Cultivation of an Adaptive Domestic Network for Surveillance and Evaluation of Emerging Infections.

Accomplishments of this program have provided numerous dividends and might benefit areas outside infectious diseases.

Effect of Culture-Independent Diagnostic Tests on Future Emerging Infections Program Surveillance.

The Centers for Disease Control and Prevention Emerging Infections Program (EIP) network conducts population-based surveillance for pathogens of public health importance. Central to obtaining estimates of disease burden and tracking microbiological characteristics of these infections is accurate laboratory detection of pathogens. The use of culture-independent diagnostic tests (CIDTs) in clinical settings presents both opportunities and challenges to EIP surveillance. Because CIDTs offer better sensitivity than culture and are relatively easy to perform, their use could potentially improve estimates of disease burden. However, changes in clinical testing practices, use of tests with different sensitivities and specificities, and changes to case definitions make it challenging to monitor trends. Isolates are still needed for performing strain typing, antimicrobial resistance testing, and identifying other molecular characteristics of organisms. In this article, we outline current and future EIP activities to address issues associated with adoption of CIDTs, which may apply to other public health surveillance.

Update on progress in electronic reporting of laboratory results to public health agencies - United States, 2014.

Since 2010, CDC has provided resources from the Prevention and Public Health Fund of the Affordable Care Act to 57 state, local, and territorial health departments through the Epidemiology and Laboratory Capacity for Infectious Diseases cooperative agreement to assist with implementation of electronic laboratory reporting (ELR)* from clinical and public health laboratories to public health agencies. To update information from a previous report about the progress in implementing ELR in the United States, CDC examined regular communications between the agency and the 57 health departments during 2012-2014. The results indicated that, as of July 2014, 67% of the approximately 20 million laboratory reports received annually for notifiable conditions were received electronically, compared with 62% in July 2013. These electronic reports were received by 55 of the 57 jurisdictions and came from 3,269 (up from nearly 2,900 in July 2013) of approximately 10,600 reporting laboratories. The proportion of laboratory reports received electronically varied by jurisdiction. In 2014, compared with 2013, the number of jurisdictions receiving >75% of laboratory reports electronically was higher (21 versus 14), and the number of jurisdictions receiving <25% of reports electronically was lower (seven versus nine). National implementation of ELR continues to increase and appears it might reach 80% of total laboratory report volume by 2016.

Decision instrument for the isolation of pneumonia patients with suspected pulmonary tuberculosis admitted through US emergency departments.

STUDY OBJECTIVE: Many patients with pneumonia are admitted to respiratory isolation for possible tuberculosis (TB), but most do not have active TB. We created a decision instrument to predict which pneumonia patients do not need admission to a TB isolation bed. METHODS: The design was a prospective case series conducted in 11 university-affiliated, urban, US emergency departments (EDs) (EMERGEncy ID NET). Participants were patients admitted to the hospital through the ED with a diagnosis of pneumonia or suspected TB. The main outcome measure was derivation and validation of a sensitive decision instrument to identify patients not having TB (and not requiring isolation) according to clinical data and chest radiographs. RESULTS: Of 5,079 pneumonia patients, 224 (4.4%) had pulmonary TB according to sputum cultures or tissue staining. The instrument derived to predict which patients did not have pulmonary TB included no TB history or previous positive tuberculin skin test result, nonimmigrant, not homeless, not recently incarcerated, no recent weight loss, and no apical infiltrate or cavitary lesion on plain chest radiograph. When tested on the validation subgroup, the decision instrument exhibited a negative predictive value of 99.7% (95% confidence interval [CI] 99.1% to 99.9%), and a sensitivity of 96.4% (95% CI 91.1% to 99.0%). CONCLUSION: A decision instrument can accurately predict which patients with pneumonia do not require admission to TB isolation rooms.

Disease surveillance and the academic, clinical, and public health communities.

The Emerging Infections Programs (EIPs), a population-based network involving 10 state health departments and the Centers for Disease Control and Prevention, complement and support local, regional, and national surveillance and research efforts. EIPs depend on collaboration between public health agencies and clinical and academic institutions to perform active, population-based surveillance for infectious diseases; conduct applied epidemiologic and laboratory research; implement and evaluate pilot prevention and intervention projects; and provide capacity for flexible public health response. Recent EIP work has included monitoring the impact of a new conjugate vaccine on the epidemiology of invasive pneumococcal disease, providing the evidence base used to derive new recommendations to prevent neonatal group B streptococcal disease, measuring the impact of foodborne diseases in the United States, and developing a systematic, integrated laboratory and epidemiologic method for syndrome-based surveillance.

Infectious disease hospitalizations among American Indian and Alaska native infants.

OBJECTIVE: To describe the burden and trends in hospitalizations associated with infectious diseases among American Indian and Alaska Native (AI/AN) infants. METHODS: First-listed infectious disease hospitalizations and hospitalization rates among AI/AN infants and infants in the general US population from 1988-1999 were analyzed by using Indian Health Service/tribal hospital discharge data and the National Hospital Discharge Survey data, respectively. RESULTS: Infectious disease hospitalizations accounted for 53% of all AI/AN infant hospitalizations and approximately 43% of all US infant hospitalizations during 1988-1999. The annual hospitalization rate for infectious diseases among AI/AN infants declined from 27,486 per 100,000 infants in 1988 to 14,178 per 100,000 infants in 1999. However, the rates for AI/AN infants within the Alaska, Southwest, and Northern Plains regions remained higher than that for the general US infant population at the end of the study period. Lower respiratory tract infection hospitalizations accounted for almost 75% of AI/AN infant infectious disease hospitalizations, and the lower respiratory tract infection hospitalization rate for AI/AN infants was twice that for US infants. CONCLUSIONS: Although infectious disease hospitalization rates for AI/AN infants have declined, AI/AN infants continue to have a higher infectious disease burden than the general US infant population.

Epidemiologic investigations of bioterrorism-related anthrax, New Jersey, 2001.

At least four Bacillus anthracis-containing envelopes destined for New York City and Washington, D.C. were processed at the Trenton Processing and Distribution Center (PDC) on September 18 and October 9, 2001. When cutaneous anthrax was confirmed in a Trenton postal worker, the PDC was closed. Four cutaneous and two inhalational anthrax cases were identified. Five patients were hospitalized; none died. Four were PDC employees; the others handled or received mail processed there. Onset dates occurred in two clusters following envelope processing at the PDC. The attack rate among the 170 employees present when the B. anthracis-containing letters were sorted on October 9 was 1.2%. Of 137 PDC environmental samples, 57 (42%) were positive. Five (10%) of 50 local post offices each yielded one positive sample. Cutaneous or inhalational anthrax developed in four postal employees at a facility where B. anthracis-containing letters were processed. Cross-contaminated mail or equipment was the likely source of infection in two other case-patients with cutaneous anthrax.

Surveillance for anthrax cases associated with contaminated letters, New Jersey, Delaware, and Pennsylvania, 2001.

In October 2001, two inhalational anthrax and four cutaneous anthrax cases, resulting from the processing of Bacillus anthracis-containing envelopes at a New Jersey mail facility, were identified. Subsequently, we initiated stimulated passive hospital-based and enhanced passive surveillance for anthrax-compatible syndromes. From October 24 to December 17, 2001, hospitals reported 240,160 visits and 7,109 intensive-care unit admissions in the surveillance area (population 6.7 million persons). Following a change of reporting criteria on November 8, the average of possible inhalational anthrax reports decreased 83% from 18 to 3 per day; the proportion of reports requiring follow-up increased from 37% (105/286) to 41% (47/116). Clinical follow-up was conducted on 214 of 464 possible inhalational anthrax patients and 98 possible cutaneous anthrax patients; 49 had additional laboratory testing. No additional cases were identified. To verify the limited scope of the outbreak, surveillance was essential, though labor-intensive. The flexibility of the system allowed interim evaluation, thus improving surveillance efficiency.

Neurocysticercosis in radiographically imaged seizure patients in U.S. emergency departments.

Neurocysticercosis appears to be on the rise in the United States, based on immigration patterns and published cases series, including reports of domestic acquisition. We used a collaborative network of U.S. emergency departments to characterize the epidemiology of neurocysticercosis in seizure patients. Data were collected prospectively at 11 university-affiliated, geographically diverse, urban U.S. emergency departments from July 1996 to September 1998. Patients with a seizure who underwent neuroimaging were included. Of the 1,801 patients enrolled in the study, 38 (2.1%) had seizures attributable to neurocysticercosis. The disease was detected in 9 of the 11 sites and was associated with Hispanic ethnicity, immigrant status, and exposure to areas where neurocysticercosis is endemic. This disease appears to be widely distributed and highly prevalent in certain populations (e.g., Hispanic patients) and areas (e.g., Southwest).

Update on Emerging Infections From the Centers for Disease Control and Prevention.

[Cheney P: Fatal human plague-Arizona and Colorado, 1996. Ann Emerg Med March 1998;31:410-411.].

Comparison of Three Selective Enrichment Methods for the Isolation of Listeria monocytogenes from Naturally Contaminated Foods.

Three selective enrichment procedures-the U.S. Food and Drug Administration (FDA) method, the U.S. Department of Agriculture (USDA) method, and the Netherlands Government Food Inspection Service (NGFIS) method-were compared for isolating Listeria monocytogenes from contaminated foods. The foods were obtained from the refrigerators of patients with culture-proven listeriosis who were identified through multistate active surveillance in a U.S. population of 19 million. The study was designed to identify foods that may be important in transmission of L. monocytogenes in sporadic cases of human listeriosis. Of 899 foods analyzed by all three methods, 121 were positive for L. monocytogenes by at least one method. The three enrichment methods detected L. monocytogenes in 65% (FDA), 74% (USDA), and 74% (NGFIS) of the foods shown to contain L. monocytogenes . The differences among the three methods were not statistically significant. However, the recovery of L. monocytogenes by a combination of any two methods (USDA-FDA 88%, USDA-NGFIS 91%, FDA-NGFIS 87%) was significantly better than that by one method alone (p < 0.02). The differences among the combinations of methods were not statistically significant. These results suggest that at least two enrichment methods must be used in combination to recover L. monocytogenes from contaminated foods with a success rate near 90%. Correlations were observed between negative results and low (<0.3 CFU/g) level of L. monocytogenes contamination for the USDA (p << 0.001) and NGFIS (p << 0.001) methods. A similar but somewhat weaker association was observed for the FDA method (p < 0.06).

Listeria monocytogenes Contamination of Turkey Franks: Evaluation of a Production Facility.

A facility which produced turkey franks that had been microbiologically linked to a case of human listeriosis was evaluated to establish prevalence of contamination and identify potential points for intervention. Listeria monocytogenes was isolated from only two of 41 environmental samples obtained in the plant. Among production line product samples analyzed by the Centers for Disease Control, 0 to 8% of samples from the production stages before the peeler-conveyor belt apparatus were positive for the case strain of L. monocytogenes , whereas 12 of 14 (86%) samples collected from this apparatus were positive (p <0.001). The most probable number (MPN) of L. monocytogenes in finished product purchased from a retail outlet was less than 0.3 per gram; however, the opened package of franks from the case patient's refrigerator had an MPN of >1100 per gram. These data suggest that systematic culturing and analysis of products and production facilities may help identify appropriate interventions to reduce L. monocytogenes contamination in food processing plants and contribute to control of L. monocytogenes in ready-to-eat meat products.