34.5%, P = 0.001) and handwashing stations (14.7% versus 30.1%, P = 0.01), but no significant changes in handwashing practices were reported. Although there was no change in knowledge, significant decreases in water treatment practices necessary for cholera and other diarrheal diseases prevention were noted in the postcampaign survey. Future OCV campaigns in Haiti should be used as an opportunity to emphasize the importance of maintaining good water, sanitation, and hygiene practices, and include a comprehensive, integrated approach for cholera control.

Shifts in geographic distribution and antimicrobial resistance during a prolonged typhoid fever outbreak--Bundibugyo and Kasese Districts, Uganda, 2009-2011

Background

Salmonella enterica serovar Typhi is transmitted by fecally contaminated food and water and causes approximately 22 million typhoid fever infections worldwide each year. Most cases occur in developing countries, where approximately 4% of patients develop intestinal perforation (IP). In Kasese District, Uganda, a typhoid fever outbreak notable for a high IP rate began in 2008. We report that this outbreak continued through 2011, when it spread to the neighboring district of Bundibugyo.

Methodology/Principal Findings

A suspected typhoid fever case was defined as IP or symptoms of fever, abdominal pain, and ≥1 of the following: gastrointestinal disruptions, body weakness, joint pain, headache, clinically suspected IP, or non-responsiveness to antimalarial medications. Cases were identified retrospectively via medical record reviews and prospectively through laboratory-enhanced case finding. Among Kasese residents, 709 cases were identified from August 1, 2009–December 31, 2011; of these, 149 were identified during the prospective period beginning November 1, 2011. Among Bundibugyo residents, 333 cases were identified from January 1–December 31, 2011, including 128 cases identified during the prospective period beginning October 28, 2011. IP was reported for 507 (82%) and 59 (20%) of Kasese and Bundibugyo cases, respectively. Blood and stool cultures performed for 154 patients during the prospective period yielded isolates from 24 (16%) patients. Three pulsed-field gel electrophoresis pattern combinations, including one observed in a Kasese isolate in 2009, were shared among Kasese and Bundibugyo isolates. Antimicrobial susceptibility was assessed for 18 isolates; among these 15 (83%) were multidrug-resistant (MDR), compared to 5% of 2009 isolates.

Conclusions/Significance

Molecular and epidemiological evidence suggest that during a prolonged outbreak, typhoid spread from Kasese to Bundibugyo. MDR strains became prevalent. Lasting interventions, such as typhoid vaccination and improvements in drinking water infrastructure, should be considered to minimize the risk of prolonged outbreaks in the future.

Typhoid fever is an acute febrile illness caused by the bacteria Salmonella Typhi and transmitted through food and water contaminated with the feces of typhoid fever patients or carriers. We investigated typhoid fever outbreaks in two neighboring Ugandan districts, Kasese and Bundibugyo, where typhoid fever outbreaks began in 2008 and 2011, respectively. In Kasese from August 2009–December 2011, we documented 709 cases of typhoid fever. In Bundibugyo from January–December 2011, we documented 333 cases. Salmonella Typhi from Bundibugyo and Kasese had indistinguishable molecular fingerprints; laboratory and epidemiological evidence indicate that the outbreak spread from Kasese to Bundibugyo. Salmonella Typhi isolated during our investigation were resistant to more antibiotics than isolates obtained from Kasese in 2009. Drinking water in both districts was fecally contaminated and the likely vehicle for the outbreaks. Our investigation highlights that in unchecked typhoid fever outbreaks, illness can become geographically dispersed and outbreak strains can become increasingly resistant to antibiotics. Lasting interventions, including investments in drinking water infrastructure and typhoid vaccination, are needed to control these outbreaks and prevent future outbreaks.

Risk factors early in the 2010 cholera epidemic, Haiti

During the early weeks of the cholera outbreak that began in Haiti in October 2010, we conducted a case-control study to identify risk factors. Drinking treated water was strongly protective against illness. Our results highlight the effectiveness of safe water in cholera control.

Removing barriers to knowing HIV status: same-day mobile HIV testing in Zimbabwe

OBJECTIVES

We developed a mobile HIV voluntary counseling testing (VCT) strategy. Our aims were (1) to describe those using the services, (2) to assess the acceptability of such services, (3) to assess reasons for not testing previously, and (4) to compare those who used the services with those who did not to determine how to increase acceptability.

METHODS

We provided free anonymous mobile VCT using 2 rapid HIV tests in 12 marketplaces in Epworth and Seke, Zimbabwe. Qualitative interviews were conducted to assess motivations for and barriers to testing. A subsample of HIV testers and individuals near testing vans who declined testing (nontesters) completed a questionnaire.

RESULTS

A total of 1099 individuals participated in mobile VCT between March 2002 and August 2003. The proportion of participants infected with HIV was 29.2%. Overall, 98.8% of participants elected to receive HIV test results the same day. Reasons for not testing previously were often logistic (eg, inconvenience of hours [25.6%] and location [20.7%] or cost [8%]). Those who used the same-day mobile testing services (testers vs. nontesters) perceived themselves at higher risk for HIV infection (adjusted odds ratio [AOR] = 1.8) but were less likely to have known people with HIV (AOR = 0.49) or where to get tested (AOR = 0.57).

CONCLUSIONS

Same-day HIV testing in community settings seems to be acceptable in sub-Saharan Africa. Barriers to HIV testing are often logistic and can be overcome with community-based strategies. These strategies need to be refined to address the needs of those not using mobile testing services.

Characterization and origin of dissolved organic carbon in Yegua ground water in Brazos County, Texas

Dissolved organic carbon (DOC) concentrations in five shallow (< 20 m) and three deeper wells (27 to 30 m) in the Eocene Yegua Formation (Brazos County in east-central Texas) ranged from 92 to 500 microns. Characterization of high, intermediate, and low molecular weight DOC fractions (HMW > 3000 amu, IMW 1000 to 3000 amu, and LMW 500 to 1000 amu) and combined neutral sugar analyses provide information on organic matter sources in the Yegua aquifers. Combined neutral sugars ranged in concentration from 0.6 to 2.7 mumol/L and comprised 0.8% to 6.7% of DOC in ground water. Glucose was the most abundant neutral sugar, followed by xylose and galactose, arabinose, mannose, rhamnose, and fucose. These combined neutral sugars were more diagenetically altered in shallow, oxic ground water as indicated by high mole % fucose + rhamnose and low neutral sugar yield. The precursors for neutral sugars are most probably angiosperm leaves, which show a similar distribution pattern of neutral sugars. Ground water DOC was depleted in 13C relative to soil-zone organic matter (OM) (-16@1000 to -19@1000). The delta 13C values of bulk DOC and HMW DOC ranged from -24@1000 to -32@1000, whereas LMW and IMW DOC ranged from -32@1000 to -34@1000 and -16@1000 to -28@1000, respectively. This variability in delta 13C values is probably related to microbial processes and selective preservation of OM. Carbon isotope analyses in bulk and different molecular weight DOC fractions imply a predominantly C3 OM source and a low contribution of soil-zone OM to DOC.

Depletion of ovarian oocytes in sublethally exposed mice to gamma radiation and its modification by 2-mercaptopropionylglycine (MPG)

Adult female Swiss albino mice were exposed to 0.6, 1.2 and 2.4 Gy of 60Co gamma radiations in presence and absence of MPG. Quantitative studies were done in serial sections of ovary at 1, 3, 5, 7, 14 and 35 days after exposure. Primary follicles were found to be most radiosensitive. The depletion in the various types of follicles was checked to some extent by prior administration of MPG, but MPG could not prevent the complete elimination of all types of follicles by the last autopsy interval studied.

Radiation response of plasma protein and albumin of peripheral blood and its modification by MPG (2-Mercaptopropionylglycine) in mice

Changes in the total protein and albumin level in the blood of six week and three week old Swiss albino mice exposed to a sublethal dose of 2.2 Gy of gamma rays after an intraperitoneal injection of 20 mg/kg body weight of the radioprotector drug MPG (2-Mercaptopropionylglycine) were studied. The results were compared with those obtained from animals irradiated with the same dose of gamma rays in the absence of the drug. Animals were sacrificed at one, three, five, seven and 14 days after irradiation. The drug has been found to modify the levels of plasma protein and albumin in the blood of the irradiated animals. The depletion observed was less marked in the drug treated animals than their respective controls. The observations have been discussed in light of relevant literature.

Determination of Aflatoxins in Peanut Butter, Using Two Liquid Chromatographic Methods: Collaborative Study

Two methods for determining aflatoxins in peanut butter, one using normal phase and the other reverse phase liquid chromatography (LC), were studied by 8 and 10 collaborators, respectively. Fluorescence detection was used for the determinative step in both methods. For reverse phase LC, aflatoxins B1 and G1 were converted to B2a and G2a; for normal phase LC, a silica gel-packed flow cell was placed in the irradiating light path of the detector. The samples included spiked and naturally contaminated peanut butter with total aflatoxin levels from about 5 to 20 ng/g and controls in a balanced pair design. For the normal phase LC method, recoveries of B1, B2, G1, and G2 from spiked samples averaged 79, 92, 74, and 88%, respectively; for the reverse phase method, the recoveries were 103, 104, 89, and 163%. For the normal phase LC method, pooled repeatabilities were 20, 23, 28, and 17% for B1, B2, G1, and G2, respectively; for the reverse phase method, the repeatabilities were 19, 22, 38, and 31%. For the normal phase method, pooled reproducibilities were 34, 33, 39, and 34% for B1, B2, G1, and G2, respectively; for the reverse phase method, the reproducibilities were 32, 46, 51, and 52%. Both methods show an improved limit of detection and better within-laboratory precision over current AOAC methods; however, between-laboratory precision is no better, and the reverse phase method shows evidence of interferences being measured. For these reasons and because of no benefits of present value, neither method was submitted for adoption as official first action.