Household Transmission of Mpox to Children and Adolescents, California, 2022.

BACKGROUND: In California, the 2022 mpox outbreak cumulated 5572 cases, 20% of US cases, as of November 28, 2022; 0.3% of cases were among children <16 years old. The secondary attack rate (SAR) for children sharing households with infected adults is unknown. METHODS: A line list of pediatric mpox household contacts aged <16 years reported through August 31, 2022 was created. It included demographic and clinical information on the contacts. Pediatric contact lists were crossmatched with the state vaccination database to identify those who received postexposure prophylaxis (PEP) with the JYNNEOS vaccine. RESULTS: We identified 129 pediatric household contacts with median age of 7 years (range, 0-15 years). Among 18 symptomatic contacts, 12 (66.7%) underwent mpox testing; 5 (41.2%) were confirmed cases, 6 (50%) were negative, and 1 (0.8%) had an indeterminate result. Six symptomatic children were not tested for mpox (33.3%). Overall, 6 infected contacts were identified, resulting in a SAR of 4.7% (6 of 129). The majority of pediatric household contacts and 4 of 6 infected children identified as Hispanic/Latino. Only 18 children (14%) reported receiving PEP. CONCLUSIONS: The SAR was overall low among pediatric household contacts; none had severe disease. This may be underestimated given low testing rates.

Subacute Sclerosing Panencephalitis: The Devastating Measles Complication That Might Be More Common Than Previously Estimated.

BACKGROUND: Subacute sclerosing panencephalitis (SSPE) is a fatal complication of measles. We reviewed California cases from 1998-2015 to understand risk factors for SPPE and estimate incidence. METHODS: SSPE cases had clinically compatible symptoms and measles antibody detection in cerebrospinal fluid (CSF) or medical record documentation of SSPE. Cases were identified though a state death certificate search, Centers for Disease Control and Prevention reports, or investigations for undiagnosed neurologic disease. Measles detection in CSF was performed by serology at the California Department of Public Health or at clinical laboratories. RESULTS: Seventeen SSPE cases were identified. Males outnumbered females 2.4:1. Twelve (71%) cases had a history of measles-like illness; all 12 had illness prior to 15 months of age. Eight (67%) children were exposed to measles in California. SSPE was diagnosed at a median age of 12 years (3-35 years), with a latency period of 9.5 years (2.5-34 years). Among measles cases reported to CDPH during 1988-1991, the incidence of SSPE was 1:1367 for children <5 years, and 1:609 for children <12 months at time of measles disease. CONCLUSIONS: SSPE cases in California occurred at a high rate among unvaccinated children, particularly those infected during infancy. Protection of unvaccinated infants requires avoidance of travel to endemic areas, or early vaccination prior to travel at age 6-11 months. Clinicians should be aware of SSPE in patients with compatible symptoms, even in older patients with no specific history of measles infection. SSPE demonstrates the high human cost of "natural" measles immunity.

Notes from the Field: Outbreak of Serogroup B Meningococcal Disease at a University - California, 2016.

On January 31, 2016, the Santa Clara County Public Health Department (SCCPHD) was notified of a suspected case of meningococcal disease in a university undergraduate student. By February 2, two additional suspected cases had been reported in undergraduate students living on the same campus. The index patient (patient A) required intensive care, whereas patients B and C had milder illness; there were no deaths. All three patients were part of overlapping social networks and had attended the same events during the week before the onset of patient A's symptoms, but whether they had direct contact with one another could not be verified. Serogroup B Neisseria meningitidis was identified in cerebrospinal fluid and blood from patient A and in blood from patient B. Serogroup B has been responsible for all U.S. college outbreaks of meningococcal disease since 2011 (1). Laboratory results for patient C were inconclusive.

Can you really swim? Validation of self and parental reports of swim skill with an inwater swim test among children attending community pools in Washington State.

BACKGROUND: Drowning is the second leading cause of unintentional injury death among US children. Multiple studies describe decreased drowning risk among children possessing some swim skills. Current surveillance for this protective factor is self/proxy-reported swim skill rather than observed inwater performance; however, children's self-report or parents' proxy report of swim skill has not been validated. This is the first US study to evaluate whether children or parents can validly report a child's swim skill. It also explores which swim skill survey measure(s) correlate with children's inwater swim performance. METHODS: For this cross-sectional convenience-based sample, pilot study, child/parent dyads (N=482) were recruited at three outdoor public pools in Washington State. Agreement between measures of self-reports and parental-reports of children's swim skill was assessed via paired analyses, and validated by inwater swim test results. RESULTS: Participants were representative of pool's patrons (ie, non-Hispanic White, highly educated, high income). There was agreement in child/parent dyads' reports of the following child swim skill measures: 'ever taken swim lessons', perceived 'good swim skills' and 'comfort in water over head'. Correlation analyses suggest that reported 'good swim skills' was the best survey measure to assess a child's swim skill-best if the parent was the informant (r=0.25-0.47). History of swim lessons was not significantly correlated with passing the swim test. CONCLUSIONS: Reported 'good swim skills' was most correlated with observed swim skill. Reporting 'yes' to 'ever taken swim lessons' did not correlate with swim skill. While non-generalisable, findings can help inform future studies.

Multidrug-resistant tuberculosis in children: A practical update on epidemiology, diagnosis, treatment and prevention.

Pediatric multidrug-resistant tuberculosis (MDR-TB) remains a significant global problem, and there are numerous barriers preventing children with MDR-TB from being identified, confirmed with microbiologic tests, and treated with a safe, practical, and effective regimen. However, several recent advances in diagnostics and treatment regimens have the promise to improve outcomes for children with MDR-TB. We introduce this review with two cases that exemplify both the challenges in management of MDR-TB in children, but also the potential to achieve a positive outcome. More than 30,000 cases of MDR-TB per year are believed to occur in children but less than 5% are confirmed microbiologically, contributing to poorer outcomes and excess mortality. Rapid molecular-based testing that provides information on rifampin susceptibility is increasingly globally available and recommended for all children suspected of TB disease--but remains limited by challenges obtaining appropriate samples and the paucibacillary nature of most pediatric TB. More complex assays allowing better characterization of drug-resistant isolates are emerging. For children diagnosed with MDR-TB, treatment regimens have traditionally been long and utilize multiple drugs associated with significant side effects, particularly injectable agents. Several new or repurposed drugs including bedaquiline, delamanid, clofazimine and linezolid now allow most treatment regimens to be shorter and all-oral. Yet data to support short, all-oral, novel regimens for young children containing pretomanid remain insufficient at present, and there is a compelling need to conduct pediatric trials of promising therapeutics and MDR-TB treatment regimens.

Interferon-γ Release Assays for Tuberculosis Infection Diagnosis in Refugees <5 Years Old.

BACKGROUND: New guidelines support using interferon-γ release assays (IGRAs) in children ≥2 years for diagnosis of latent tuberculosis infection (LTBI). However, lack of experience in young children and concern that IGRAs are less sensitive than tuberculin skin tests (TSTs) limit their use. Our aim was to identify active tuberculosis (TB) cases among high risk children <5 years and tested for LTBI with an IGRA. METHODS: . Retrospective review of domestic TB screening data from California's Refugee Health Electronic Information System for children <5 years old who resettled in California between October, 2013 and December, 2016. Children were crossmatched with the California TB registry to identify cases of TB disease between October 2013 and December 2018. RESULTS: A total of 3371 children <5 years were identified; the majority were born in countries with high TB incidence (>150 cases per 100 000). Half received IGRAs (n = 1878; 56%), a quarter received TSTs (n = 811; 24%); 1.4% of children were IGRA-positive (n = 26) and 13% were TST-positive (n = 106). Twenty-two IGRA results were indeterminate (1.2%). Sixteen children had both tests; 9 were discrepant (positive TST with negative IGRA). No cases of TB disease were identified during 10 797 person-years of follow-up. CONCLUSIONS: IGRA positivity was less than TST positivity in high risk children <5 years old. Despite fewer LTBI diagnoses in the IGRA-tested population, no cases of TB disease among children who tested negative were identified, suggesting IGRA is valuable tool for identifying LTBI in this population.

Interferon-γ Release Assay Performance for Tuberculosis in Childhood.

BACKGROUND: Interferon-γ release assays (IGRAs) are important adjunctive tests for diagnosing tuberculosis (TB) disease in children. METHODS: We analyzed California TB registry data for patients ≤18 years with laboratory-confirmed TB disease during 2010-2015 to identify case characteristics associated with test selection and performance and measure IGRA sensitivity. RESULTS: In total, 778 cases of TB were reported; 360 were laboratory confirmed. Indeterminate IGRAs were associated with being <1 year old (prevalence rate ratio 9.23; 95% confidence interval 2.87 to 29.8) and having central nervous system disease (prevalence rate ratio 2.69; 95% confidence interval 1.06 to 6.86) on multivariable analysis. Ninety-five children had both an IGRA and tuberculin skin test (TST) performed. Among those, the sensitivity of IGRA in 5- to 18-year-olds was 96% (66 out of 69) vs 83% (57 out of 69) for TST (P = .01); IGRA sensitivity compared with TST in children ages 2 to 4 was 91% (10 out of 11) vs 91% (10 out of 11) (P > .99), and the sensitivity compared with TST in children aged <2 years was 80% (12 out of 15) vs 87% (13 out of 15) (P > .99). CONCLUSIONS: This is the largest North American analysis of IGRA use and performance among children with TB disease. In children <5 years old, IGRA sensitivity is similar to TST, but sensitivity of both tests are reduced in children <2 years old. Indeterminate results are higher in children <1 year old and in central nervous system disease. In children ≥5 years old with laboratory-confirmed TB, IGRA has greater sensitivity than TST and should be considered the preferred immunodiagnostic test..

An Observational Study of Severe Pertussis in 100 Infants ≤120 Days of Age.

BACKGROUND: Pertussis in young infants is a unique, severe, afebrile, cough illness that is frequently fatal. METHODS: All pertussis cases ≤120 days of age admitted to a pediatric intensive care unit in California between October 1, 2013, and April 25, 2015, were evaluated. RESULTS: Of 100 pertussis patients ≤120 days of age admitted to pediatric intensive care unit, there were 5 deaths. The white blood cell counts in the fatal cases were significantly higher than in the nonfatal cases. Thirty-four percent of patients were intubated, 18% received inotropic and/or vasoactive support, 22% received steroid, 4% received extracorporal membrane oxygenation, and 3% underwent exchange blood transfusion. The median age at the time of illness onset in the patients who died was 23 days. CONCLUSIONS: These data, as well as data from previous California studies, suggest updated strategies for the management of severe pertussis. These include perform serial white blood cell counts, treat all presumptive cases with azithromycin, evaluate for pulmonary hypertension, intubate and administer oxygen for apneic episodes and administer inotropic/vasoactive agents for cardiogenic shock. Do not administer steroids or nitric oxide. Criteria for exchange blood transfusion therapy for leukocytosis with lymphocytosis are suggested.