Concurrent assessment of diffusive and advective PAH movement strongly affected by temporal and spatial changes.

Chemical movement influences exposure, remediation and interventions. Understanding chemical movement in addition to chemical concentrations at contaminated sites is critical to informed decision making. Using seepage meters and passive sampling devices we assessed both diffusive and advective flux of bioavailable polycyclic aromatic hydrocarbons (PAHs) at three time points, across two seasons, at a former creosote site in St. Helens, Oregon, United States. To our knowledge, this is the first time both diffusive and advective fluxes have been measured simultaneously at a contaminated site. Concentrations of 39 parent PAHs were determined by gas chromatography triple quadrupole mass spectrometry. Across both seasons and all sites, diffusive flux of PAHs was up to three orders of magnitude larger than advective flux. Release of PAHs from sediments and water were identified, likely from legacy contamination, as well as deposition from the air into the site from contemporary and other sources. The majority of PAH movement was comprised of three and four ring PAHs. Chemical movement on the site was found to be spatially and temporally variable. Volatilization decreased and atmospheric deposition increased from summer to fall. At the locations with higher levels of contamination, sum PAH release from sediments decreased by more than two orders of magnitude from summer to late fall. These data reflect the spatial heterogeneity and temporal variability of this site and demonstrate the importance of seasonality in assessing chemical movement at contaminated sites. Results from this study can inform future legacy site assessments to optimize remediation strategies and assess remediation effectiveness.

Chemical contaminant exposures assessed using silicone wristbands among fuel station attendants, taxi drivers and commercial motorcycle riders in Kampala, Uganda.

There are concerns over traffic-related air pollution in Uganda's capital, Kampala. Individuals in the transportation sector are hypothesized to be at greater risk for exposure to volatile organic compounds, given their proximity to vehicle exhaust. Silicone wristbands are a wearable technology that passively sample individuals' chemical exposures. We conducted a pilot cross sectional study to measure personal exposures to volatile organic compounds among 14 transportation workers who wore a wristband for five days. We analyzed for 75 volatile organic compounds; 33 chemicals (35%) were detected and quantified in at least 50% of the samples and 15 (16%) chemicals were detected and quantified across all the samples. Specific chemicals were associated with participants' occupation. The findings can guide future large studies to inform policy and practice to reduce exposure to chemicals in the environment in Kampala.

The Superfund Research Program Analytics Portal: linking environmental chemical exposure to biological phenotypes.

The OSU/PNNL Superfund Research Program (SRP) represents a longstanding collaboration to quantify Polycyclic Aromatic Hydrocarbons (PAHs) at various superfund sites in the Pacific Northwest and assess their potential impact on human health. To link the chemical measurements to biological activity, we describe the use of the zebrafish as a high-throughput developmental toxicity model that provides quantitative measurements of the exposure to chemicals. Toward this end, we have linked over 150 PAHs found at Superfund sites to the effect of these same chemicals in zebrafish, creating a rich dataset that links environmental exposure to biological response. To quantify this response, we have implemented a dose-response modelling pipeline to calculate benchmark dose parameters which enable potency comparison across over 500 chemicals and 12 of the phenotypes measured in zebrafish. We provide a rich dataset for download and analysis as well as a web portal that provides public access to this dataset via an interactive web site designed to support exploration and re-use of these data by the scientific community at http://srp.pnnl.gov .

Wildfire Impact on Indoor and Outdoor PAH Air Quality.

Air quality impacts from wildfires are poorly understood, particularly indoors. As frequencies increase, it is important to optimize methodologies to understand and reduce chemical exposures from wildfires. Public health recommendations use air quality estimates from outdoor stationary air monitors, discounting indoor air conditions, and do not consider chemicals in the vapor phase, known to elicit adverse effects. We investigated vapor-phase polycyclic aromatic hydrocarbons (PAHs) in indoor and outdoor air before, during, and after wildfires using a community-engaged research approach. Paired passive air samplers were deployed at 15 locations across four states. Twelve unique PAHs were detected only in outdoor air during wildfires, highlighting a PAH exposure mixture for future study. Heavy-molecular-weight (HMW) outdoor PAH concentrations and average Air Quality Index (AQI) values were positively correlated (p < 0.001). Indoor PAH concentrations were higher in 77% of samples across all sampling events. Even during wildfires, 58% of sampled locations still had higher indoor PAH air concentrations. When AQI values exceeded 140 (unhealthy for sensitive groups), outdoor PAH concentrations became similar to or higher than indoors. Cancer and noncancer inhalation risk estimates from vapor-phase PAHs were higher indoors than outdoors, regardless of the wildfire impact. Consideration of indoor air quality and vapor-phase PAHs could inform public health recommendations regarding wildfires.

Associating Increased Chemical Exposure to Hurricane Harvey in a Longitudinal Panel Using Silicone Wristbands.

Hurricane Harvey was associated with flood-related damage to chemical plants and oil refineries, and the flooding of hazardous waste sites, including 13 Superfund sites. As clean-up efforts began, concerns were raised regarding the human health impact of possible increased chemical exposure resulting from the hurricane and subsequent flooding. Personal sampling devices in the form of silicone wristbands were deployed to a longitudinal panel of individuals (n = 99) within 45 days of the hurricane and again one year later in the Houston metropolitan area. Using gas chromatography−mass spectroscopy, each wristband was screened for 1500 chemicals and analyzed for 63 polycyclic aromatic hydrocarbons (PAHs). Chemical exposure levels found on the wristbands were generally higher post-Hurricane Harvey. In the 1500 screen, 188 chemicals were detected, 29 were detected in at least 30% of the study population, and of those, 79% (n = 23) were found in significantly higher concentrations (p < 0.05) post-Hurricane Harvey. Similarly, in PAH analysis, 51 chemicals were detected, 31 were detected in at least 30% of the study population, and 39% (n = 12) were found at statistically higher concentrations (p < 0.05) post-Hurricane Harvey. This study indicates that there were increased levels of chemical exposure after Hurricane Harvey in the Houston metropolitan area.

Frequency of transmission, asymptomatic shedding, and airborne spread of Streptococcus pyogenes in schoolchildren exposed to scarlet fever: a prospective, longitudinal, multicohort, molecular epidemiological, contact-tracing study in England, UK.

BACKGROUND: Despite recommendations regarding prompt treatment of cases and enhanced hygiene measures, scarlet fever outbreaks increased in England between 2014 and 2018. We aimed to assess the effects of standard interventions on transmission of Streptococcus pyogenes to classroom contacts, households, and classroom environments to inform future guidance. METHODS: We did a prospective, longitudinal, multicohort, molecular epidemiological, contact-tracing study in six settings across five schools in Greater London, UK. Schools and nurseries were eligible to participate if they had reported two cases of scarlet fever within 10 days of each other among children aged 2-8 years from the same class, with the most recent case arising in the preceding 48 h. We cultured throat swabs from children with scarlet fever, classroom contacts, and household contacts at four timepoints. We also cultured hand swabs and cough plates from all cases in years 1 and 2 of the study, and from classroom contacts in year 2. Surface swabs from toys and other fomites in classrooms were cultured in year 1, and settle plates from classrooms were collected in year 2. Any sample with S pyogenes detected was recorded as positive and underwent emm genotyping and genome sequencing to compare with the outbreak strain. FINDINGS: Six classes, comprising 12 cases of scarlet fever, 17 household contacts, and 278 classroom contacts were recruited between March 1 and May 31, 2018 (year 1), and between March 1 and May 31, 2019 (year 2). Asymptomatic throat carriage of the outbreak strains increased from 11 (10%) of 115 swabbed children in week 1, to 34 (27%) of 126 in week 2, to 26 (24%) of 108 in week 3, and then five (14%) of 35 in week 4. Compared with carriage of outbreak S pyogenes strains, colonisation with non-outbreak and non-genotyped S pyogenes strains occurred in two (2%) of 115 swabbed children in week 1, five (4%) of 126 in week 2, six (6%) of 108 in week 3, and in none of the 35 children in week 4 (median carriage for entire study 2·8% [IQR 0·0-6·6]). Genome sequencing showed clonality of outbreak isolates within each of six classes, confirming that recent transmission accounted for high carriage. When transmissibility was tested, one (9%) of 11 asymptomatic carriers of emm4 and five (36%) of 14 asymptomatic carriers of emm3.93 had a positive cough plate. The outbreak strain was identified in only one (2%) of 60 surface swabs taken from three classrooms; however, in the two classrooms with settle plates placed in elevated locations, two (17%) of 12 and six (50%) of 12 settle plates yielded the outbreak strain. INTERPRETATION: Transmission of S pyogenes in schools is intense and might occur before or despite reported treatment of cases, underlining a need for rapid case management. Despite guideline adherence, heavy shedding of S pyogenes by few classroom contacts might perpetuate outbreaks, and airborne transmission has a plausible role in its spread. These findings highlight the need for research to improve understanding and to assess effectiveness of interventions to reduce airborne transmission of S pyogenes. FUNDING: Action Medical Research, UK Research Innovation, and National Institute for Health Research.

Invasive Group A Streptococcus Outbreaks Associated with Home Healthcare, England, 2018-2019.

Healthcare-associated invasive group A Streptococcus (iGAS) outbreaks are common worldwide, but only England has reported outbreaks associated with home healthcare (HHC). We describe 10 outbreaks during 2018-2019 in England. A total of 96 iGAS cases (range 2-39 per outbreak) and 28 deaths (case-fatality rate 29%) occurred. Outbreak duration ranged from 3-517 days; median time between sequential cases was 20.5 days (range 1-225 days). Outbreak identification was difficult, but emm typing and whole-genome sequencing improved detection. Network analyses indicated multiple potential transmission routes. Screening of 366 HHC workers from 9 outbreaks identified group A Streptococcus carriage in just 1 worker. Outbreak control required multiple interventions, including improved infection control, equipment decontamination, and antimicrobial prophylaxis for staff. Transmission routes and effective interventions are not yet clear, and iGAS outbreaks likely are underrecognized. To improve patient safety and reduce deaths, public health agencies should be aware of HHC-associated iGAS.

Preschool-Age Children's Pesticide Exposures in Child Care Centers and at Home in Northern California.

INTRODUCTION: Young children may be exposed to pesticides used in child care centers and their family homes. We examined pesticide use and environmental and behavioral factors potentially associated with child exposures in these settings. METHOD: Preschool-age children (n = 125) wore silicone wristbands to assess pesticide exposures in their child care centers and home environments. Information about environmental and behavioral exposure determinants was collected using parent surveys, child care director interviews, and observations. RESULTS: Commonly detected pesticides were bifenthrin, chlorpyrifos, cypermethrin, fipronil, and cis- and trans-permethrin. Pesticide chemical storage onsite, cracks in the walls, using doormats, observed pests, or evidence of pests were associated with child exposures. Exposures were higher in counties with higher agricultural or commercial pesticide use or when children lived in homes near agricultural fields. DISCUSSION: Young children are being exposed to harmful pesticides, and interventions are needed to lower their risk of health problems later in life.

Firefighter exposures to potential endocrine disrupting chemicals measured by military-style silicone dog tags.

Studies suggest that exposure to potential endocrine disrupting chemicals (pEDCs) may contribute to adverse health outcomes, but pEDC exposures among firefighters have not been fully characterized. Previously, we demonstrated the military-style silicone dog tag as a personal passive sampling device for assessing polycyclic aromatic hydrocarbon exposures among structural firefighters. This follow-up analysis examined the pEDC exposures based on department call volume, duty shift, and questionnaire variables. Structural firefighters (n = 56) were from one high and one low fire call volume department (Kansas City, MO metropolitan area) and wore separate dog tags while on- and off-duty (ndogtags = 110). The targeted 1530 analyte semi-quantitative screening method was conducted using gas chromatography mass spectrometry (npEDCs = 433). A total of 47 pEDCs were detected, and several less-frequently-detected pEDCs (<75%) were more commonly detected in off- compared to on-duty dog tags (conditional logistic regression). Of the 11 phthalates and fragrances detected most frequently (>75%), off-duty pEDC concentrations were strongly correlated (r = 0.31-0.82, p < 0.05), suggesting co-applications of phthalates and fragrances in consumer products. Questionnaire variables of "regular use of conventional cleaning products" and "fireplace in the home" were associated with select elevated pEDC concentrations by duty shift (paired t-test). This suggested researchers should include detailed questions about consumer product use and home environment when examining personal pEDC exposures.

Designing Equitable, Transparent Community-Engaged Disaster Research.

Disaster research faces significant infrastructure challenges: regional and federal coordination, access to resources, and community collaboration. Disasters can lead to chemical exposures that potentially impact human health and cause concern in affected communities. Community-engaged research, which incorporates local knowledge and voices, is well-suited for work with communities that experience impacts of environmental exposures following disasters. We present three examples of community-engaged disaster research (CEnDR) following oil spills, hurricanes, and wildfires, and their impact on long-term social, physical, and technical community infrastructure. We highlight the following CEnDR structures: researcher/community networks; convenient research tools; adaptable data collection modalities for equitable access; and return of data.

A pseudo-outbreak of Rhinocladiella similis in a bronchoscopy unit of a tertiary care teaching hospital in London, United Kingdom.

Outbreaks of fungal infections due to emerging and rare species are increasingly reported in healthcare settings. We investigated a pseudo-outbreak of Rhinocladiella similis in a bronchoscopy unit of a tertiary care teaching hospital in London, UK. We aimed to determine route of healthcare-associated transmission and prevent additional infections. From July 2018 through February 2019, we detected a pseudo-outbreak of R. similis isolated from bronchoalveolar lavage (BAL) fluid samples collected from nine patients who had undergone bronchoscopy in a multispecialty teaching hospital, during a period of 8 months. Isolates were identified by MALDI-TOF mass spectrometry. Antifungal susceptibility testing was performed by EUCAST broth microdilution. To determine genetic relatedness among R. similis isolates, we undertook amplified fragment length polymorphism analysis. To determine the potential source of contamination, an epidemiological investigation was carried out. We reviewed patient records retrospectively and audited steps taken during bronchoscopy as well as the subsequent cleaning and decontamination procedures. Fungal cultures were performed on samples collected from bronchoscopes and automated endoscope washer-disinfector systems. No patient was found to have an infection due to R. similis either before or after bronchoscopy. One bronchoscope was identified to be used among all affected patients with positive fungal cultures. Physical damage was found in the index bronchoscope; however, no fungus was recovered after sampling of the affected scope or the rinse water of automated endoscope washer-disinfectors. Use of the scope was halted, and, during the following 12-month period, Rhinocladiella species were not isolated from any BAL specimen. All pseudo-outbreak isolates were identified as R. similis with high genetic relatedness (>90% similarity) on ALFP analysis. The study emphasises the emergence of a rare and uncommon black yeast R. similis, with reduced susceptibility to echinocandins, in a bronchoscope-related pseudo-outbreak with a potential water-related reservoir. Our findings highlight the importance of prolonged fungal culture and species-level identification of melanised yeasts isolated from bronchoscopy samples. Possibility of healthcare-associated transmission should be considered when R. similis is involved in clinical microbiology samples.

Discovery of firefighter chemical exposures using military-style silicone dog tags.

Occupational chemical hazards in the fire service are hypothesized to play a role in increased cancer risk, and reliable sampling technologies are necessary for conducting firefighter chemical exposure assessments. This study presents the military-style dog tag as a new configuration of silicone passive sampling device to sample individual firefighters' exposures at one high and one low fire call volume department in the Kansas City, Missouri metropolitan area. The recruited firefighters (n = 56) wore separate dog tags to assess on- and off-duty exposures (ndogtags = 110), for a total of 30 24 h shifts. Using a 63 PAH method (GC-MS/MS), the tags detected 45 unique PAHs, of which 18 have not been previously reported as firefighting exposures. PAH concentrations were higher for on- compared to off-duty tags (0.25 < Cohen's d ≤ 0.80) and for the high compared to the low fire call volume department (0.25 ≤ d < 0.70). Using a 1530 analyte screening method (GC-MS), di-n-butyl phthalate, diisobutyl phthalate, guaiacol, and DEET were commonly detected analytes. The number of fire attacks a firefighter participated in was more strongly correlated with PAH concentrations than firefighter rank or years in the fire service. This suggested that quantitative data should be employed for firefighter exposure assessments, rather than surrogate measures. Because several detected analytes are listed as possible carcinogens, future firefighter exposure studies should consider evaluating complex mixtures to assess individual health risks.

Discovery of common chemical exposures across three continents using silicone wristbands.

To assess differences and trends in personal chemical exposure, volunteers from 14 communities in Africa (Senegal, South Africa), North America (United States (U.S.)) and South America (Peru) wore 262 silicone wristbands. We analysed wristband extracts for 1530 unique chemicals, resulting in 400 860 chemical data points. The number of chemical detections ranged from 4 to 43 per wristband, with 191 different chemicals detected, and 1339 chemicals were not detected in any wristband. No two wristbands had identical chemical detections. We detected 13 potential endocrine disrupting chemicals in over 50% of all wristbands and found 36 chemicals in common between chemicals detected in three geographical wristband groups (Africa, North America and South America). U.S. children (less than or equal to 11 years) had the highest percentage of flame retardant detections compared with all other participants. Wristbands worn in Texas post-Hurricane Harvey had the highest mean number of chemical detections (28) compared with other study locations (10-25). Consumer product-related chemicals and phthalates were a high percentage of chemical detections across all study locations (36-53% and 18-42%, respectively). Chemical exposures varied among individuals; however, many individuals were exposed to similar chemical mixtures. Our exploratory investigation uncovered personal chemical exposure trends that can help prioritize certain mixtures and chemical classes for future studies.

Artificial turf: chemical flux and development of silicone wristband partitioning coefficients.

This work provides the first quantitative measure of in situ flux of semi-volatile contaminants on artificial turf fields. Passive samplers were used to identify gas-phase PAHs and OPAHs not previously reported associated with artificial turf. Utilizing a broad and targeted screen, we assess both artificial turf and from crumb rubber for 1,529 chemicals, including several with known health effects including benzo[c]fluorene. We also report the presence of 25 chemicals that have not yet been reported in artificial turf literature, including some with known effects on human health. This is the first report of bioavailable gas-phase PAH and OPAH concentrations on an outdoor field, to date gas-phase concentrations have only been reported from indoor facilities. Turf air and air were highly correlated at all three sites, and particularly at the recently-installed indoor site. Finally, thermal extraction and silicone passive samplers are highly suitable for larger-scale sampling campaigns that aim for less solvent and sample processing. We demonstrate for the first time that silicone passive samplers can be used to quantify volatile and semi-volatile organic chemicals from artificial turf. Co-deploying silicone passive samplers and conventional low density polyethylene, we develop partitioning coefficients that can be used for silicone passive air sampling environmental assessment.

A Candida auris Outbreak and Its Control in an Intensive Care Setting.

BACKGROUND: Candida auris is an emerging and multidrug-resistant pathogen. Here we report the epidemiology of a hospital outbreak of C. auris colonization and infection. METHODS: After identification of a cluster of C. auris infections in the neurosciences intensive care unit (ICU) of the Oxford University Hospitals, United Kingdom, we instituted an intensive patient and environmental screening program and package of interventions. Multivariable logistic regression was used to identify predictors of C. auris colonization and infection. Isolates from patients and from the environment were analyzed by whole-genome sequencing. RESULTS: A total of 70 patients were identified as being colonized or infected with C. auris between February 2, 2015, and August 31, 2017; of these patients, 66 (94%) had been admitted to the neurosciences ICU before diagnosis. Invasive C. auris infections developed in 7 patients. When length of stay in the neurosciences ICU and patient vital signs and laboratory results were controlled for, the predictors of C. auris colonization or infection included the use of reusable skin-surface axillary temperature probes (multivariable odds ratio, 6.80; 95% confidence interval [CI], 2.96 to 15.63; P<0.001) and systemic fluconazole exposure (multivariable odds ratio, 10.34; 95% CI, 1.64 to 65.18; P=0.01). C. auris was rarely detected in the general environment. However, it was detected in isolates from reusable equipment, including multiple axillary skin-surface temperature probes. Despite a bundle of infection-control interventions, the incidence of new cases was reduced only after removal of the temperature probes. All outbreak sequences formed a single genetic cluster within the C. auris South African clade. The sequenced isolates from reusable equipment were genetically related to isolates from the patients. CONCLUSIONS: The transmission of C. auris in this hospital outbreak was found to be linked to reusable axillary temperature probes, indicating that this emerging pathogen can persist in the environment and be transmitted in health care settings. (Funded by the National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Oxford University and others.).

National outbreak of Pseudomonas aeruginosa associated with an aftercare solution following piercings, July to September 2016, England.

We report a national Pseudomonas aeruginosa outbreak from a common source following piercings between July and September 2016 in England. The multi-agency outbreak investigation included active case finding, microbiological testing of environmental samples and case specimens including Variable Number Tandem Repeat (VNTR) typing and a retrospective cohort study. Overall, 162 outbreak cases (29 confirmed, 14 probable and 119 possible) and 14 non-outbreak cases were identified; all confirmed cases had ear piercings (93% cartilage). Outbreak cases were predominantly female (95%) and had a median age of 18 years (interquartile range: 13-56 years). Nineteen outbreak cases required surgery under general anaesthetic The same outbreak VNTR type (11,3,5,3,3,3,6,4,7) was isolated from bottles of an aftercare solution from a single manufacturer and in specimens from confirmed cases who attended eight different piercing studios supplied with this product. In the cohort study, use of aftercare solution was associated with becoming a case (aOR: 4.60, 95% confidence interval: 1.65-12.90). Environmental, microbiological and epidemiological investigations confirmed that contamination during production of aftercare solution was the source of this national outbreak; highlighting challenges in the regulation of a cosmetic products used in the piercing industry and that guidance on piercing aftercare may need to be reviewed.

Serial Clustering of Late-Onset Group B Streptococcal Infections in the Neonatal Unit: A Genomic Re-evaluation of Causality.

Background: Invasive Group B streptococcus (GBS) is a major cause of serious neonatal infection. Current strategies to reduce early-onset GBS disease have no impact on late-onset disease (LOD). Although GBS LOD is viewed as a sporadic event in the community, LOD arising within the neonatal intensive care unit (ICU) raises questions about mode of acquisition. Methods: Following a cluster of 4 GBS LOD cases, enhanced surveillance for all GBS LOD was undertaken over 2 years in the neonatal ICU supported by neonatal rectal screening. GBS isolates were serotyped and genome-sequenced. Results: Twelve late -onset invasive GBS episodes were identified (incidence 0.6/1000 live births). Genomic analysis revealed that 11/12 GBS isolates (92%) were linked to at least one other LOD isolate. Isolates from the first cluster were serotype V, resistant to macrolides and lincosamides, and sequencing confirmed isolates were indistinguishable, or distinguishable by only one SNP difference, from each other. Rectal carriage was rare. Prospective surveillance identified three further clusters of LOD due to serotypes Ia (3 cases), Ib (2 cases), and III (2 cases), that would not have been identified without surveillance and genome sequencing, leading to a re-evaluation of interventions required to prevent GBS LOD. Conclusion: Acquisition routes for LOD GBS in the neonatal ICU are poorly understood; cases may not necessarily be sporadic. Within this neonatal ICU, our data suggest that a single case of LOD GBS sepsis should be considered a potential nosocomial transmission event warranting prompt investigation, heightened infection prevention vigilance and action where required.

Preparation and performance features of wristband samplers and considerations for chemical exposure assessment.

Wristbands are increasingly used for assessing personal chemical exposures. Unlike some exposure assessment tools, guidelines for wristbands, such as preparation, applicable chemicals, and transport and storage logistics, are lacking. We tested the wristband's capacity to capture and retain 148 chemicals including polychlorinated biphenyls (PCBs), pesticides, flame retardants, polycyclic aromatic hydrocarbons (PAHs), and volatile organic chemicals (VOCs). The chemicals span a wide range of physical-chemical properties, with log octanol-air partitioning coefficients from 2.1 to 13.7. All chemicals were quantitatively and precisely recovered from initial exposures, averaging 102% recovery with relative SD ≤21%. In simulated transport conditions at +30 °C, SVOCs were stable up to 1 month (average: 104%) and VOC levels were unchanged (average: 99%) for 7 days. During long-term storage at -20 °C up to 3 (VOCs) or 6 months (SVOCs), all chemical levels were stable from chemical degradation or diffusional losses, averaging 110%. Applying a paired wristband/active sampler study with human participants, the first estimates of wristband-air partitioning coefficients for PAHs are presented to aid in environmental air concentration estimates. Extrapolation of these stability results to other chemicals within the same physical-chemical parameters is expected to yield similar results. As we better define wristband characteristics, wristbands can be better integrated in exposure science and epidemiological studies.

Insidious Risk of Severe Mycobacterium chimaera Infection in Cardiac Surgery Patients.

BACKGROUND: An urgent UK investigation was launched to assess risk of invasive Mycobacterium chimaera infection in cardiothoracic surgery and a possible association with cardiopulmonary bypass heater-cooler units following alerts in Switzerland and The Netherlands. METHODS: Parallel investigations were pursued: (1) identification of cardiopulmonary bypass-associated M. chimaera infection through national laboratory and hospital admissions data linkage; (2) cohort study to assess patient risk; (3) microbiological and aerobiological investigations of heater-coolers in situ and under controlled laboratory conditions; and (4) whole-genome sequencing of clinical and environmental isolates. RESULTS: Eighteen probable cases of cardiopulmonary bypass-associated M. chimaera infection were identified; all except one occurred in adults. Patients had undergone valve replacement in 11 hospitals between 2007 and 2015, a median of 19 months prior to onset (range, 3 months to 5 years). Risk to patients increased after 2010 from <0.2 to 1.65 per 10000 person-years in 2013, a 9-fold rise for infections within 2 years of surgery (rate ratio, 9.08 [95% CI, 1.81-87.76]). Endocarditis was the most common presentation (n = 11). To date, 9 patients have died. Investigations identified aerosol release through breaches in heater-cooler tanks. Mycobacterium chimaera and other pathogens were recovered from water and air samples. Phylogenetic analysis found close clustering of strains from probable cases. CONCLUSIONS: We identified low but escalating risk of severe M. chimaera infection associated with heater-coolers with cases in a quarter of cardiothoracic centers. Our investigations strengthen etiological evidence for the role of heater-coolers in transmission and raise the possibility of an ongoing, international point-source outbreak. Active management of heater-coolers and heightened clinical awareness are imperative given the consequences of infection.