Lessons Learned From Implementation of Mpox Surveillance During an Outbreak Response in Tennessee, 2022

OBJECTIVES

Mpox surveillance was integral during the 2022 outbreak response. We evaluated implementation of mpox surveillance in Tennessee during an outbreak response and made recommendations for surveillance during emerging infectious disease outbreaks.

METHODS

To understand surveillance implementation, system processes, and areas for improvement, we conducted 8 semistructured focus groups and 7 interviews with 36 health care, laboratory, and health department representatives during September 9-20, 2022. We categorized and analyzed session transcription and notes. We analyzed completeness and timeliness of surveillance data, including 349 orthopoxvirus-positive laboratory reports from commercial, public health, and health system laboratories during July 1-August 31, 2022.

RESULTS

Participants described an evolving system and noted that existing informatics platforms inefficiently supported iterations of reporting requirements. Clear communication, standardization of terminology, and shared, adaptable, and user-friendly informatics platforms were prioritized for future emerging infectious disease surveillance systems. Laboratory-reported epidemiologic information was often incomplete; only 55% (191 of 349) of reports included patient address and telephone number. The median time from symptom onset to specimen collection was 5 days (IQR, 3-6 d), from specimen collection to laboratory reporting was 3 days (IQR, 1-4 d), from laboratory reporting to patient interview was 1 day (IQR, 1-3 d), and from symptom onset to patient interview was 9 days (IQR, 7-12 d).

CONCLUSIONS

Future emerging infectious disease responses would benefit from standardized surveillance approaches that facilitate rapid implementation. Closer collaboration among informatics, laboratory, and clinical partners across jurisdictions and agencies in determining system priorities and designing workflow processes could improve flexibility of the surveillance platform and completeness and timeliness of laboratory reporting. Improved timeliness will facilitate public health response and intervention, thereby mitigating morbidity.

Early and Increased Influenza Activity Among Children - Tennessee, 2022-23 Influenza Season

Influenza seasons typically begin in October and peak between December and February (1); however, the 2022-23 influenza season in Tennessee began in late September and was characterized by high pediatric hospitalization rates during November. This report describes a field investigation conducted in Tennessee during November 2022, following reports of increasing influenza hospitalizations. Data from surveillance networks, patient surveys, and whole genome sequencing of influenza virus specimens were analyzed to assess influenza activity and secondary illness risk. Influenza activity increased earlier than usual among all age groups, and rates of influenza-associated hospitalization among children were high in November, reaching 12.6 per 100,000 in children aged <5 years, comparable to peak levels typically seen in high-severity seasons. Circulating influenza viruses were genetically similar to vaccine components. Among persons who received testing for influenza at outpatient clinics, children were twice as likely to receive a positive influenza test result as were adults. Among household contacts exposed to someone with influenza, children were more than twice as likely to become ill compared with adults. As the influenza season continues, it is important for all persons, especially those at higher risk for severe disease, to protect themselves from influenza. To prevent influenza and severe influenza complications, all persons aged ≥6 months should get vaccinated, avoid contact with ill persons, and take influenza antivirals if recommended and prescribed.

SARS-CoV-2 Outbreak among Malayan Tigers and Humans, Tennessee, USA, 2020

We report an outbreak of severe acute respiratory syndrome coronavirus 2 involving 3 Malayan tigers (Panthera tigris jacksoni) at a zoo in Tennessee, USA. Investigation identified naturally occurring tiger-to-tiger transmission; genetic sequence change occurred with viral passage. We provide epidemiologic, environmental, and genomic sequencing data for animal and human infections.

189. Potential Tiger-to-Human Transmission of SARS-CoV-2 at a Tennessee Zoo: A One Health Approach to Outbreak Investigation

Background

Human-to-feline and airborne transmission among cats of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has been described, though documented feline-to-human transmission has not been reported. In October 2020, all 3 Malayan tigers at a Tennessee AZA accredited zoo were diagnosed with symptomatic SARS-CoV-2 infection. We investigated to determine source and prevent further transmission.

Methods

Tiger nasal swab specimens were tested at the National Veterinary Services Laboratories (NVSL). An environmental assessment at the zoo was completed. We interviewed 18 staff who interacted with the tigers during the 2 weeks before animal symptom onset. Confirmed human cases were defined as persons testing positive for SARS-CoV-2 by RT-PCR during September 28–October 29, with tiger interaction during their 14-day incubation period. Interviewed staff had repeat SARS-CoV-2 RT-PCR and serum IgG testing on October 29. Tigers and staff testing positive had specimens sent to CDC for genomic sequencing. Tiger sequences were compared phylogenetically with 30 geographically associated human cases collected within 2 weeks of the outbreak and > 200 background sequences from TN.

Results

NVSL confirmed SARS-CoV-2 infection in all 3 tigers. Environmental assessment identified fencing between humans and animals allowing airflow and an open outdoor exhibit observation point above the habitat. Confirmed cases were identified in a tiger keeper and veterinary assistant; both developed symptoms after exposure to symptomatic tigers and one sample was genotyped. Staff did not report known contact with ill visitors. All staff were negative for SARS-CoV-2 IgG. The tigers and most temporally and geographically associated cases had genetic sequences in clade 20G and B.1.2. Tiger sequences were 3-6 single nucleotide polymorphisms different from the positive tiger keeper (Figure).

Figure. Whole-genome phylogenetic analysis.

Whole-genome phylogenetic analysis from a portion of clade 20G showing divergence estimates from SARS-CoV-2 Wuhan-Hu-1 reference genome with sequences from humans living in Tennessee and Malayan tigers sampled during the outbreak investigation in October 2020. Sequence analysis showed 3-6 single nucleotide polymorphisms (SNPs) differences between one human tiger keeper and all three tiger sequences. Differences are indicated by one-step edges (lines) between colored dots (individual SARS-CoV-2 sequenced infections). Numbers indicate unique sequences. Note not all analyzed sequences are shown in this figure.

Conclusion

Using a One Health approach, we concluded the index tiger was likely infected via transmission from an ill visitor at an exhibit observation point or unidentified asymptomatic staff. Infection spread to the other 2 tigers and tiger-to-human transmission to 2 staff is possible thereafter. The zoo was advised on infection control practices for humans and animals, and no additional cases were identified.

Disclosures

William Schaffner, MD, VBI Vaccines (Consultant)

Fatal Multisystem Inflammatory Syndrome in Adult after SARS-CoV-2 Natural Infection and COVID-19 Vaccination

We describe a fatal case of multisystem inflammatory syndrome in an adult with onset 22 days after a second dose of mRNA coronavirus disease vaccine. Serologic and clinical findings indicated severe acute respiratory syndrome coronavirus 2 infection occurred before vaccination. The immunopathology of this syndrome, regardless of vaccination status, remains poorly understood.

Preoperative lymphopaenia, mortality, and morbidity after elective surgery: systematic review and meta-analysis

BACKGROUND

In the general adult population, lymphopaenia is associated with an increased risk for hospitalisation with infection and infection-related death. The quality of evidence and strength of association between perioperative lymphopaenia across different surgical procedures and mortality/morbidity has not been examined by systematic review or meta-analysis.

METHODS

We searched MEDLINE, Embase, Web of Science, Google Scholar, and Cochrane databases from their inception to June 29, 2020 for observational studies reporting lymphocyte count and in-hospital mortality rate in adults. We defined preoperative lymphopaenia as a lymphocyte count 1.0-1.5×109 L-1. Meta-analysis was performed using either fixed or random effects models. Quality was assessed using the Newcastle-Ottawa Scale. The I2 index was used to quantify heterogeneity. The primary outcome was in-hospital mortality rate and mortality rate at 30 days.

RESULTS

Eight studies met the inclusion criteria for meta-analysis, comprising 4811 patients (age range, 46-91 yr; female, 20-79%). These studies examined preoperative lymphocyte count exclusively. Studies were of moderate to high quality overall, ranking >7 using the Newcastle-Ottawa Scale. Preoperative lymphopaenia was associated with a threefold increase in mortality rate (risk ratio [RR]=3.22; 95% confidence interval [CI], 2.19-4.72; P<0.01, I2=0%) and more frequent major postoperative complications (RR=1.33; 95% CI, 1.21-1.45; P<0.01, I2=6%), including cardiovascular morbidity (RR=1.77; 95% CI, 1.45-2.15; P<0.01, I2=0%), infections (RR=1.45; 95% CI, 1.19-1.76; P<0.01, I2=0%), and acute renal dysfunction (RR=2.66; 95% CI, 1.49-4.77; P<0.01, I2=1%).

CONCLUSION

Preoperative lymphopaenia is associated with death and complications more frequently, independent of the type of surgery.

PROSPERO REGISTRY NUMBER

CRD42020190702.

Injection Drug Use-Associated Candidemia: Incidence, Clinical Features, and Outcomes, East Tennessee, 2014-2018

BACKGROUND

Injection drug use (IDU) is an established but uncommon risk factor for candidemia. Surveillance for candidemia is conducted in East Tennessee, an area heavily impacted by the opioid crisis and IDU. We evaluated IDU-associated candidemia to characterize the epidemiology and estimate the burden.

METHODS

We assessed the proportion of candidemia cases related to IDU during January 1, 2014-September 30, 2018, estimated candidemia incidence in the overall population and among persons who inject drugs (PWID), and reviewed medical records to compare clinical features and outcomes among IDU-associated and non-IDU candidemia cases.

RESULTS

The proportion of IDU-associated candidemia cases in East Tennessee increased from 6.1% in 2014 to 14.5% in 2018. Overall candidemia incidence in East Tennessee was 13.5/100 000, and incidence among PWID was 402-1895/100 000. Injection drug use-associated cases were younger (median age, 34.5 vs 60 years) and more frequently had endocarditis (39% vs 3%). All-cause 30-day mortality was 8% among IDU-associated cases versus 25% among non-IDU cases.

CONCLUSIONS

A growing proportion of candidemia in East Tennessee is associated with IDU, posing an additional burden from the opioid crisis. The lower mortality among IDU-associated cases likely reflects in part the younger demographic; however, Candida endocarditis seen among approximately 40% underscores the seriousness of the infection and need for prevention.

Early elevation in plasma high-sensitivity troponin T and morbidity after elective noncardiac surgery: prospective multicentre observational cohort study

BACKGROUND

Elevated high-sensitivity troponin (hsTnT) after noncardiac surgery is associated with higher mortality, but the temporal relationship between early elevated troponin and the later development of noncardiac morbidity remains unclear.

METHODS

Prospective observational study of patients aged ≥45 yr undergoing major noncardiac surgery at four UK hospitals (two masked to hsTnT). The exposure of interest was early elevated troponin, as defined by hsTnT >99th centile (≥15 ng L^-1) within 24 h after surgery. The primary outcome was morbidity 72 h after surgery, defined by the Postoperative Morbidity Survey (POMS). Secondary outcomes were time to become morbidity-free and Clavien-Dindo ≥grade 3 complications.

RESULTS

Early elevated troponin (median 21 ng L^-1 [16-32]) occurred in 992 of 4335 (22.9%) patients undergoing elective noncardiac surgery (mean [standard deviation, sd] age, 65 [11] yr; 2385 [54.9%] male). Noncardiac morbidity was more frequent in 494/992 (49.8%) patients with early elevated troponin compared with 1127/3343 (33.7%) patients with hsTnT <99th centile (odds ratio [OR]=1.95; 95% confidence interval [CI], 1.69-2.25). Patients with early elevated troponin had a higher risk of proven/suspected infectious morbidity (OR=1.54; 95% CI, 1.24-1.91) and critical care utilisation (OR=2.05; 95% CI, 1.73-2.43). Clavien-Dindo ≥grade 3 complications occurred in 167/992 (16.8%) patients with early elevated troponin, compared with 319/3343 (9.5%) patients with hsTnT <99th centile (OR=1.78; 95% CI, 1.48-2.14). Absence of early elevated troponin was associated with morbidity-free recovery (OR=0.44; 95% CI, 0.39-0.51).

CONCLUSIONS

Early elevated troponin within 24 h of elective noncardiac surgery precedes the subsequent development of noncardiac organ dysfunction and may help stratify levels of postoperative care in real time.

Surveillance, Epidemiology, and Estimated Burden of Neonatal Abstinence Syndrome, Tennessee, 2013-2016

OBJECTIVES

Between 2003 and 2013, the rate of neonatal abstinence syndrome (NAS)-a postnatal drug withdrawal syndrome-in Tennessee increased approximately 10-fold. NAS surveillance is relatively new, and underestimation associated with surveillance has not been described. We compared data from the Tennessee NAS public health surveillance system (TNSS) with a second source of NAS data, hospital discharge data system (HDDS), and estimated the true number of infants with NAS using capture-recapture methods.

METHODS

We obtained NAS data on cases of NAS among Tennessee infants from TNSS and HDDS from January 1, 2013, through December 31, 2016. We matched cases of NAS identified in TNSS to cases identified in HDDS. We estimated the true number of infants with NAS by using the Lincoln-Peterson estimator capture-recapture methodology.

RESULTS

During the study period, 4070 infants with NAS were reported to TNSS, and 5321 infants with NAS were identified in HDDS; 2757 were in both data sets. Using capture-recapture methods, the total estimated number of infants with NAS during the study period was 7855 (annual mean = 1972; estimated range = 1531-2427), which was 93% more than in TNSS and 48% more than in HDDS. Drugs used for the medication-assisted treatment of substance use disorder were the most commonly reported substances associated with NAS (n = 2389, 59%).

CONCLUSIONS

TNSS underestimated the total burden of NAS based on the capture-recapture estimate. Case-based public health surveillance is important for monitoring the burden of and risk factors for NAS and helping guide public health interventions.

Genetic Susceptibility to Postdiarrheal Hemolytic-Uremic Syndrome After Shiga Toxin-Producing Escherichia coli Infection: A Centers for Disease Control and Prevention FoodNet Study

Background

Postdiarrheal hemolytic-uremic syndrome (D+HUS) following Shiga toxin-producing Escherichia coli (STEC) infection is a serious condition lacking specific treatment. Host immune dysregulation and genetic susceptibility to complement hyperactivation are implicated in non-STEC-related HUS. However, genetic susceptibility to D+HUS remains largely uncharacterized.

Methods

Patients with culture-confirmed STEC diarrhea, identified through the Centers for Disease Control and Prevention FoodNet surveillance system (2007-2012), were serotyped and classified by laboratory and/or clinical criteria as having suspected, probable, or confirmed D+HUS or as controls and underwent genotyping at 200 loci linked to nondiarrheal HUS or similar pathologies. Genetic associations with D+HUS were explored by multivariable regression, with adjustment for known risk factors.

Results

Of 641 enrollees with STEC O157:H7, 80 had suspected D+HUS (41 with probable and 32 with confirmed D+HUS). Twelve genes related to cytokine signaling, complement pathways, platelet function, pathogen recognition, iron transport, and endothelial function were associated with D+HUS in multivariable-adjusted analyses (P ≤ .05). Of 12 significant single-nucleotide polymorphisms (SNPs), 5 were associated with all levels of D+HUS (intergenic SNP rs10874639, TFRC rs3804141, EDN1 rs5370, GP1BA rs121908064, and B2M rs16966334), and 7 SNPs (6 non-complement related) were associated with confirmed D+HUS (all P < .05).

Conclusions

Polymorphisms in many non-complement-related genes may contribute to D+HUS susceptibility. These results require replication, but they suggest novel therapeutic targets in patients with D+HUS.

Educational Disabilities Among Children Born With Neonatal Abstinence Syndrome

BACKGROUND

Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome that can occur after intrauterine opioid exposure. Adverse neurobehavioral outcomes have been documented in infants with NAS; however, educational outcomes have not been thoroughly examined. We analyzed Tennessee data to understand the need for special educational services among infants who are born with NAS.

METHODS

By using Tennessee Medicaid and birth certificate data, infants who were born in Tennessee between 2008 and 2011 with a history of NAS were matched (1:3) to infants who were born during the same period without a history of NAS. Groups were matched on the basis of sex, race and/or ethnicity, age, birth region of residence, and Medicaid enrollment status. Data were linked to Tennessee Department of Education special education data during early childhood (3-8 years of age). Conditional multivariable logistic regression was used to assess associations between NAS and selected special education outcomes.

RESULTS

A total of 1815 children with a history of NAS and 5441 children without NAS were assessed. Children with NAS were significantly more likely to be referred for a disability evaluation (351 of 1815 [19.3%] vs 745 of 5441 [13.7%]; P < .0001), to meet criteria for a disability (284 of 1815 [15.6%] vs 634 of 5441 [11.7%]; P < .0001), and to require classroom therapies or services (278 of 1815 [15.3%] vs 620 of 5441 [11.4%]; P < .0001). These findings were sustained in a multivariable analysis, with multiple models controlling for maternal tobacco use, maternal education status, birth weight, gestational age, and/or NICU admission.

CONCLUSIONS

Results of this novel analysis linking health and education data revealed that children with a history of NAS were significantly more likely to have a subsequent educational disability.

MicroRNAs in Acute Kidney Injury

BACKGROUND

It is increasingly recognised that improved diagnosis, prognosis and treatment of acute kidney injury (AKI) requires an understanding of distinct underling cellular and molecular mechanisms (endotypes) that may distinguish overtly similar clinical AKI presentations. One important avenue of research is the post-transcriptional regulation of gene expression in response to kidney injury mediated by microRNAs.

SUMMARY

This mini-review summarises the use of microRNAs as diagnostic and prognostic biomarkers in AKI. The contribution of microRNAs to the pathophysiology of AKI will be highlighted along with the potential for therapeutic applications. Key Messages: While there is great potential for a better understanding of AKI, microRNAs form a complex regulatory network. Understanding the role and significance of microRNAs in the context of AKI and critical illness is a major endeavour in translational medicine, requiring the integration of clinical and experimental data.

Evaluation of a Spotted Fever Group Rickettsia Public Health Surveillance System in Tennessee

Spotted fever group (SFG) rickettsioses are endemic in Tennessee, with ∼2,500 cases reported during 2000-2012. Because of this substantial burden of disease, we performed a three-part evaluation of Tennessee's routine surveillance for SFG rickettsioses cases and deaths to assess the system's effectiveness. Tennessee Department of Health (TDH) SFG rickettsioses surveillance records were matched to three patient series: 1) patients with positive serologic specimens from a commercial reference laboratory during 2010-2011, 2) tertiary medical center patients with positive serologic tests during 2007-2013, and 3) patients identified from death certificates issued during 1995-2014 with SFG rickettsiosis-related causes of death. Chart reviews were performed and patients were classified according to the Council of State and Territorial Epidemiologists' case definition. Of 254 SFG Rickettsia-positive serologic specimens from the reference laboratory, 129 (51%) met the case definition for confirmed or probable cases of rickettsial disease after chart review. The sensitivity of the TDH surveillance system to detect cases was 45%. Of the 98 confirmed or probable cases identified from the medical center, the sensitivity of the TDH surveillance system to detect cases was 34%. Of 27 patients identified by death certificates, 12 (44%) were classified as confirmed or probable cases; four (33%) were reported to TDH, but none were correctly identified as deceased. Cases of SFG rickettsioses were underreported and fatalities not correctly identified. Efforts are needed to improve SFG rickettsiosis surveillance in Tennessee.

Water Quality Survey of Splash Pads After A Waterborne Salmonellosis Outbreak--Tennessee, 2014

Waterborne outbreaks of salmonellosis are uncommon. The Tennessee Department of Health investigated a salmonellosis outbreak of 10 cases with the only common risk factor being exposure to a single splash pad. Risks included water splashed in the face at the splash pad and no free residual chlorine in the water system. We surveyed water quality and patron behaviors at splash pads statewide. Of the 29 splash pads participating in the water quality survey, 24 (83%) used a recirculating water system. Of the 24, 5 (21%) water samples were tested by polymerase chain reaction and found to be positive for E. coli, Giardia, norovirus, or Salmonella. Among 95 patrons observed, we identified common high-risk behaviors of sitting on the fountain or spray head and putting mouth to water. Water venue regulations and improved education of patrons are important to aid prevention efforts.

Cryptosporidiosis Outbreak Associated With a Single Hotel

We investigated a gastrointestinal illness cluster among persons who attended a baseball tournament (>200 teams) during July 2015. We interviewed representatives of 19 teams; illness was reported among only the 9 (47%) teams that stayed at Hotel A (p < .01). We identified 55 primary cases. A case-control study demonstrated that pool exposure at Hotel A was significantly associated with illness (odds ratio: 7.3; 95% confidence interval: 3.6, 15.2). Eight out of nine (89%) stool specimens tested were positive for Cryptosporidium, with C. hominis IfA12G1 subtype identified in two specimens. The environmental health assessment detected a low free available chlorine level, and pool water tested positive for E. coli and total coliforms. A possible diarrheal contamination event, substantial hotel pool use, and use of cyanuric acid might have contributed to this outbreak and magnitude. Aquatic facilities practicing proper operation and maintenance (e.g., following the Centers for Disease Control and Prevention’s Model Aquatic Health Code) can protect the public’s health.

Novel Clinical and Pathologic Findings in a Heartland Virus-Associated Death

We describe an investigation into a Heartland virus (HRTV)-associated death in Tennessee with novel clinical and pathologic findings. HRTV can cause rapidly fatal, widely disseminated infection with multisystem organ failure in patients without substantial comorbidities. We identified viral antigen in multiple organ tissues where it was not detected previously.

Population survey of attitudes and beliefs regarding organic, genetically modified, and irradiated foods

BACKGROUND

Sales of organic foods are increasing due to public demand, while genetically modified (GM) and irradiated foods are often viewed with suspicion.

AIM

The aim of this research was to examine consumer attitudes toward organic, GM and irradiated foods to direct educational efforts regarding their consumption Methods: A telephone survey of 1838 residents in Tennessee, USA was conducted regarding organic, GM, and irradiated foods.

RESULTS

Approximately half of respondents (50.4%) purchased organic food during the previous 6 months ('consumers'). The most common beliefs about organic foods by consumers were higher cost (92%), and fewer pesticides (89%). Consumers were more likely than non-consumers to believe organic food tasted better (prevalence ratio 3.6; 95% confidence interval 3.02-4.23). A minority of respondents were familiar with GM foods (33%) and irradiated foods (22%).

CONCLUSION

Organic food consumption is common in Tennessee, but knowledge about GM and irradiated foods is less common. Consumer health education should emphasize the benefits of these food options, and the safety of GM and irradiated foods.

Implementation Of Prescription Drug Monitoring Programs Associated With Reductions In Opioid-Related Death Rates

Over the past two decades the number of opioid pain relievers sold in the United States rose dramatically. This rise in sales was accompanied by an increase in opioid-related overdose deaths. In response, forty-nine states (all but Missouri) created prescription drug monitoring programs to detect high-risk prescribing and patient behaviors. Our objectives were to determine whether the implementation or particular characteristics of the programs were effective in reducing opioid-related overdose deaths. In adjusted analyses we found that a state's implementation of a program was associated with an average reduction of 1.12 opioid-related overdose deaths per 100,000 population in the year after implementation. Additionally, states whose programs had robust characteristics-including monitoring greater numbers of drugs with abuse potential and updating their data at least weekly-had greater reductions in deaths, compared to states whose programs did not have these characteristics. We estimate that if Missouri adopted a prescription drug monitoring program and other states enhanced their programs with robust features, there would be more than 600 fewer overdose deaths nationwide in 2016, preventing approximately two deaths each day.

Notes from the Field: Intoxication and Deaths Associated with Ingestion of a Racing Fuel and Carbonated Soft Drink Mixture - Tennessee, January 2016

In January 2016, the Tennessee Poison Center and Tennessee Department of Health learned of the deaths of two adolescents, and the nonfatal intoxication of two other adolescents, after ingestion of a mixture of racing fuel (approximately 100% methanol) and a carbonated soft drink. The Tennessee Department of Health reviewed medical records and police reports to learn more about the racing fuel source, assess ongoing risk, and guide prevention efforts. These are the first reported deaths in the United States associated with ingestion of this racing fuel mixture.

Training in Infectious Disease Epidemiology through the Emerging Infections Program Sites

EIP sites contribute substantially to training current and future public health professionals.

One objective of the Emerging Infections Program (EIP) of the US Centers for Disease Control and Prevention is to provide training opportunities in infectious disease epidemiology. To determine the extent of training performed since the program's inception in 1995, we reviewed training efforts at the 10 EIP sites. By 2015, all sites hosted trainees (most were graduate public health students and physicians) who worked on a variety of infectious disease surveillance and epidemiologic projects. Trainee projects at all sites were used for graduate student theses or practicums. Numerous projects resulted in conference presentations and publications in peer-reviewed journals. Local public health and health care partners have also benefitted from EIP presentations and training. Consideration should be given to standardizing and documenting EIP training and to sharing useful training initiatives with other state and local health departments and academic institutions.

Enhancing Lyme Disease Surveillance by Using Administrative Claims Data, Tennessee, USA

Lyme disease is underreported in the United States. We used insurance administrative claims data to determine the value of such data in enhancing case ascertainment in Tennessee during January 2011–June 2013. Although we identified ≈20% more cases of Lyme disease (5/year), the method was resource intensive and not sustainable in this low-incidence state.

Foodborne Diseases Active Surveillance Network-2 Decades of Achievements, 1996-2015

FoodNet has provided a foundation for food safety policy and illness prevention since 1996.

The Foodborne Diseases Active Surveillance Network (FoodNet) provides a foundation for food safety policy and illness prevention in the United States. FoodNet conducts active, population-based surveillance at 10 US sites for laboratory-confirmed infections of 9 bacterial and parasitic pathogens transmitted commonly through food and for hemolytic uremic syndrome. Through FoodNet, state and federal scientists collaborate to monitor trends in enteric illnesses, identify their sources, and implement special studies. FoodNet’s major contributions include establishment of reliable, active population-based surveillance of enteric diseases; development and implementation of epidemiologic studies to determine risk and protective factors for sporadic enteric infections; population and laboratory surveys that describe the features of gastrointestinal illnesses, medical care–seeking behavior, frequency of eating various foods, and laboratory practices; and development of a surveillance and research platform that can be adapted to address emerging issues. The importance of FoodNet’s ongoing contributions probably will grow as clinical, laboratory, and informatics technologies continue changing rapidly.

An Economic Evaluation of PulseNet: A Network for Foodborne Disease Surveillance

The PulseNet surveillance system is a molecular subtyping network of public health and food regulatory agency laboratories designed to identify and facilitate investigation of foodborne illness outbreaks. This study estimates health and economic impacts associated with PulseNet. The staggered adoption of PulseNet across the states offers a natural experiment to evaluate its effectiveness, which is measured as reduction of reported illnesses due to improved information, enhanced industry accountability, and more-rapid recalls. Economic impacts attributable to PulseNet include medical costs and productivity losses averted due to reduced illness. Program costs are also reported. Better information and accountability from enhanced surveillance is associated with large reductions of reported illnesses. Data collected between 1994 and 2009 were assembled and analyzed between 2010 and 2015. Conservatively, accounting for underreporting and underdiagnosis, 266,522 illnesses from Salmonella, 9,489 illnesses from Escherichia coli (E. coli), and 56 illnesses due to Listeria monocytogenes are avoided annually. This reduces medical and productivity costs by $507 million. Additionally, direct effects from improved recalls reduce illnesses from E. coli by 2,819 and Salmonella by 16,994, leading to $37 million in costs averted. Annual costs to public health agencies are $7.3 million. The PulseNet system makes possible the identification of food safety risks by detecting widespread or non-focal outbreaks. This gives stakeholders information for informed decision making and provides a powerful incentive for industry. Furthermore, PulseNet enhances the focus of regulatory agencies and limits the impact of outbreaks. The health and economic benefits from PulseNet and the foodborne disease surveillance system are substantial.

Spatiotemporal Co-occurrence of Flanders and West Nile Viruses Within Culex Populations in Shelby County, Tennessee

West Nile virus (WNV) and Flanders virus (FLAV) can cocirculate in Culex mosquitoes in parts of North America. A large dataset of mosquito pools tested for WNV and FLAV was queried to understand the spatiotemporal relationship between these two viruses in Shelby County, TN. We found strong evidence of global clustering (i.e., spatial autocorrelation) and overlapping of local clustering (i.e., Hot Spots based on Getis Ord Gi*) of maximum likelihood estimates (MLE) of infection rates (IR) during 2008-2013. Temporally, FLAV emerges and peaks on average 10.2 wk prior to WNV based on IR. Higher levels of WNV IR were detected within 3,000 m of FLAV-positive pool buffers than outside these buffers.

Challenges to Arboviral Surveillance in Tennessee: Health-Care Providers' Attitudes and Behaviors

Surveillance of arboviruses depends on health-care providers' ability to diagnose and report human cases of disease. The purposes of this study were to assess Tennessee providers' 1) self-efficacy toward diagnosis and management, 2) clinical practices, and 3) variation in these measures by provider characteristics. A survey was e-mailed to 13,851 providers, of which 916 (7%) responded. Respondents diagnosed more arboviruses in the previous year than were recorded in surveillance records, an indication of underreporting. Respondents had low to moderate self-efficacy toward diagnosis and management of arboviruses. Although more than 70% (N = 589) used paired serology, only 46% (N = 396) asked patients to return for a convalescent specimen draw within the correct time frame. One of the most commonly reported barriers to testing was uncertainty about which tests to order. Providers working in family medicine and urgent care, nurse practitioners, and those at outpatient facilities had lower rates of high self-efficacy than their counterparts working in other settings and from other specialties. Clinical practices were influenced by specialty, designation, setting, and geography but not by years of experience. Education to improve arboviral surveillance in Tennessee is warranted. Topics could include proper diagnosis and management, appropriate testing and overcoming barriers to testing, and public health reporting.

Postdiarrheal hemolytic uremic syndrome in United States children: clinical spectrum and predictors of in-hospital death

OBJECTIVE

To assess the clinical spectrum of postdiarrheal hemolytic uremic syndrome (D(+)HUS) hospitalizations and sought predictors of in-hospital death to help identify children at risk of poor outcomes.

STUDY DESIGN

We assessed clinical variables collected through population-based surveillance of D(+)HUS in children <18 years old hospitalized in 10 states during 1997-2012 as predictors of in-hospital death by using tree modeling.

RESULTS

We identified 770 cases. Of children with information available, 56.5% (430 of 761) required dialysis, 92.6% (698 of 754) required a transfusion, and 2.9% (22 of 770) died; few had a persistent dialysis requirement (52 [7.3%] of 716) at discharge. The tree model partitioned children into 5 groups on the basis of 3 predictors (highest leukocyte count and lowest hematocrit value during the 7 days before to 3 days after the diagnosis of hemolytic uremic syndrome, and presence of respiratory tract infection [RTI] within 3 weeks before diagnosis). Patients with greater leukocyte or hematocrit values or a recent RTI had a greater probability of in-hospital death. The largest group identified (n = 533) had none of these factors and had the lowest odds of death. Many children with RTI had recent antibiotic treatment for nondiarrheal indications.

CONCLUSION

Most children with D(+)HUS have good hospitalization outcomes. Our findings support previous reports of increased leukocyte count and hematocrit as predictors of death. Recent RTI could be an additional predictor, or a marker of other factors such as antibiotic exposure, that may warrant further study.

Assessment of administrative claims data for public health reporting of Salmonella in Tennessee

In the USA, approximately 4% of the estimated 1 million Salmonella infections occurring annually are reported to public health. Administrative claims data from large health insurance companies capture disease-specific data which could potentially enhance public health surveillance. To determine the utility of medical claims data for public health reporting of Salmonella, we assessed medical claims data from BlueCross BlueShield of Tennessee (BCBST) members compared to Tennessee Department of Health (TDH) surveillance data. BCBST Salmonella cases diagnosed during 2007-2011 were matched to TDH Salmonella cases reported during the same time period. Matches and non-matches were validated using medical records. Of the 450 BCBST cases identified, 72% matched TDH cases. All culture-confirmed BCBST cases were reported to TDH. Non-matched BCBST cases included clinical diagnoses which were culture negative or not tested. Our findings indicate administrative claims data are not currently a viable mechanism for enhancing routine reporting of Salmonella infections.

High-risk use by patients prescribed opioids for pain and its role in overdose deaths

IMPORTANCE

From January 1, 2003, through December 31, 2010, drug overdose deaths in Tennessee increased from 422 to 1059 per year. More of these deaths involved prescription opioids than heroin and cocaine combined.

OBJECTIVE

To assess the contribution of certain opioid-prescribing patterns to the risk of overdose death.

DESIGN, SETTING, AND PARTICIPANTS

We performed a matched case-control study that analyzed opioid prescription data from the Tennessee Controlled Substances Monitoring Program (TNCSMP) from January 1, 2007, through December 31, 2011, to identify risk factors associated with opioid-related overdose deaths from January 1, 2009, through December 31, 2010. Case patients were ascertained from death certificate data. Age- and sex-matched controls were randomly selected from among live patients in the TNCSMP.

MAIN OUTCOMES AND MEASURES

We defined a high-risk number of prescribers or pharmacies as 4 or more per year and high-risk dosage as a daily mean of more than 100 morphine milligram equivalents (MMEs) per year. The main outcome was opioid-related overdose death.

RESULTS

From January 1, 2007, through December 31, 2011, one-third of the population of Tennessee filled an opioid prescription each year, and opioid prescription rates increased from 108.3 to 142.5 per 100 population per year. Among all patients in Tennessee prescribed opioids during 2011, 7.6% used more than 4 prescribers, 2.5% used more than 4 pharmacies, and 2.8% had a mean daily dosage greater than 100 MMEs. Increased risk of opioid-related overdose death was associated with 4 or more prescribers (adjusted odds ratio [aOR], 6.5; 95% CI, 5.1-8.5), 4 or more pharmacies (aOR, 6.0; 95% CI, 4.4-8.3), and more than 100 MMEs (aOR, 11.2; 95% CI, 8.3-15.1). Persons with 1 or more risk factor accounted for 55% of all overdose deaths.

CONCLUSIONS AND RELEVANCE

High-risk use of prescription opioids is frequent and increasing in Tennessee and is associated with increased overdose mortality. Use of prescription drug–monitoring program data to direct risk-reduction measures to the types of patients overrepresented among overdose deaths might reduce mortality associated with opioid abuse.

An outbreak of bed bug infestation in an office building

Since 2000, resurgence in bed bugs has occurred in the U.S. Reports of infestations of homes, hospitals, hotels, and offices have been described. On September 1, 2011, complaints of itching and bites among workers in an office were reported to the Tennessee Department of Health. A retrospective cohort study and environmental assessments were performed in response to the complaints. Canines certified to detect live bed bugs were used to inspect the office and arthropod samples were collected. Of 76 office workers, 61 (80%) were interviewed; 39 (64%) met the case definition. Pruritic maculopapular lesions were consistent with arthropod bites. One collected arthropod sample was identified as a bed bug by three entomologists. Exposures associated with symptoms included working in a cubicle in which a canine identified bed bugs (risk ratio [RR]: 1.8; 95% confidence interval [CI]: 1.3-3.6), and self-reported seasonal allergies (RR: 1.6, 95% CI: 1.0-2.4). Bed bugs represent a reemerging and challenging environmental problem with clinical, psychological, and financial impacts.

Notes from the field: Heartland virus disease - United States, 2012-2013

Heartland virus is a newly identified phlebovirus that was first isolated from two northwestern Missouri farmers hospitalized with fever, leukopenia, and thrombocytopenia in 2009. Based on the patients' clinical findings and their reported exposures, the virus was suspected to be transmitted by ticks. After this discovery, CDC worked with state and local partners to define the ecology and modes of transmission of Heartland virus, develop diagnostic assays, and identify additional cases to describe the epidemiology and clinical disease. From this work, it was learned that Heartland virus is found in the Lone Star tick (Amblyomma americanum). Six additional cases of Heartland virus disease were identified during 2012-2013; four of those patients were hospitalized, including one with comorbidities who died.

Contributing factors in restaurant-associated foodborne disease outbreaks, FoodNet sites, 2006 and 2007

An estimated 48 million cases of foodborne illness occur each year in the United States, resulting in approximately 128,000 hospitalizations and 3,000 deaths. Over half of all foodborne disease outbreaks reported to the Centers for Disease Control and Prevention are associated with eating in restaurants or delicatessens. We reviewed data from restaurant-associated foodborne disease outbreaks to better understand the factors that contribute to these outbreaks. Data on restaurant-associated foodborne disease outbreaks reported by sites participating in the Foodborne Diseases Active Surveillance Network (FoodNet) were analyzed to characterize contributing factors reported in foodborne disease outbreaks and the levels of evidence used to identify these factors. Of 457 foodborne disease outbreaks reported in 2006 and 2007 by FoodNet sites, 300 (66%) were restaurant associated, and of these 295 (98%) had at least one reported contributing factor. One to nine (with a median of two) contributing factors were reported per outbreak. Of the 257 outbreaks with a single etiology reported, contributing factors associated with food worker health and hygiene were reported for 165 outbreaks (64%), factors associated with food preparation practices within the establishment were reported for 88 outbreaks (34%), and factors associated with contamination introduced before reaching the restaurant were reported for 56 outbreaks (22%). The pronounced role of food workers in propagating outbreaks makes it clear that more work is needed to address prevention at the local level. Food workers should be instructed not to prepare food while ill to prevent the risk of transmitting pathogens.

Infections in pediatric postdiarrheal hemolytic uremic syndrome: factors associated with identifying shiga toxin-producing Escherichia coli

OBJECTIVE

To describe pathogens identified through routine clinical practice and factors associated with identifying Shiga toxin-producing Escherichia coli (STEC) infection in patients with postdiarrheal hemolytic uremic syndrome (DHUS).

DESIGN

Population-based active surveillance.

SETTING

Hospitals in the FoodNet surveillance areas from 2000 through 2010.

PARTICIPANTS

Children younger than 18 years with DHUS.

MAIN EXPOSURES

Testing for STEC and demographic and clinical characteristics.

MAIN OUTCOME MEASURES

Percentage of patients with evidence of infection with likely HUS-causing agents and associations between exposures and evidence of STEC infection.

RESULTS

Of 617 patients, 436 (70.7%) had evidence of infection with likely HUS-causing agents: STEC O157 (401 patients), non-O157 STEC (21 patients), O157 and non-O157 STEC (1 patient), Streptococcus pneumoniae (11 patients), and other pathogens (2 patients). Among patients without microbiological evidence of STEC, 76.9% of those tested had serologic evidence of STEC infection. Children more likely to have evidence of STEC infections included those patients tested for STEC less than 4 days after diarrhea onset, 12 months or older (71.6% vs 27.8% if <12 months of age), with infections as part of an outbreak (94.3% vs 67.3%), with bloody diarrhea (77.2% vs 40.4%), with onset during June through September (76.9% vs 60.1%), with a leukocyte count greater than 18 000/μL (to convert to ×10(9)/L, multiply by 0.001) (75.7% vs 65.3%), or with only moderate anemia (hemoglobin 7.0 g/dL [to convert to grams per liter, multiply by 10] or hematocrit greater than 20% [to convert to a proportion of 1, multiply by 0.01]) (75.1% vs 66.3%). However, many of these associations were weaker among children with thorough STEC testing.

CONCLUSIONS

Early stool collection for E coli O157 culture and Shiga toxin testing of all children with possible bacterial enteric infection will increase detection of STEC strains causing HUS. In the absence of microbiological evidence of STEC, serologic testing should be performed.

Thrombotic thrombocytopenic purpura (TTP)-like illness associated with intravenous Opana ER abuse--Tennessee, 2012

On August 13, 2012, a nephrologist reported to the Tennessee Department of Health (TDH) three cases of unexplained thrombotic thrombocytopenic purpura (TTP), a rare but serious blood disorder characterized by microangiopathic hemolytic anemia and thrombocytopenia. The annual incidence is approximately 1 per 100,000 population. Known risk factors for TTP include infection with Shiga toxin-producing Escherichia coli (STEC) and the use of drugs, including platelet aggregation inhibitors, quinine, and cocaine. The three patients were intravenous (IV) drug users who resided in a rural county in northeast Tennessee. To identify other cases of TTP-like illness that might be associated with injection-drug use, TDH conducted a statewide investigation. By the end of October, a total of 15 such cases had been reported; none were fatal. A case-control study was conducted, and investigators determined that the cases of TTP-like illness were associated with dissolving and injecting tablets of Opana ER (Endo Pharmaceuticals), a recently reformulated extended-release form of oxymorphone (an opioid pain reliever) intended for oral administration. Fourteen of the 15 patients reported injecting reformulated Opana ER. Seven of the 15 were treated for sepsis in addition to TTP-like illness. Twelve patients reported chronic hepatitis C or had positive test results for anti-HCV antibody. Health-care providers who prescribe Opana ER and pharmacists who dispense it should inform patients of the risks from the drug when used other than as prescribed. Health-care providers should ask patients with TTP-like illness of unknown etiology about any IV drug abuse. Suspected cases can be reported to public health officials.

Variability among states in investigating foodborne disease outbreaks

Over 1,100 foodborne disease outbreaks cause over 23,000 illnesses in the United States annually, but the rates of outbreaks reported and successful investigation vary dramatically among states. We used data from the Centers for Disease Control and Prevention's outbreak reporting database, Association of Public Health Laboratories' PulseNet laboratory subtyping network survey and Salmonella laboratory survey, national public health surveillance data, and national surveys to examine potential causes of this variability. The mean rate of reporting of Salmonella outbreaks was higher in states requiring submission of all isolates to the state public health laboratory, compared to those that do not (5.9 vs. 4.1 per 10 million population, p=0.0062). Rates of overall outbreak reporting or successful identification of an etiology or food vehicle did not correlate at the state level with population, rates of sporadic disease reporting, health department organizational structure, or self-reported laboratory or epidemiologic capacity. Foodborne disease outbreak surveillance systems are complex, and improving them will require a multi-faceted approach to identifying and overcoming barriers.

Fungal infections associated with contaminated methylprednisolone in Tennessee

BACKGROUND

We investigated an outbreak of fungal infections of the central nervous system that occurred among patients who received epidural or paraspinal glucocorticoid injections of preservative-free methylprednisolone acetate prepared by a single compounding pharmacy.

METHODS

Case patients were defined as patients with fungal meningitis, posterior circulation stroke, spinal osteomyelitis, or epidural abscess that developed after epidural or paraspinal glucocorticoid injections. Clinical and procedure data were abstracted. A cohort analysis was performed.

RESULTS

The median age of the 66 case patients was 69 years (range, 23 to 91). The median time from the last epidural glucocorticoid injection to symptom onset was 18 days (range, 0 to 56). Patients presented with meningitis alone (73%), the cauda equina syndrome or focal infection (15%), or posterior circulation stroke with or without meningitis (12%). Symptoms and signs included headache (in 73% of the patients), new or worsening back pain (in 50%), neurologic symptoms (in 48%), nausea (in 39%), and stiff neck (in 29%). The median cerebrospinal fluid white-cell count on the first lumbar puncture among patients who presented with meningitis, with or without stroke or focal infection, was 648 per cubic millimeter (range, 6 to 10,140), with 78% granulocytes (range, 0 to 97); the protein level was 114 mg per deciliter (range, 29 to 440); and the glucose concentration was 44 mg per deciliter (range, 12 to 121) (2.5 mmol per liter [range, 0.7 to 6.7]). A total of 22 patients had laboratory confirmation of Exserohilum rostratum infection (21 patients) or Aspergillus fumigatus infection (1 patient). The risk of infection increased with exposure to lot 06292012@26, older vials, higher doses, multiple procedures, and translaminar approach to epidural glucocorticoid injection. Voriconazole was used to treat 61 patients (92%); 35 patients (53%) were also treated with liposomal amphotericin B. Eight patients (12%) died, seven of whom had stroke.

CONCLUSIONS

We describe an outbreak of fungal meningitis after epidural or paraspinal glucocorticoid injection with methylprednisolone from a single compounding pharmacy. Rapid recognition of illness and prompt initiation of therapy are important to prevent complications. (Funded by the Tennessee Department of Health and the Centers for Disease Control and Prevention.).

Invasive listeriosis in the Foodborne Diseases Active Surveillance Network (FoodNet), 2004-2009: further targeted prevention needed for higher-risk groups

BACKGROUND

Listeriosis can cause severe disease, especially in fetuses, neonates, older adults, and persons with certain immunocompromising and chronic conditions. We summarize US population-based surveillance data for invasive listeriosis from 2004 through 2009.

METHODS

We analyzed Foodborne Diseases Active Surveillance Network (FoodNet) data for patients with Listeria monocytogenes isolated from normally sterile sites. We describe the epidemiology of listeriosis, estimate overall and specific incidence rates, and compare pregnancy-associated and nonpregnancy-associated listeriosis by age and ethnicity.

RESULTS

A total of 762 listeriosis cases were identified during the 6-year reporting period, including 126 pregnancy-associated cases (17%), 234 nonpregnancy-associated cases(31%) in patients aged <65 years, and 400 nonpregnancy-associated cases (53%) in patients aged ≥ 65 years. Eighteen percent of all cases were fatal. Meningitis was diagnosed in 44% of neonates. For 2004-2009, the overall annual incidence of listeriosis varied from 0.25 to 0.32 cases per 100,000 population. Among Hispanic women, the crude incidence of pregnancy-associated listeriosis increased from 5.09 to 12.37 cases per 100,000 for the periods of 2004-2006 and 2007-2009, respectively; among non-Hispanic women, pregnancy-associated listeriosis increased from 1.74 to 2.80 cases per 100,000 for the same periods. Incidence rates of nonpregnancy-associated listeriosis in patients aged ≥ 65 years were 4-5 times greater than overall rates annually.

CONCLUSIONS

Overall listeriosis incidence did not change significantly from 2004 through 2009. Further targeted prevention is needed, including food safety education and messaging (eg, avoiding Mexican-style cheese during pregnancy). Effective prevention among pregnant women, especially Hispanics, and older adults would substantially affect overall rates.

Characteristics of foodborne disease outbreak investigations conducted by Foodborne Diseases Active Surveillance Network (FoodNet) sites, 2003-2008

BACKGROUND

A mean of ≥ 1000 foodborne disease outbreaks (FBDOs) causing ≥ 20,000 illnesses are reported to the Centers for Disease Control and Prevention (CDC) annually. We evaluated characteristics of successful outbreak investigations (ie, those that identified an etiologic agent or food vehicle) in the Foodborne Diseases Active Surveillance Network (FoodNet).

METHODS

FBDOs were defined as the occurrence of ≥ 2 cases of a similar illness resulting from ingestion of a common food. FBDOs reported to CDC Foodborne Disease Outbreak Surveillance System during 2003-2008 with FoodNet supplemental data available were included in the analyses.

RESULTS

Data regarding 1200 FBDOs were available. An etiologic agent was confirmed in 715 (60%); a food vehicle was identified in 387 (32%). At least 4 fecal specimens were collected in 425 of 639 outbreaks (67%) with a confirmed etiologic agent and 48 of 232 (21%) without a confirmed etiologic agent (odds ratio [OR], 7.6; 95% confidence interval [CI], 5.3-10.9). A food vehicle was identified in 314 (47%) of 671 outbreaks investigated using a case-control or cohort study, compared with only 73 (14%) of 529 outbreaks investigated by using other methods (OR, 5.5; 95% CI, 4.1-7.3). At least 1 barrier affecting the success of the investigation was reported for 655 outbreaks, including too few patients (n = 172; 26%), too few stool specimens (n = 167; 25%), and too few control subjects (n = 152; 23%).

CONCLUSIONS

Etiologic agent and vehicle are frequently undetermined in FBDOs. Greater emphasis on fecal specimen collection and overcoming barriers to pursuing analytic epidemiologic studies can improve ascertainment of these factors.

Changing epidemiology of Yersinia enterocolitica infections: markedly decreased rates in young black children, Foodborne Diseases Active Surveillance Network (FoodNet), 1996-2009

BACKGROUND

Yersinia enterocolitica causes an estimated 116,716 illnesses annually in the United States. Black children have historically had the highest rates of infection, with incidence peaking in the winter.

METHODS

The Foodborne Diseases Active Surveillance Network (FoodNet) conducts active surveillance for laboratory-confirmed Y. enterocolitica infections, defined as the isolation of Y. enterocolitica or unspeciated Yersinia from a human clinical specimen. We calculated the average annual crude incidence rate per 100,000 persons from 1996 through 2009 and described rates by age, race, and geographic site. To account for changes in the FoodNet catchment area, we used a negative binomial model to estimate statistical changes in incidence using the average annual incidence in 1996-1998 as the baseline.

RESULTS

From 1996 through 2009, 2085 Y. enterocolitica infections were reported to FoodNet. The average annual crude incidence was 0.5 per 100,000 persons and was highest in blacks (0.9 per 100,000 persons). Over time, the rate in blacks declined from 3.9 to 0.4 per 100,000 persons. Declines among other racial groups were not as pronounced. The largest decline occurred in black children <5 years old (from 41.5 per 100,000 persons in 1996 to 3.5 per 100,000 persons in 2009). From 2007 through 2009, the highest rate of infection was in Asian children (5.1 per 100,000 persons). Compared with 1996-1998, the incidence in 2009 was 66% (95% confidence interval, 51%-77%) lower among children <5 years old.

CONCLUSIONS

Y. enterocolitica infections in FoodNet sites have significantly declined since 1996. These declines were greatest in young black children, the group that initially had the highest incidence, possibly as the result of educational efforts in Georgia.

Nonculture diagnostic tests for enteric diseases

The diagnosis of acute gastroenteritis (AGE) has traditionally been based on culture results of feces from patients with diarrhea. Virtually everything we know about disease and the epidemiology of enteric pathogens, such as Salmonella spp., Shiga toxin-producing Escherichia coli (STEC), e.g., O157, and Campylobacter spp., has been generated from the study of patients with culture-confirmed infections. However, this pattern may be changing because AGE diagnostics are moving away from culture toward rapid nonculture methods. These infections are mainly foodborne and therefore preventable, and it is of paramount importance that public health surveillance for these infections is consistent and reliable.