SARS-CoV-2 Cases Reported on International Arriving and Domestic Flights: United States, January 2020-December 2021.

Objectives. To describe trends in the number of air travelers categorized as infectious with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2; the virus that causes COVID-19) in the context of total US COVID-19 vaccinations administered, and overall case counts of SARS-CoV-2 in the United States. Methods. We searched the Quarantine Activity Reporting System (QARS) database for travelers with inbound international or domestic air travel, a positive SARS-CoV-2 lab result, and a surveillance categorization of SARS-CoV-2 infection reported during January 2020 to December 2021. Travelers were categorized as infectious during travel if they had arrival dates from 2 days before to 10 days after symptom onset or a positive viral test. Results. We identified 80 715 persons meeting our inclusion criteria; 67 445 persons (83.6%) had at least 1 symptom reported. Of 67 445 symptomatic passengers, 43 884 (65.1%) reported an initial symptom onset date after their flight arrival date. The number of infectious travelers mirrored the overall number of US SARS-CoV-2 cases. Conclusions. Most travelers in the study were asymptomatic during travel, and therefore unknowingly traveled while infectious. During periods of high community transmission, it is important for travelers to stay up to date with COVID-19 vaccinations and consider wearing a high-quality mask to decrease the risk of transmission. (Am J Public Health. 2023;113(8):904-908. https://doi.org/10.2105/AJPH.2023.307325).

Adapting Longstanding Public Health Collaborations between Government of Kenya and CDC Kenya in Response to the COVID-19 Pandemic, 2020-2021.

Kenya's Ministry of Health (MOH) and the US Centers for Disease Control and Prevention in Kenya (CDC Kenya) have maintained a 40-year partnership during which measures were implemented to prevent, detect, and respond to disease threats. During the COVID-19 pandemic, the MOH and CDC Kenya rapidly responded to mitigate disease impact on Kenya's 52 million residents. We describe activities undertaken jointly by the MOH and CDC Kenya that lessened the effects of COVID-19 during 5 epidemic waves from March through December 2021. Activities included establishing national and county-level emergency operations centers and implementing workforce development and deployment, infection prevention and control training, laboratory diagnostic advancement, enhanced surveillance, and information management. The COVID-19 pandemic provided fresh impetus for the government of Kenya to establish a national public health institute, launched in January 2022, to consolidate its public health activities and counter COVID-19 and future infectious, vaccine-preventable, and emerging zoonotic diseases.

Monkeypox in a Traveler Returning from Nigeria - Dallas, Texas, July 2021.

Monkeypox is a rare, sometimes life-threatening zoonotic infection that occurs in west and central Africa. It is caused by Monkeypox virus, an orthopoxvirus similar to Variola virus (the causative agent of smallpox) and Vaccinia virus (the live virus component of orthopoxvirus vaccines) and can spread to humans. After 39 years without detection of human disease in Nigeria, an outbreak involving 118 confirmed cases was identified during 2017-2018 (1); sporadic cases continue to occur. During September 2018-May 2021, six unrelated persons traveling from Nigeria received diagnoses of monkeypox in non-African countries: four in the United Kingdom and one each in Israel and Singapore. In July 2021, a man who traveled from Lagos, Nigeria, to Dallas, Texas, became the seventh traveler to a non-African country with diagnosed monkeypox. Among 194 monitored contacts, 144 (74%) were flight contacts. The patient received tecovirimat, an antiviral for treatment of orthopoxvirus infections, and his home required large-scale decontamination. Whole genome sequencing showed that the virus was consistent with a strain of Monkeypox virus known to circulate in Nigeria, but the specific source of the patient's infection was not identified. No epidemiologically linked cases were reported in Nigeria; no contact received postexposure prophylaxis (PEP) with the orthopoxvirus vaccine ACAM2000.

'They can stigmatize you': a qualitative assessment of the influence of school factors on engagement in care and medication adherence among adolescents with HIV in Western Kenya.

School-related factors may influence retention in care and adherence to antiretroviral therapy (ART) among adolescents with human immunodeficiency virus (HIV). We analyzed data from in-depth interviews with 40 adolescents with HIV (aged 14 -19 years), 40 caregivers of adolescents with HIV, and 4 focus group discussions with healthcare workers to evaluate contextual factors affecting adherence to ART and clinic attendance among adolescents, with a focus on the school environment. Informed by Anderson's Model of Health Services Utilization, transcripts were systematically coded and synthesized to identify school-related themes. All groups identified the school environment as a critical barrier to engagement in HIV care and medication adherence for adolescents with HIV. Adolescent participants reported inflexible school schedules and disclosure to school staff as the biggest challenges adhering to clinic appointments and ART. Adolescents described experiencing stigma and discrimination by peers and school staff and would adjust when, where and how often they took ART to avoid inadvertent disclosure. Boarding school students faced challenges because they had limited private space or time. Caregivers were often instrumental in navigating school permissions, including identifying a treatment supporter among school staff. Additional research engaging school staff may guide interventions for schools to reduce stigma and improve adherence and retention.

Reducing travel-related SARS-CoV-2 transmission with layered mitigation measures: symptom monitoring, quarantine, and testing.

BACKGROUND: Balancing the control of SARS-CoV-2 transmission with the resumption of travel is a global priority. Current recommendations include mitigation measures before, during, and after travel. Pre- and post-travel strategies including symptom monitoring, antigen or nucleic acid amplification testing, and quarantine can be combined in multiple ways considering different trade-offs in feasibility, adherence, effectiveness, cost, and adverse consequences. METHODS: We used a mathematical model to analyze the expected effectiveness of symptom monitoring, testing, and quarantine under different estimates of the infectious period, test-positivity relative to time of infection, and test sensitivity to reduce the risk of transmission from infected travelers during and after travel. RESULTS: If infection occurs 0-7 days prior to travel, immediate isolation following symptom onset prior to or during travel reduces risk of transmission while traveling by 30-35%. Pre-departure testing can further reduce risk, with testing closer to the time of travel being optimal even if test sensitivity is lower than an earlier test. For example, testing on the day of departure can reduce risk while traveling by 44-72%. For transmission risk after travel with infection time up to 7 days prior to arrival at the destination, isolation based on symptom monitoring reduced introduction risk at the destination by 42-56%. A 14-day quarantine after arrival, without symptom monitoring or testing, can reduce post-travel risk by 96-100% on its own. However, a shorter quarantine of 7 days combined with symptom monitoring and a test on day 5-6 after arrival is also effective (97--100%) at reducing introduction risk and is less burdensome, which may improve adherence. CONCLUSIONS: Quarantine is an effective measure to reduce SARS-CoV-2 transmission risk from travelers and can be enhanced by the addition of symptom monitoring and testing. Optimal test timing depends on the effectiveness of quarantine: with low adherence or no quarantine, optimal test timing is close to the time of arrival; with effective quarantine, testing a few days later optimizes sensitivity to detect those infected immediately before or while traveling. These measures can complement recommendations such as social distancing, using masks, and hand hygiene, to further reduce risk during and after travel.

Noncommunicable disease burden among HIV patients in care: a national retrospective longitudinal analysis of HIV-treatment outcomes in Kenya, 2003-2013.

BACKGROUND: Over the last decade, the Kenyan HIV treatment program has grown exponentially, with improved survival among people living with HIV (PLHIV). In the same period, noncommunicable diseases (NCDs) have become a leading contributor to disease burden. We sought to characterize the burden of four major NCDs (cardiovascular diseases, cancer, chronic respiratory diseases and diabetes mellitus) among adult PLHIV in Kenya. METHODS: We conducted a nationally representative retrospective medical chart review of HIV-infected adults aged ≥15 years enrolled in HIV care in Kenya from October 1, 2003 through September 30, 2013. We estimated proportions of four NCD categories among PLHIV at enrollment into HIV care, and during subsequent HIV care visits. We compared proportions and assessed distributions of co-morbidities using the Chi-Square test. We calculated NCD incidence rates and their confidence intervals in assessing cofactors for developing NCDs. RESULTS: We analyzed 3170 records of HIV-infected patients; 2115 (66.3%) were from women. Slightly over half (51.1%) of patient records were from PLHIVs aged above 35 years. Close to two-thirds (63.9%) of PLHIVs were on ART. Proportion of any documented NCD among PLHIV was 11.5% (95% confidence interval [CI] 9.3, 14.1), with elevated blood pressure as the most common NCD 343 (87.5%) among PLHIV with a diagnosed NCD. Despite this observation, only 17 (4.9%) patients had a corresponding documented diagnosis of hypertension in their medical record. Overall NCD incidence rates for men and women were (42.3 per 1000 person years [95% CI 35.8, 50.1] and 31.6 [95% CI 27.7, 36.1], respectively. Compared to women, the incidence rate ratio for men developing an NCD was 1.3 [95% CI 1.1, 1.7], p = 0.0082). No differences in NCD incidence rates were seen by marital or employment status. At one year of follow up 43.8% of PLHIV not on ART had been diagnosed with an NCD compared to 3.7% of patients on ART; at five years the proportions with a diagnosed NCD were 88.8 and 39.2% (p < 0.001), respectively. CONCLUSIONS: PLHIV in Kenya have a high prevalence of NCD diagnoses. In the absence of systematic, effective screening, NCD burden is likely underestimated in this population. Systematic screening and treatment for NCDs using standard guidelines should be integrated into HIV care and treatment programs in sub-Saharan Africa.

Conveyance Contact Investigation for Imported Middle East Respiratory Syndrome Cases, United States, May 2014.

In 2014, the Centers for Disease Control and Prevention conducted conveyance contact investigations for 2 Middle East respiratory syndrome cases imported into the United States, comprising all passengers and crew on 4 international and domestic flights and 1 bus. Of 655 contacts, 78% were interviewed; 33% had serologic testing. No secondary cases were identified.

Notes from the Field: Outbreak of Zika Virus Disease - American Samoa, 2016.

During December 2015-January 2016, the American Samoa Department of Health (ASDoH) detected through surveillance an increase in the number of cases of acute febrile rash illness. Concurrently, a case of laboratory-confirmed Zika virus infection, a mosquito-borne flavivirus infection documented to cause microcephaly and other severe brain defects in some infants born to women infected during pregnancy (1,2) was reported in a traveler returning to New Zealand from American Samoa. In the absence of local laboratory capacity to test for Zika virus, ASDoH initiated arboviral disease control measures, including public education and vector source reduction campaigns. On February 1, CDC staff members were deployed to American Samoa to assist ASDoH with testing and surveillance efforts.

Evolution of ebola virus disease from exotic infection to global health priority, Liberia, mid-2014.

Over the span of a few weeks during July and August 2014, events in West Africa changed perceptions of Ebola virus disease (EVD) from an exotic tropical disease to a priority for global health security. We describe observations during that time of a field team from the Centers for Disease Control and Prevention and personnel of the Liberian Ministry of Health and Social Welfare. We outline the early epidemiology of EVD within Liberia, including the practical limitations on surveillance and the effect on the country's health care system, such as infections among health care workers. During this time, priorities included strengthening EVD surveillance; establishing safe settings for EVD patient care (and considering alternative isolation and care models when Ebola Treatment Units were overwhelmed); improving infection control practices; establishing an incident management system; and working with Liberian airport authorities to implement EVD screening of departing passengers.

Measles Outbreak Associated with Vaccine Failure in Adults--Federated States of Micronesia, February-August 2014.

On May 15, 2014, CDC was notified of two laboratory-confirmed measles cases in the Federated States of Micronesia (FSM), after 20 years with no reported measles. FSM was assisted by the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and CDC in investigating suspected cases, identify contacts, conduct analyses to guide outbreak vaccination response, and review vaccine cold chain practices. During February­August, three of FSM's four states reported measles cases: Kosrae (139 cases), Pohnpei (251), and Chuuk (3). Two thirds of cases occurred among adults aged ≥20 years; of these, 49% had received ≥2 doses of measles-containing vaccine (MCV). Apart from infants aged <12 months who were too young for routine vaccination, measles incidence was lower among children than adults. A review of current cold chain practices in Kosrae revealed minor weaknesses; however, an absence of historical cold chain maintenance records precluded an evaluation of earlier problems. Each state implemented vaccination campaigns targeting children as young as age 6 months through adults up to age 57 years. The preponderance of cases in this outbreak associated with vaccine failure in adults highlights the need for both thorough case investigation and epidemiologic analysis to guide outbreak response vaccination. Routine childhood vaccination coverage achieved in recent years limited the transmission of measles among children. Even in areas where transmission has not occurred for years, maintaining high 2-dose MCV coverage through routine and supplemental immunization is needed to prevent outbreaks resulting from increased measles susceptibility in the population.

Airport exit and entry screening for Ebola--August-November 10, 2014.

In response to the largest recognized Ebola virus disease epidemic now occurring in West Africa, the governments of affected countries, CDC, the World Health Organization (WHO), and other international organizations have collaborated to implement strategies to control spread of the virus. One strategy recommended by WHO calls for countries with Ebola transmission to screen all persons exiting the country for "unexplained febrile illness consistent with potential Ebola infection." Exit screening at points of departure is intended to reduce the likelihood of international spread of the virus. To initiate this strategy, CDC, WHO, and other global partners were invited by the ministries of health of Guinea, Liberia, and Sierra Leone to assist them in developing and implementing exit screening procedures. Since the program began in August 2014, an estimated 80,000 travelers, of whom approximately 12,000 were en route to the United States, have departed by air from the three countries with Ebola transmission. Procedures were implemented to deny boarding to ill travelers and persons who reported a high risk for exposure to Ebola; no international air traveler from these countries has been reported as symptomatic with Ebola during travel since these procedures were implemented.

Zika virus outbreak on Yap Island, Federated States of Micronesia.

BACKGROUND: In 2007, physicians on Yap Island reported an outbreak of illness characterized by rash, conjunctivitis, and arthralgia. Although serum from some patients had IgM antibody against dengue virus, the illness seemed clinically distinct from previously detected dengue. Subsequent testing with the use of consensus primers detected Zika virus RNA in the serum of the patients but no dengue virus or other arboviral RNA. No previous outbreaks and only 14 cases of Zika virus disease have been previously documented. METHODS: We obtained serum samples from patients and interviewed patients for information on clinical signs and symptoms. Zika virus disease was confirmed by a finding of Zika virus RNA or a specific neutralizing antibody response to Zika virus in the serum. Patients with IgM antibody against Zika virus who had a potentially cross-reactive neutralizing-antibody response were classified as having probable Zika virus disease. We conducted a household survey to estimate the proportion of Yap residents with IgM antibody against Zika virus and to identify possible mosquito vectors of Zika virus. RESULTS: We identified 49 confirmed and 59 probable cases of Zika virus disease. The patients resided in 9 of the 10 municipalities on Yap. Rash, fever, arthralgia, and conjunctivitis were common symptoms. No hospitalizations, hemorrhagic manifestations, or deaths due to Zika virus were reported. We estimated that 73% (95% confidence interval, 68 to 77) of Yap residents 3 years of age or older had been recently infected with Zika virus. Aedes hensilli was the predominant mosquito species identified. CONCLUSIONS: This outbreak of Zika virus illness in Micronesia represents transmission of Zika virus outside Africa and Asia. Although most patients had mild illness, clinicians and public health officials should be aware of the risk of further expansion of Zika virus transmission.

"They Just Tell Me to Abstain:" Variable Access to and Uptake of Sexual and Reproductive Health Services Among Adolescents Living With HIV in Kenya.

Background: To improve holistic care for adolescents living with HIV (ALHIV), including integration of sexual and reproductive health services (SRHS), the Kenya Ministry of Health implemented an adolescent package of care (APOC). To inform optimized SRH service delivery, we sought to understand the experiences with SRHS for ALHIV, their primary caregivers, and health care workers (HCWs) following APOC implementation. Methods: We completed a mixed methods evaluation to characterize SRHS provided and personal experiences with access and uptake using surveys conducted with facility managers from 102 randomly selected large HIV treatment facilities throughout Kenya. Among a subset of 4 APOC-trained facilities in a high burden county, we conducted in-depth interviews (IDIs) with 40 ALHIV and 40 caregivers of ALHIV, and 4 focus group discussions (FGDs) with HCWs. Qualitative data was analyzed using thematic analysis. Facility survey data was analyzed using descriptive statistics. Results: Of 102 surveyed facilities, only 56% reported training in APOC and 12% reported receiving additional adolescent-related SRHS training outside of APOC. Frequency of condom provision to ALHIV varied, with 65% of facilities providing condoms daily and 11% never providing condoms to ALHIV. Family planning (FP) was provided to ALHIV daily in 60% of facilities, whereas 14% of facilities reported not providing any FP services to ALHIV. Screening and treatment for STIs for adolescents were provided at all clinics, with 67% providing STI services daily. Three key themes emerged characterizing experiences with adolescent SRHS access and uptake: (1) HCWs were the preferred source for SRH information, (2) greater adolescent autonomy was a facilitator of SRH discussions with HCWs, and (3) ALHIV had variable access to and limited uptake of SRHS within APOC-trained health facilities. The primary SRHS reported available to ALHIV were abstinence and condom use education. There was variable access to FP, condoms, pregnancy and STI testing, and partner services. Adolescents reported limited utilization of SRHS beyond education. Conclusions: Our results indicate a gap in SRHS offered within APOC trained facilities and highlight the importance of adolescent autonomy when providing SRHS and further HCW training to improve SRHS integration within HIV care for ALHIV.

Persistence of Ebola virus after the end of widespread transmission in Liberia: an outbreak report.

BACKGROUND: Outbreak response efforts for the 2014-15 Ebola virus disease epidemic in west Africa brought widespread transmission to an end. However, subsequent clusters of infection have occurred in the region. An Ebola virus disease cluster in Liberia in November, 2015, that was identified after a 15-year-old boy tested positive for Ebola virus infection in Monrovia, raised the possibility of transmission from a persistently infected individual. METHODS: Case investigations were done to ascertain previous contact with cases of Ebola virus disease or infection with Ebola virus. Molecular investigations on blood samples explored a potential linkage between Ebola virus isolated from cases in this November, 2015, cluster and epidemiologically linked cases from the 2014-15 west African outbreak, according to the national case database. FINDINGS: The cluster investigated was the family of the index case (mother, father, three siblings). Ebola virus genomes assembled from two cases in the November, 2015, cluster, and an epidemiologically linked Ebola virus disease case in July, 2014, were phylogenetically related within the LB5 sublineage that circulated in Liberia starting around August, 2014. Partial genomes from two additional individuals, one from each cluster, were also consistent with placement in the LB5 sublineage. Sequencing data indicate infection with a lineage of the virus from a former transmission chain in the country. Based on serology and epidemiological and genomic data, the most plausible scenario is that a female case in the November, 2015, cluster survived Ebola virus disease in 2014, had viral persistence or recurrent disease, and transmitted the virus to three family members a year later. INTERPRETATION: Investigation of the source of infection for the November, 2015, cluster provides evidence of Ebola virus persistence and highlights the risk for outbreaks after interruption of active transmission. These findings underscore the need for focused prevention efforts among survivors and sustained capacity to rapidly detect and respond to new Ebola virus disease cases to prevent recurrence of a widespread outbreak. FUNDING: US Centers for Disease Control and Prevention, Defense Threat Reduction Agency, and WHO.

Indigenous health in Australia, New Zealand, and the Pacific.

We survey Indigenous health issues across the Pacific with a case study approach that focuses on Australia, New Zealand, Hawai'i, and US Associated Micronesia. For each case study, we provide an overview of the Indigenous population, its colonial history, and current health and social outcomes. In the discussion that follows, we flag some of the key policy initiatives that have been developed to address Indigenous health disadvantage, albeit within the context of continuing debates about Indigenous rights and policy.

Chikungunya virus disease outbreak in Yap State, Federated States of Micronesia.

BACKGROUND: Chikungunya virus is a mosquito-borne alphavirus which causes an acute febrile illness associated with polyarthralgia. Beginning in August 2013, clinicians from the Yap State Department of Health in the Federated States of Micronesia (FSM) identified an unusual cluster of illness which was subsequently confirmed to be chikungunya virus disease. Chikungunya virus disease previously had not been recognized in FSM. METHODOLOGY/PRINCIPAL FINDINGS: Information from patients presenting to healthcare facilities was collected and analyzed. During August 11, 2013, to August 10, 2014, a total of 1,761 clinical cases were reported for an attack rate of 155 clinical cases per 1,000 population. Among residents of Yap Main Island, 3% were hospitalized. There were no deaths. The outbreak began on Yap Main Island and rapidly spread throughout Yap Main Island and to three neighboring islands. CONCLUSIONS/SIGNIFICANCE: Chikungunya virus can cause explosive outbreaks with substantial morbidity. Given the increasing globalization of chikungunya virus, strong surveillance systems and access to laboratory testing are essential to detect outbreaks.

Travel and Border Health Measures to Prevent the International Spread of Ebola.

During the 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa, CDC implemented travel and border health measures to prevent international spread of the disease, educate and protect travelers and communities, and minimize disruption of international travel and trade. CDC staff provided in-country technical assistance for exit screening in countries in West Africa with Ebola outbreaks, implemented an enhanced entry risk assessment and management program for travelers at U.S. ports of entry, and disseminated information and guidance for specific groups of travelers and relevant organizations. New and existing partnerships were crucial to the success of this response, including partnerships with international organizations, such as the World Health Organization, the International Organization for Migration, and nongovernment organizations, as well as domestic partnerships with the U.S. Department of Homeland Security and state and local health departments. Although difficult to assess, travel and border health measures might have helped control the epidemic's spread in West Africa by deterring or preventing travel by symptomatic or exposed persons and by educating travelers about protecting themselves. Enhanced entry risk assessment at U.S. airports facilitated management of travelers after arrival, including the recommended active monitoring. These measures also reassured airlines, shipping companies, port partners, and travelers that travel was safe and might have helped maintain continued flow of passenger traffic and resources needed for the response to the affected region. Travel and border health measures implemented in the countries with Ebola outbreaks laid the foundation for future reconstruction efforts related to borders and travel, including development of regional surveillance systems, cross-border coordination, and implementation of core capacities at designated official points of entry in accordance with the International Health Regulations (2005). New mechanisms developed during this response to target risk assessment and management of travelers arriving in the United States may enhance future public health responses. The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

Diabetes mellitus prevalence in out-patient Marshallese adults on Ebeye Island, Republic of the Marshall Islands.

The purpose of this study was to use a low-cost method of estimating prevalence of diabetes mellitus for a small island population receiving medical care from a single facility. A suitable sample of 692 (16.4%) from a total of 4,223 medical records of Ebeye Island Marshallese adult outpatients 30 or more years of age was reviewed in July and August 2000 for evidence of diabetes mellitus. Diagnosed diabetes was defined as having a diagnosis of diabetes noted in the chart. In patients without a diagnosis of diabetes, undiagnosed diabetes was defined as one fasting whole blood glucose > or = 70 mmol/l (126 mg/dl) or one random whole blood glucose > or = 11.1 mmol/l (200 mg/dl). Impaired fasting glucose was defined as one fasting whole blood glucose 6.1-7.0 mmol/l (110-125 mg/dl). For this population of adults 30 or more years in age, the crude prevalence of diabetes [diagnosed cases 13% (confidence interval, CI = 10-15%) and undiagnosed cases 6.9% (CI = 5.0-8.8%)] was 20% (CI = 17-23%). As the population of Ebeye is younger than the world population, adjustment to a standard world population gives an age-adjusted prevalence of diabetes in adults 30 or more years of age of 27%, and an age-adjusted prevalence in adults 20 or more years of age of 20%. In comparison, the crude prevalence of diagnosed and undiagnosed diabetes in the U.S. in adults 20 or more years of age is 8.3%, and the worldwide prevalence in adults 20 or more years of age is 4.0%. Limitations of our methodology include lack of randomization, lack of access to proper laboratory equipment, and passive case-finding, necessitating revision of standard diagnostic criteria. Prevalence rates of diabetes in Marshallese outpatients are thus significantly higher than US or worldwide rates. In addition, there are many cases of undiagnosed diabetes in the RMI. Recommended are a cross-sectional serosurvey of a large age- and gender-stratified population, increased resources to care for people with diabetes, and public health interventions to improve nutrition and facilitate physical activity in order to lower the prevalence of diabetes. The large-scale social forces that lead to diabetes need to be addressed accordingly.