Pharyngeal Co-Infections with Monkeypox Virus and Group A Streptococcus, United States, 2022.

We report 2 cases of pharyngeal monkeypox virus and group A Streptococcus co-infection in the United States. No rash was observed when pharyngitis symptoms began. One patient required intubation before mpox was diagnosed. Healthcare providers should be aware of oropharyngeal mpox manifestations and possible co-infections; early treatment might prevent serious complications.

Ocular Monkeypox - United States, July-September 2022.

As of October 11, 2022, a total of 26,577 monkeypox cases had been reported in the United States.* Although most cases of monkeypox are self-limited, lesions that involve anatomically vulnerable sites can cause complications. Ocular monkeypox can occur when Monkeypox virus (MPXV) is introduced into the eye (e.g., from autoinoculation), potentially causing conjunctivitis, blepharitis, keratitis, and loss of vision (1). This report describes five patients who acquired ocular monkeypox during July-September 2022. All patients received treatment with tecovirimat (Tpoxx)†; four also received topical trifluridine (Viroptic).§ Two patients had HIV-associated immunocompromise and experienced delays between clinical presentation with monkeypox and initiation of monkeypox-directed treatment. Four patients were hospitalized, and one experienced marked vision impairment. To decrease the risk for autoinoculation, persons with monkeypox should be advised to practice hand hygiene and to avoid touching their eyes, which includes refraining from using contact lenses (2). Health care providers and public health practitioners should be aware that ocular monkeypox, although rare, is a sight-threatening condition. Patients with signs and symptoms compatible with ocular monkeypox should be considered for urgent ophthalmologic evaluation and initiation of monkeypox-directed treatment. Public health officials should be promptly notified of cases of ocular monkeypox. Increased clinician awareness of ocular monkeypox and of approaches to prevention, diagnosis, and treatment might reduce associated morbidity.

Evaluating the Presence of Replication-Competent Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From Nursing Home Residents With Persistently Positive Reverse Transcription Polymerase Chain Reaction (RT-PCR) Results.

Replication-competent virus has not been detected in individuals with mild to moderate coronavirus disease 2019 (COVID-19) more than 10 days after symptom onset. It is unknown whether these findings apply to nursing home residents. Of 273 specimens collected from nursing home residents >10 days from the initial positive test, none were culture positive.

Temperature and oxygen saturation in skilled nursing facility residents positive for SARS-CoV-2 prior to symptom onset.

BACKGROUND: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) spreads rapidly amongst residents of skilled nursing facilities (SNFs). The rapid transmission dynamics and high morbidity and mortality that occur in SNFs emphasize the need for early detection of cases. We hypothesized that residents of SNFs infected with SARS-CoV-2 would demonstrate an acute change in either temperature or oxygen saturation (SpO2 ) prior to symptom onset. The Minnesota Department of Health (MDH) conducted a retrospective analysis of both temperature and SpO2 at two separate SNFs to assess the utility of these quantitative markers to identify SARS-CoV-2 infection prior to the development of symptoms. METHODS: A retrospective analysis was conducted of 165 individuals positive for SARS-CoV-2 who were residents of SNFs that experienced coronavirus disease 2019 (COVID-19) outbreaks during April-June 2020 in a metropolitan area of Minnesota. Age, sex, symptomology, temperature and SpO2 values, date of symptom onset, and date of positive SARS-CoV-2 test were analyzed. Temperature and SpO2 values for the period 14 days before and after the date of initial positive test were included. Descriptive analyses evaluated changes in temperature and SpO2 , defined as either exceeding a set threshold or demonstrating an acute change between consecutive measurements. RESULTS: Two (1%) residents had a temperature value ≥100°F, and 30 (18%) had at least one value ≥99°F within 14 days before symptom development. One hundred and sixteen residents (70%) had at least one SpO2 value ≤94%, while 131 (80%) had an acute decrease in SpO2 of ≥3% between consecutive values in the 14 days prior to symptom onset. CONCLUSIONS: Our results suggest that acute change in SpO2 might be useful in the identification of SARS-CoV-2 infection prior to the development of symptoms among residents living in SNFs. Facilities may consider adding SpO2 to daily temperature and symptom screening checklists to improve early detection of residents of SNFs infected with SARS-CoV-2.

Transmission Dynamics of Severe Acute Respiratory Syndrome Coronavirus 2 in High-Density Settings, Minnesota, USA, March-June 2020.

Coronavirus disease has disproportionately affected persons in congregate settings and high-density workplaces. To determine more about the transmission patterns of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in these settings, we performed whole-genome sequencing and phylogenetic analysis on 319 (14.4%) samples from 2,222 SARS-CoV-2-positive persons associated with 8 outbreaks in Minnesota, USA, during March-June 2020. Sequencing indicated that virus spread in 3 long-term care facilities and 2 correctional facilities was associated with a single genetic sequence and that in a fourth long-term care facility, outbreak cases were associated with 2 distinct sequences. In contrast, cases associated with outbreaks in 2 meat-processing plants were associated with multiple SARS-CoV-2 sequences. These results suggest that a single introduction of SARS-CoV-2 into a facility can result in a widespread outbreak. Early identification and cohorting (segregating) of virus-positive persons in these settings, along with continued vigilance with infection prevention and control measures, is imperative.

COVID-19 Mortality Among American Indian and Alaska Native Persons - 14 States, January-June 2020.

American Indian/Alaska Native (AI/AN) persons experienced disproportionate mortality during the 2009 influenza A(H1N1) pandemic (1,2). Concerns of a similar trend during the coronavirus disease 2019 (COVID-19) pandemic led to the formation of a workgroup* to assess the prevalence of COVID-19 deaths in the AI/AN population. As of December 2, 2020, CDC has reported 2,689 COVID-19-associated deaths among non-Hispanic AI/AN persons in the United States.† A recent analysis found that the cumulative incidence of laboratory-confirmed COVID-19 cases among AI/AN persons was 3.5 times that among White persons (3). Among 14 participating states, the age-adjusted AI/AN COVID-19 mortality rate (55.8 deaths per 100,000; 95% confidence interval [CI] = 52.5-59.3) was 1.8 (95% CI = 1.7-2.0) times that among White persons (30.3 deaths per 100,000; 95% CI = 29.9-30.7). Although COVID-19 mortality rates increased with age among both AI/AN and White persons, the disparity was largest among those aged 20-49 years. Among persons aged 20-29 years, 30-39 years, and 40-49 years, the COVID-19 mortality rates among AI/AN were 10.5, 11.6, and 8.2 times, respectively, those among White persons. Evidence that AI/AN communities might be at increased risk for COVID-19 illness and death demonstrates the importance of documenting and understanding the reasons for these disparities while developing collaborative approaches with federal, state, municipal, and tribal agencies to minimize the impact of COVID-19 on AI/AN communities. Together, public health partners can plan for medical countermeasures and prevention activities for AI/AN communities.

Serial Testing for SARS-CoV-2 and Virus Whole Genome Sequencing Inform Infection Risk at Two Skilled Nursing Facilities with COVID-19 Outbreaks - Minnesota, April-June 2020.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), can spread rapidly in high-risk congregate settings such as skilled nursing facilities (SNFs) (1). In Minnesota, SNF-associated cases accounted for 3,950 (8%) of 48,711 COVID-19 cases reported through July 21, 2020; 35% of SNF-associated cases involved health care personnel (HCP*), including six deaths. Facility-wide, serial testing in SNFs has been used to identify residents with asymptomatic and presymptomatic SARS-CoV-2 infection to inform mitigation efforts, including cohorting of residents with positive test results and exclusion of infected HCP from the workplace (2,3). During April-June 2020, the Minnesota Department of Health (MDH), with CDC assistance, conducted weekly serial testing at two SNFs experiencing COVID-19 outbreaks. Among 259 tested residents, and 341 tested HCP, 64% and 33%, respectively, had positive reverse transcription-polymerase chain reaction (RT-PCR) SARS-CoV-2 test results. Continued SARS-CoV-2 transmission was potentially facilitated by lapses in infection prevention and control (IPC) practices, up to 12-day delays in receiving HCP test results (53%) at one facility, and incomplete HCP participation (71%). Genetic sequencing demonstrated that SARS-CoV-2 viral genomes from HCP and resident specimens were clustered by facility, suggesting facility-based transmission. Residents and HCP working in SNFs are at risk for infection with SARS-CoV-2. As part of comprehensive COVID-19 preparation and response, including early identification of cases, SNFs should conduct serial testing of residents and HCP, maximize HCP testing participation, ensure availability of personal protective equipment (PPE), and enhance IPC practices† (4-5).

Sociocultural factors perpetuating the practices of early marriage and childbirth in Sylhet District, Bangladesh.

BACKGROUND: The practice of adolescent marriage continues in communities throughout Bangladesh, with adolescent childbearing a common result. This early childbearing is associated with increased medical risks for both mothers and their newborns. METHODS: Because of the need to understand the persistence of these behaviors in spite of the risks, various qualitative research methods were used to identify and better understand the various socio cultural factors perpetuating the practices of early marriage and childbirth. RESULTS: Delaying the first birth after marriage can cause rumors of infertility, bring shame on the family, and in some cases lead the husband's family to seek another wife for their son. In addition, social stigma for childless women, emigration of husbands, and the belief that using modern contraceptives prior to the birth of the first child results in infertility also inhibits couples from delaying their first pregnancy. DISCUSSION AND CONCLUSIONS: Future efforts to promote delay in marriage and subsequent early childbearing should focus on allaying the fears of infertility related to delay in childbearing or secondary to contraceptive use, both for newly married couples and household decision-makers such as mothers-in-law.

Local understandings and current barriers to optimal birth intervals among recently delivered women in Sylhet District, Bangladesh.

BACKGROUND: Sylhet Division in Bangladesh has the highest proportion of births spaced less than 36 months (46.5%) in Bangladesh. METHODS: Formative research was conducted on current fertility-related practices in order to explore how to integrate the promotion of healthy fertility practices into a package of maternal and neonatal care interventions. In-depth interviews, focus group discussions and other qualitative methods were utilized with recently delivered women, their families, community health workers and community leaders in Sylhet Division. RESULTS: Mothers of young children generally understood the benefits of both healthy timing and spacing of pregnancies. However, a variety of factors prevent these desired behaviours from becoming actualized, including the roles of women in the provision of children/grandchildren, local understandings of modern contraceptive methods, perceived side effects, lack of communication regarding healthy fertility practices between partners and extended family members, and limited female autonomy. CONCLUSIONS: In order to increase families' ability to achieve optimal birth intervals, we propose the promotion and integration of healthy fertility practices into antenatal and newborn care interventions, focusing on providing biomedically correct and culturally appropriate information on modern contraceptive methods to the entire family, while simultaneously encouraging open spousal and family communication patterns regarding timing and spacing of pregnancy.

Effective health interventions for adolescents that could be integrated with human papillomavirus vaccination programs.

PURPOSE: We reviewed published data to identify health interventions for 9-15-year-old girls and boys that could to be usefully integrated with programs of human papillomavirus (HPV) vaccination in low- and middle-income countries (LMICs). METHODS: Relevant literature reviews, bibliographic databases, and journals were searched to identify health-related interventions, other than immunizations, that had been found to have beneficial outcomes among adolescent girls and/or boys. An intervention was excluded if there was no evidence of its effective delivery in LMICs or no demonstrated potential for its adaptation for delivery in such countries, and/or if there was, apparently, no feasible way in which it could be delivered during a course of HPV vaccinations. RESULTS: Overall, 33 different interventions were found to have had beneficial outcomes among adolescents living in LMICs. Of these, 19 were excluded because they were deemed too expensive or too difficult to deliver within the calendar of a HPV vaccination program. The remaining 14 health-related interventions, in the fields of screening (for schistosomiasis and defects in vision), health education (on mosquito-borne diseases, the benefits of exercise, accessing health care, and sexual and reproductive health), skills building (improving condom usage) and delivery of commodities (anthelminthic drugs, vitamin A supplements, soap and/or bed nets) were deemed potential candidates for delivery in conjunction with the HPV vaccine. CONCLUSIONS: The potential benefits and selection of other health-related interventions that are delivered in conjunction with HPV vaccine will be influenced by a range of factors, including the ease of delivery, the epidemiology of the priority health problems affecting adolescents, the vaccine delivery schedule, and various environmental, economic, and social factors. However, there appear to be several interventions that could usefully be integrated in many, if not all, HPV vaccination programs. The ability to deliver multiple interventions along with HPV vaccine could not only offer important efficiencies but also serve as an entry point to increase adolescents' access to health care and services.