Update on the Epidemiology of coccidioidomycosis in the United States.

The incidence of reported coccidioidomycosis in the past two decades has increased greatly; monitoring its changing epidemiology is essential for understanding its burden on patients and the healthcare system and for identifying opportunities for prevention and education. We provide an update on recent coccidioidomycosis trends and public health efforts nationally and in Arizona, California, and Washington State. In Arizona, enhanced surveillance shows that coccidioidomycosis continues to be associated with substantial morbidity. California reported its highest yearly number of cases ever in 2016 and has implemented interventions to reduce coccidioidomycosis in the prison population by excluding certain inmates from residing in prisons in high-risk areas. Coccidioidomycosis is emerging in Washington State, where phylogenetic analyses confirm the existence of a unique Coccidioides clade. Additional studies of the molecular epidemiology of Coccidioides will improve understanding its expanding endemic range. Ongoing public health collaborations and future research priorities are focused on characterizing geographic risk, particularly in the context of environmental change; identifying further risk reduction strategies for high-risk groups; and improving reporting of cases to public health agencies.

Evaluation of Routine HIV Opt-Out Screening and Continuum of Care Services Following Entry into Eight Prison Reception Centers--California, 2012.

Early diagnosis of human immunodeficiency virus (HIV) infection and initiation of antiretroviral treatment (ART) improves health outcomes and prevents HIV transmission. Before 2010, HIV testing was available to inmates in the California state prison system upon request. In 2010, the California Correctional Health Care Services (CCHCS) integrated HIV opt-out screening into the health assessment for inmates entering California state prisons. Under this system, a medical care provider informs the inmate that an HIV test is routinely done, along with screening for sexually transmitted, communicable, and vaccine-preventable diseases, unless the inmate specifically declines the test. During 2012-2013, CCHCS, the California Department of Public Health, and CDC evaluated HIV screening, rates of new diagnoses, linkage to and retention in care, ART response, and post-release linkage to care among California prison inmates. All prison inmates are processed through one of eight specialized reception center facilities, where they undergo a comprehensive evaluation of their medical needs, mental health, and custody requirements for placement in one of 35 state prisons. Among 17,436 inmates who entered a reception center during April-September 2012, 77% were screened for HIV infection; 135 (1%) tested positive, including 10 (0.1%) with newly diagnosed infections. Among the 135 HIV-positive patient-inmates, 134 (99%) were linked to care within 90 days of diagnosis, including 122 (91%) who initiated ART. Among 83 who initiated ART and remained incarcerated through July 2013, 81 (98%) continued ART; 71 (88%) achieved viral suppression (<200 HIV RNA copies/mL). Thirty-nine patient-inmates were released on ART; 12 of 14 who were linked to care within 30 days of release were virally suppressed at that time. Only one of nine persons with a viral load test conducted between 91 days and 1 year post-release had viral suppression. Although high rates of viral suppression were achieved in prison, continuity of care in the community remains a challenge. An infrastructure for post-release linkage to care is needed to help ensure sustained HIV disease control.

Rates and risk factors for Coccidioidomycosis among prison inmates, California, USA, 2011.

In California, coccidioidomycosis is a disease acquired by inhaling spores of Coccidioides immitis, a fungus found in certain arid regions, including the San Joaquin Valley, California, USA, where 8 state prisons are located. During 2011, we reviewed coccidioidomycosis rates at 2 of the prisons that consistently report >80% of California's inmate cases and determined inmate risk factors for primary, severe (defined as pulmonary coccidioidomycosis requiring >10 hospital days), and disseminated coccidioidomycosis (defined by hospital discharge International Classification of Disease, Ninth Revision code). Inmates of African American ethnicity who were >40 years of age were at significantly higher risk for primary coccidioidomycosis than their white counterparts (odds ratio = 2.0, 95% CI 1.5-2.8). Diabetes was a risk factor for severe pulmonary coccidioidomycosis, and black race a risk factor for disseminated disease. These findings contributed to a court decision mandating exclusion of black inmates and inmates with diabetes from the 2 California prisons with the highest rates of coccidioidomycosis.

California's Prisoner Protections for Family and Community Health Act : Implementing a Mandated Condom Access Program in State Prisons, 2015-2016.

In 2014, California passed Assembly Bill 966, which required condom access for persons incarcerated in all 35 California state prisons (33 men's and 2 women's prisons). The California Correctional Health Care Services and the Sexually Transmitted Disease Control Branch and the Office of AIDS of the California Department of Public Health collaborated in a prison administration-led multidisciplinary implementation workgroup. Our workgroup, representing public health, correctional health, legal and legislative affairs, labor relations, and prison staff members, participated in 4 planning meetings during May-September 2015. We surveyed prison staff members and incarcerated men to identify and address potential challenges; conceptualized a tamper-resistant condom dispenser; developed educational materials, frequently asked questions for staff members, and fact sheets for the public; and conducted forums for custody and medical staff members at each prison. Key lessons learned included the need for high-level custody support, engagement of labor unions early in the decision-making process, and flexibility within defined parameters for sites to determine best practices given their unique institutional population, culture, and physical layout. Condom access was initiated at 4 prisons in July 2015 and expanded incrementally to the remaining 29 men's prisons through July 2016. A total of 243 563 condoms were accessed in the men's prisons, for an average of 354 condoms per 1000 population per month. The start-up dispenser cost was $69 825 (735 dispensers at $95 each). We estimated an annual condom cost of $0.60 per person. Although staff members and incarcerated men expressed concern that this legislation would condone sex and provide repositories for contraband, no serious adverse incidents involving condoms were reported. California demonstrated that condom access is a safe, low-cost intervention with high uptake for a large correctional system and provided a replicable implementation model for other states. Prison condom programs have the potential to decrease transmission of sexually transmitted infections (STIs) among incarcerated persons and their communities, which are often disproportionately affected by STIs, HIV, and other chronic diseases.

Risk Stratification With Coccidioidal Skin Test to Prevent Valley Fever Among Inmates, California, 2015.

Two California state prisons (A and B) have very high rates of coccidioidomycosis (Valley Fever). The prison health care service sought to improve their prevention strategy by risk stratification with a newly available spherulin-based Coccidioides delayed-type hypersensitivity test. Of the 36,789 voluntarily screened inmates, 4.7% experienced adverse reactions. A positive test (8.6% of those tested) was independently associated with (1) incarceration at prisons A and B, (2) admission to prison from a Coccidioides-endemic county, (3) length of stay at prisons A and B, and (4) increasing age. These findings suggest that the test is safe and performing well at risk stratification; the prison system now restricts inmates with negative tests from prisons A and B. This novel use of the test might benefit other coccidioidomycosis prevention programs.

Tuberculosis outbreak in a housing unit for human immunodeficiency virus-infected patients in a correctional facility: transmission risk factors and effective outbreak control.

In 1995, an outbreak of tuberculosis (TB) occurred among residents of a correctional-facility housing unit for inmates infected with human immunodeficiency virus (HIV). We isolated and treated patients who were suspected to have TB. To determine risk factors for in-prison transmission of TB, we conducted a case-control study to compare inmate case patients infected with a distinct outbreak strain of TB with control subjects who resided in the HIV unit. We identified 15 case patients during a 4-month period. Among inmates with a CD4 count of <100 cells/mm(3), case patients were more likely than control subjects to spend >/=20 hours per week in a communal day room (odds ratio, 42; P=.002) and were less likely to have a television in their single-person room (odds ratio, 0.10; P=.003). The communal day room was a likely site of transmission. Successful collaboration between the correctional system and public health departments halted the outbreak.

Dramatic decrease in the incidence of Salmonella serotype Enteritidis infections in 5 FoodNet sites: 1996-1999.

Salmonella serotype Enteritidis (SE) emerged as the most common Salmonella serotype among infected persons in the United States during the 1980s and 1990s, with infections reaching a peak in 1995. During the past decade, farm-to-table control measures have been instituted in the United States, particularly in regions with the highest incidence of SE infection. We report trends in the incidence of SE in the 5 original surveillance areas of the Foodborne Diseases Active Surveillance Network during 1996-1999: Minnesota, Oregon, and selected counties in California, Connecticut, and Georgia. Overall, the incidence of SE decreased 46% from 1996 to 1999. The greatest decrease was in Connecticut (71%), followed by northern California (50%), Minnesota (46%), and Oregon (13%). Although SE infection remains an important public health concern, there has been a remarkable decrease in its incidence. This decrease may be a result of targeted interventions, including on-farm control measures, refrigeration, and education efforts.

Chicken consumption is a newly identified risk factor for sporadic Salmonella enterica serotype Enteritidis infections in the United States: a case-control study in FoodNet sites.

The sources of sporadic Salmonella enterica serotype Enteritidis (SE) infections in the United States are unclear. To determine risk factors for sporadic SE infection, we conducted a population-based case-control study in 5 Foodborne Disease Active Surveillance Network surveillance areas. During the 12-month study, 396 cases of SE infection were ascertained. Among the 182 case patients and 345 controls, SE infection was univariately associated with international travel (matched odds ratio [MOR], 61; 95% confidence interval [CI], 8-447), eating undercooked eggs (MOR, 2.2; 95%CI, 1-5), and eating chicken prepared outside of the home (MOR, 2.2; 95% CI, 1.3-3.4). Multivariate analysis revealed that eating chicken outside of the home remained the only significant risk factor for illness (MOR, 2.0; 95% CI, 1.1-3.6). Chicken consumption has not previously been identified in the United States as a risk factor for SE infection. Measures to prevent SE infections include educating consumers and food handlers about food safety and interventions to decrease contamination of eggs and poultry.

A multistate outbreak of Escherichia coli O157:H7 infection linked to consumption of beef tacos at a fast-food restaurant chain.

We investigated a multistate outbreak of Escherichia coli O157:H7 infections. Isolates from 13 case patients from California, Nevada, and Arizona were matched by pulsed-field gel electrophoresis subtyping. Five case patients (38%) were hospitalized, and 3 (23%) developed hemolytic uremic syndrome; none died. The median age was 12 years (range, 2-75 years), and 10 (77%) were female. Case-control studies found an association between illness and eating beef tacos at a national Mexican-style fast-food restaurant chain (88% of cases versus 38% of controls; matched OR, undefined; 95% confidence interval, 1.49 to infinity; P=.009). A trace-back investigation implicated an upstream supplier of beef, but a farm investigation was not possible. This outbreak illustrates the value of employing hospital laboratory-based surveillance to detect local clusters of infections and the effectiveness of using molecular subtyping to identify geographically dispersed outbreaks. The outbreak investigation also highlights the need for a more efficient tracking system for food products.

Prenatal screening for infectious diseases and opportunities for prevention.

OBJECTIVE: To characterize adherence with recommendations for prenatal infectious disease screening and missed opportunities for prevention of congenital and perinatal infections. METHODS: Demographic, prenatal, and peripartum information was abstracted from labor and delivery records of a random, stratified sample of live births in 1998 and 1999 to residents of eight active surveillance areas. Adherence with prenatal screening recommendations was evaluated for hepatitis B, syphilis, rubella, human immunodeficiency virus (HIV), and group B streptococcus (GBS). Characteristics of missed opportunities for disease prevention were assessed by univariate and multivariable analysis to account for survey design. RESULTS: Prenatal screening rates for hepatitis B surface antigen (HBsAg) (96.5%), syphilis (98.2%), and rubella (97.3%) were high. Areas of excess syphilis morbidity did not adhere to recommendations for third-trimester retesting. Testing rates for HIV (57.2%) and GBS (52.0%) were lower and had wide geographic variation. Postpartum rubella vaccination was documented for only 65.7% of rubella-susceptible women. Inadequate prenatal care was the single strongest predictor of missed opportunities for prenatal testing (relative risk 14.6; 95% confidence interval 6.3, 33.7). Blacks were less likely than whites to receive adequate prenatal care and prenatal tests, more likely to test positive for HBsAg and syphilis, and less likely to receive recommended prevention interventions such as postpartum rubella vaccination for susceptible women. CONCLUSIONS: Adherence to both long-standing and more recent recommendations for congenital and perinatal disease prevention can be improved, thus perhaps reducing racial disparities in the use of prenatal screening and appropriate prevention interventions.

A cluster of Escherichia coli O157: nonmotile infections associated with recreational exposure to lake water.

OBJECTIVES: To identify cases and determine risk factors for an outbreak of Escherichia coli (E. coli) O157: nonmotile (NM) infections in children attending a summer day care program in California. METHODS: The authors conducted a retrospective cohort study; the cohort comprised first and second graders who attended the day care program during the last week in August 1999. Shiga toxin testing and molecular subtyping using pulsed-field gel electrophoresis were performed on isolates. Lake water, lake bottom sediment samples, and waterfowl feces from the lake environs were cultured for E. coli O157. RESULTS: Three cases of Shiga toxin-producing E. coli O157: NM infections with matching pulsed-field gel electrophoresis patterns and four probable cases were found. Children who swallowed more than a mouthful of water had a higher attack rate than those who swallowed less than a mouthful or none at all (43% vs. 10%, relative risk = 4.43, 95% confidence interval 1.12, 17.50). CONCLUSIONS: E. coli O157: NM infections were associated with swallowing water from a freshwater lake. Potential sources of contamination include feces from humans, cattle, or deer. This outbreak illustrates the value in screening patients with diarrhea for E. coli O157, submitting isolates to public health laboratories, and using molecular techniques to identify related cases. Outbreaks associated with contaminated freshwater could be averted by prevention and early detection of contamination.

Risk, Feasibility, and Cost Evaluation of a Prisoner Condom Access Pilot Program in One California State Prison.

This study evaluated the safety and security impact, feasibility, and cost of a program to provide condoms to inmates. A 1-year pilot study of wall-mounted condom dispensing machines in one California state prison compared pre- and post-intervention rates of penal code violations related to sexual misconduct, contraband, controlled substances, and violence. The rates of penal code violations were unchanged or decreased compared to the pre-pilot year. Discreetly located condom dispensers were vandalized less frequently than those in plain view (p < .05). Distributing condoms using the pilot model would cost less than $2 per inmate annually. Results suggest that the use of discreetly located dispensing machines is an acceptable, feasible, low-cost option to prevent the transmission of sexually transmitted diseases and poses no safety or security risk in a typical medium-security prison setting.

Syphilis outbreak at a California men's prison, 2007-2008: propagation by lapses in clinical management, case management, and public health surveillance.

This field report describes an investigation to identify cases to control a syphilis outbreak in a prison and determine whether clinical, case management, and surveillance practices influenced the outbreak occurrence, detection, or management. Key performance measures were assessed to evaluate timeliness and quality of clinical and case management activities and surveillance practices. Thirty cases were found. Prior to the investigation, median times for clinical and reporting/surveillance measures were 15 days from primary and secondary (P&S) symptom onset to exam, 7 days from P&S exam to treatment, and 63 days from serologic test to the state's receipt of case. After the investigation, these measures improved to 8, 4.5, and 28 days, respectively. Lack of adherence to surveillance and clinical management protocols likely contributed to this outbreak, which was curtailed by aggressive control measures.

Population-based trends in pediatric hemolytic uremic syndrome in California, 1994-1999: substantial underreporting and public health implications.

This paper describes the epidemiology of childhood hemolytic uremic syndrome (HUS) in California, for which hospitalization data were used, and the proportion of cases reported to public health authorities. HUS discharge data for children < or =17 years of age were extracted from the population-based California Patient Discharge Data Set for 1994-1999 and were linked electronically with HUS reports to public health authorities. Incidence rates per 100,000 children were calculated. The authors identified 585 HUS hospitalizations; 369 were incident cases. The average HUS incidence rate was 0.67 (95% confidence interval: 0.61, 0.74); rates rose modestly from 1994 (0.59, 95% confidence interval: 0.44, 0.78) to 1997 (0.80, 95% confidence interval: 0.63, 10.0) and decreased modestly thereafter (0.59, 95% confidence interval: 0.45, 0.77). Rates were highest for northern California children < or =5 years of age (1.85, 95% confidence interval: 1.55, 2.19). The hospital case-fatality rate was 2.7% (95% confidence interval: 1.1, 4.4); the median charge was $39,500 per child. Only 43.9% of HUS cases in the California Patient Discharge Data Set were reported to public health authorities. Despite heightened efforts to control Shiga toxin-producing Escherichia coli exposures (the predominant cause of childhood HUS in the United States), HUS incidence rates remained relatively stable in California. Reporting HUS cases to public health authorities is important for disease control.

Alfalfa seed decontamination in a Salmonella outbreak.

Based on in vitro data, the U.S. Food and Drug Administration recommends chemical disinfection of raw sprout seeds to reduce enteric pathogens contaminating the seed coats. However, little is known about the effectiveness of decontamination at preventing human disease. In 1999, an outbreak of Salmonella enterica serotype Mbandaka occurred in Oregon, Washington, Idaho, and California. Based on epidemiologic and pulsed-field gel electrophoresis evidence from 87 confirmed cases, the outbreak was linked to contaminated alfalfa seeds grown in California's Imperial Valley. Trace-back and trace-forward investigations identified a single lot of seeds used by five sprout growers during the outbreak period. Cases of salmonellosis were linked with two sprout growers who had not employed chemical disinfection; no cases were linked to three sprout growers who used disinfection. This natural experiment provides empiric evidence that chemical disinfection can reduce the human risk for disease posed by contaminated seed sprouts.