Mpox Cases Among Cisgender Women and Pregnant Persons - United States, May 11-November 7, 2022.

Monkeypox (mpox) cases in the 2022 outbreak have primarily occurred among adult gay, bisexual, and other men who have sex with men (MSM); however, other populations have also been affected (1). To date, data on mpox in cisgender women and pregnant persons have been limited. Understanding transmission in these populations is critical for mpox prevention. In addition, among pregnant persons, Monkeypox virus can be transmitted to the fetus during pregnancy or to the neonate through close contact during or after birth (2-5). Adverse pregnancy outcomes, including spontaneous abortion and stillbirth, have been reported in previous mpox outbreaks (3). During May 11-November 7, 2022, CDC and U.S. jurisdictional health departments identified mpox in 769 cisgender women aged ≥15 years, representing 2.7% of all reported mpox cases.† Among cases with available data, 44% occurred in cisgender women who were non-Hispanic Black or African American (Black), 25% who were non-Hispanic White (White), and 23% who were Hispanic or Latino (Hispanic). Among cisgender women with available data, 73% reported sexual activity or close intimate contact as the likely route of exposure, with mpox lesions most frequently reported on the legs, arms, and genitals. Twenty-three mpox cases were reported in persons who were pregnant or recently pregnant§; all identified as cisgender women based on the mpox case report form.¶ Four pregnant persons required hospitalization for mpox. Eleven pregnant persons received tecovirimat, and no adverse reactions were reported. Continued studies on mpox transmission risks in populations less commonly affected during the outbreak, including cisgender women and pregnant persons, are important to assess and understand the impact of mpox on sexual, reproductive, and overall health.

Impact of population based indoor residual spraying with and without mass drug administration with dihydroartemisinin-piperaquine on malaria prevalence in a high transmission setting: a quasi-experimental controlled before-and-after trial in northeastern Uganda.

BACKGROUND: Declines in malaria burden in Uganda have slowed. Modelling predicts that indoor residual spraying (IRS) and mass drug administration (MDA), when co-timed, have synergistic impact. This study investigated additional protective impact of population-based MDA on malaria prevalence, if any, when added to IRS, as compared with IRS alone and with standard of care (SOC). METHODS: The 32-month quasi-experimental controlled before-and-after trial enrolled an open cohort of residents (46,765 individuals, 1st enumeration and 52,133, 4th enumeration) of Katakwi District in northeastern Uganda. Consented participants were assigned to three arms based on residential subcounty at study start: MDA+IRS, IRS, SOC. IRS with pirimiphos methyl and MDA with dihydroartemisinin- piperaquine were delivered in 4 co-timed campaign-style rounds 8 months apart. The primary endpoint was population prevalence of malaria, estimated by 6 cross-sectional surveys, starting at baseline and preceding each subsequent round. RESULTS: Comparing malaria prevalence in MDA+IRS and IRS only arms over all 6 surveys (intention-to-treat analysis), roughly every 6 months post-interventions, a geostatistical model found a significant additional 15.5% (95% confidence interval (CI): [13.7%, 17.5%], Z = 9.6, p = 5e-20) decrease in the adjusted odds ratio (aOR) due to MDA for all ages, a 13.3% reduction in under 5's (95% CI: [10.5%, 16.8%], Z = 4.02, p = 5e-5), and a 10.1% reduction in children 5-15 (95% CI: [8.5%, 11.8%], Z = 4.7, p = 2e-5). All ages residents of the MDA + IRS arm enjoyed an overall 80.1% reduction (95% CI: [80.0%, 83.0%], p = 0.0001) in odds of qPCR confirmed malaria compared with SOC residents. Secondary difference-in-difference analyses comparing surveys at different timepoints to baseline showed aOR (MDA + IRS vs IRS) of qPCR positivity between 0.28 and 0.66 (p < 0.001). Of three serious adverse events, one (nonfatal) was considered related to study medications. Limitations include the initial non-random assignment of study arms, the single large cluster per arm, and the lack of an MDA-only arm, considered to violate equipoise. CONCLUSIONS: Despite being assessed at long time points 5-7 months post-round, MDA plus IRS provided significant additional protection from malaria infection over IRS alone. Randomized trials of MDA in large areas undergoing IRS recommended as well as cohort studies of impact on incidence. TRIAL REGISTRATION: This trial was retrospectively registered 11/07/2018 with the Pan African Clinical Trials Registry (PACTR201807166695568).

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Transmission Associated With an Indoor Music Event That Required Proof of Full Vaccination Against Coronavirus Disease 2019 (COVID-19) Prior to Entry-Seattle, July 2021.

In July 2021, Public Health-Seattle & King County investigated a coronavirus disease 2019 (COVID-19) outbreak at an indoor event intended for fully vaccinated individuals, revealing unvaccinated staff, limited masking, poor ventilation, and overcrowding. Supporting businesses to develop and implement comprehensive COVID-19 prevention plans is essential for reducing spread in these settings.

Monkeypox Outbreak - Nine States, May 2022.

On May 17, 2022, the Massachusetts Department of Public Health (MDPH) Laboratory Response Network (LRN) laboratory confirmed the presence of orthopoxvirus DNA via real-time polymerase chain reaction (PCR) from lesion swabs obtained from a Massachusetts resident. Orthopoxviruses include Monkeypox virus, the causative agent of monkeypox. Subsequent real-time PCR testing at CDC on May 18 confirmed that the patient was infected with the West African clade of Monkeypox virus. Since then, confirmed cases* have been reported by nine states. In addition, 28 countries and territories,† none of which has endemic monkeypox, have reported laboratory-confirmed cases. On May 17, CDC, in coordination with state and local jurisdictions, initiated an emergency response to identify, monitor, and investigate additional monkeypox cases in the United States. This response has included releasing a Health Alert Network (HAN) Health Advisory, developing interim public health and clinical recommendations, releasing guidance for LRN testing, hosting clinician and public health partner outreach calls, disseminating health communication messages to the public, developing protocols for use and release of medical countermeasures, and facilitating delivery of vaccine postexposure prophylaxis (PEP) and antivirals that have been stockpiled by the U.S. government for preparedness and response purposes. On May 19, a call center was established to provide guidance to states for the evaluation of possible cases of monkeypox, including recommendations for clinical diagnosis and orthopoxvirus testing. The call center also gathers information about possible cases to identify interjurisdictional linkages. As of May 31, this investigation has identified 17§ cases in the United States; most cases (16) were diagnosed in persons who identify as gay, bisexual, or men who have sex with men (MSM). Ongoing investigation suggests person-to-person community transmission, and CDC urges health departments, clinicians, and the public to remain vigilant, institute appropriate infection prevention and control measures, and notify public health authorities of suspected cases to reduce disease spread. Public health authorities are identifying cases and conducting investigations to determine possible sources and prevent further spread. This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy.¶.

Epidemiologic and Clinical Features of Children and Adolescents Aged <18 Years with Monkeypox - United States, May 17-September 24, 2022.

Data on monkeypox in children and adolescents aged <18 years are limited (1,2). During May 17­September 24, 2022, a total of 25,038 monkeypox cases were reported in the United States,† primarily among adult gay, bisexual, and other men who have sex with men (3). During this period, CDC and U.S. jurisdictional health departments identified Monkeypox virus (MPXV) infections in 83 persons aged <18 years, accounting for 0.3% of reported cases. Among 28 children aged 0­12 years with monkeypox, 64% were boys, and most had direct skin-to-skin contact with an adult with monkeypox who was caring for the child in a household setting. Among 55 adolescents aged 13­17 years, most were male (89%), and male-to-male sexual contact was the most common presumed exposure route (66%). Most children and adolescents with monkeypox were non-Hispanic Black or African American (Black) (47%) or Hispanic or Latino (Hispanic) (35%). Most (89%) were not hospitalized, none received intensive care unit (ICU)­level care, and none died. Monkeypox in children and adolescents remains rare in the United States. Ensuring equitable access to monkeypox vaccination, testing, and treatment is a critical public health priority. Vaccination for adolescents with risk factors and provision of prevention information for persons with monkeypox caring for children might prevent additional infections.

Spatial clustering of cholera cases in the Kathmandu Valley: implications for a ring vaccination strategy.

BACKGROUND: In mid-2016, a cholera outbreak occurred in Kathmandu Valley, Nepal. This retrospective study aims to determine if a reactive, ring vaccination strategy would have been useful in preventing cholera transmission during that outbreak. METHODS: Data on cholera cases were collected as part of hospital-based surveillance in the Kathmandu Valley in 2016. Global Positioning System (GPS) coordinates were obtained during household visits. Geographic clusters of cases were visually determined and tested statistically for clustering. Cluster size was determined based on the distribution of cases around the index case. RESULTS: GPS coordinates for 69 cases were analysed. Six geographic clusters were identified, all of which showed significant clustering of cases. Approximately 85% of cases within a cluster occurred more than 7 d after the index case. The median ring size was 1 km, with a population of 14 000 people. CONCLUSIONS: Cholera cases were clustered in space and the majority of cases occurred over 1 week after the initial cases in the cluster, allowing for an opportunity to prevent transmission through the use of the vaccine soon after the initial case was identified. A ring vaccination strategy may be especially useful for large urban areas with recurrent seasonal outbreaks but where the specific locations for such outbreaks are not predictable.

Laboratory and Field Evaluation of the Crystal VC-O1 Cholera Rapid Diagnostic Test.

Cholera is a severe acute, highly transmissible diarrheal disease which affects many low- and middle-income countries. Outbreaks of cholera are confirmed using microbiological culture, and additional cases during the outbreak are generally identified based on clinical case definitions, rather than laboratory confirmation. Many low-resource areas where cholera occurs lack the capacity to perform culture in an expeditious manner. A simple, reliable, and low-cost rapid diagnostic test (RDT) would improve identification of cases allowing rapid response to outbreaks. Several commercial RDTs are available for cholera testing with two lines to detect either serotypes O1 and O139; however, issues with sensitivity and specificity have not been optimal with these bivalent tests. Here, we report an evaluation of a new commercially available cholera dipstick test which detects only serotype O1. In both laboratory and field studies in Kenya, we demonstrate high sensitivity (97.5%), specificity (100%), and positive predictive value (100%) of this new RDT targeting only serogroup O1. This is the first field evaluation for the new Crystal VC-O1 RDT; however, with these high-performance metrics, this RDT could significantly improve cholera outbreak detection and improve surveillance for better understanding of cholera disease burden.

Suture Button Suspensionplasty in the Treatment of Carpometacarpal Arthritis: A Retrospective Analysis of One Surgeon's Experience Over 9 Years.

Purpose: Trapeziectomy with suture button suspensionplasty (SBS) to treat thumb carpometacarpal (CMC) arthritis has been proposed as an alternative to ligament reconstruction tendon interposition. There have been limited large-scale or long-term reports regarding SBS outcomes. Single-surgeon intermediate follow-up is reported. Methods: We conducted a retrospective review of patients undergoing SBS procedures by a single surgeon. Implant manufacturer and postoperative immobilization protocol were recorded. Surgical outcomes, complications, and revision procedures were identified. Postoperative Disabilities of the Arm, Shoulder, and Hand scores were collected. Results: A total of 242 SBS surgeries were included, involving 215 patients, average age 64.82 years (range, 42-86 years). Average follow-up was 35 ± 25 months. In all, 183 Arthrex and 59 Stryker systems were used, 42 of which were immobilized for 6 weeks after surgery and 200 of which were mobilized at 2 weeks afterward. Postoperative Disabilities of the Arm, Shoulder, and Hand surveys were completed by 122 patients (57%), with an average score of 12. No scaphometacarpal abutment was reported. Thirteen complications were reported (5%), 7 of which were implant-associated (3%) and 6 of which were not (2%). Implant-associated complications consisted of 3 suture button pull-outs, 2 thumb-index metacarpal abutments, one suture tail irritation, and one index metacarpal fracture. Operative revision was required in 4 of 7 implant-associated cases and 5 of 6 non-implant associated cases. No suture button pull-outs required revision surgery. Conclusions: Results for a large series of SBS for CMC arthroplasty with intermediate follow-up revealed excellent clinical outcomes and low complication rates. Clinical relevance: Suture button suspensionplasty as an alternative to ligament reconstruction tendon interposition may be a viable option for treating thumb CMC arthritis. In addition, a technique to manage thumb-index metacarpal abutment is described.

Use of surveys to evaluate an integrated oral cholera vaccine campaign in response to a cholera outbreak in Hoima district, Uganda.

OBJECTIVES: To evaluate the quality and coverage of the campaign to distribute oral cholera vaccine (OCV) during a cholera outbreak in Hoima, Uganda to guide future campaigns of cholera vaccine. DESIGN: Survey of communities targeted for vaccination to determine vaccine coverage rates and perceptions of the vaccination campaign, and a separate survey of vaccine staff who carried out the campaign. SETTING: Hoima district, Uganda. PARTICIPANTS: Representative clusters of households residing in the communities targeted for vaccination and staff members who conducted the vaccine campaign. RESULTS: Among 209 households (1274 individuals) included in the coverage survey, 1193 (94%; 95% CI 92% to 95%) reported receiving at least one OCV dose and 998 (78%; 95% CI 76% to 81%) reported receiving two doses. Among vaccinated individuals, minor complaints were reported by 71 persons (5.6%). Individuals with 'some' education (primary school or above) were more knowledgeable regarding the required OCV doses compared with non-educated (p=0.03). Factors negatively associated with campaign implementation included community sensitisation time, staff payment and problems with field transport. Although the campaign was carried out quickly, the outbreak was over before the campaign started. Most staff involved in the campaign (93%) were knowledgeable about cholera control; however, 29% did not clearly understand how to detect and manage adverse events following immunisation. CONCLUSION: The campaign achieved high OCV coverage, but the surveys provided insights for improvement. To achieve high vaccine coverage, more effort is needed for community sensitisation, and additional resources for staff transportation and timely payment for campaign staff is required. Pretest and post-test assessment of staff training can identify and address knowledge and skill gaps.

Lessons Learned from Enhancing Sentinel Surveillance for Cholera in Post-Earthquake Nepal in 2016.

A major earthquake in 2015 that struck Nepal created a favorable environment for the rapid spread of infectious diseases. In anticipation of a cholera outbreak in 2016, UNICEF, Johns Hopkins University, and the Group for Technical Assistance, Nepal, collaborated to assist the government of Nepal to strengthen early warning surveillance, laboratory-based diagnosis, and field investigation. This article outlines the challenges and lessons learned in cholera prevention and control based on the authors' experiences in 2016. Priorities for the future plan should include sustaining the enhanced surveillance system for acute gastroenteritis and cholera, rolling out a rapid diagnostic test, and ensuring rapid and systematic epidemiological investigation and environmental testing.

Feasibility of a Comprehensive Targeted Cholera Intervention in The Kathmandu Valley, Nepal.

A comprehensive targeted intervention (CTI) was designed and deployed in the neighborhoods of cholera cases in the Kathmandu Valley with the intent of reducing rates among the neighbors of the case. This was a feasibility study to determine whether clinical centers, laboratories, and field teams were able to mount a rapid, community-based response to a case within 2 days of hospital admission. Daily line listings were requested from 15 participating hospitals during the monsoon season, and a single case initiated the CTI. A standard case definition was used: acute watery diarrhea, with or without vomiting, in a patient aged 1 year or older. Rapid diagnostic tests and bacterial culture were used for confirmation. The strategy included household investigation of cases; water testing; water, sanitation, and hygiene (WASH) intervention; and health education. A CTI coverage survey was conducted 8 months postintervention. From June to December of 2016, 169 cases of Vibrio cholerae O1 were confirmed by bacterial culture. Average time to culture result was 3 days. On average, the CTI Rapid Response Team (RRT) was able to visit households 1.7 days after the culture result was received from the hospital (3.9 days from hospital admission). Coverage of WASH and health behavior messaging campaigns were 30.2% in the target areas. Recipients of the intervention were more likely to have knowledge of cholera symptoms, treatment, and prevention than non-recipients. Although the RRT were able to investigate cases at the household within 2 days of a positive culture result, the study identified several constraints that limited a truly rapid response.

Emergency response in water, sanitation and hygiene to control cholera in post-earthquake Nepal in 2016.

After the 2015 earthquake in Nepal that killed approximately 9,000 people, the country faced an increased risk of cholera outbreaks due to extensive destruction of water and sanitation infrastructure and massive displacement. The disaster revealed long-standing weaknesses in water and sanitation systems in the country. Anticipating a cholera outbreak in 2016, UNICEF, Johns Hopkins University, and the Group for Technical Assistance partnered to support the Government of Nepal to ensure a safe water supply and improve sanitation and hygiene. This article discusses challenges, gaps, lessons learned and recommendations that were drawn from the authors' experience in cholera prevention and control in post-earthquake Nepal. Challenges identified include lack of regular water quality testing and monitoring, inconsistent use of point-of-use water treatment products, and lack of a fast-track mechanism for rapid response. The article argues for building a resilient water and sanitation system to secure sustainable and equitable access to safe drinking water.

Use of Near-Infrared Spectroscopy to Detect Sustained Hyperaemia Following Lower Extremity Trauma.

INTRODUCTION: Patients who sustain lower extremity trauma are at highest risk for acute compartment syndrome (ACS) during the first 48 hours after surgical stabilization. Near-infrared spectroscopy (NIRS) may be a useful monitoring tool for ACS during this period; however, expected normal values have yet to be established. This study sought to evaluate whether the expected hyperaemic response is present 48 hours postoperatively, using NIRS. MATERIALS AND METHODS: Participants consisted of 25 cases with acute unilateral lower extremity fractures. NIRS measurements for hemoglobin saturated with oxygen (rSO2) were taken approximately 48 hours after surgical stabilization for each compartment bilaterally, using the contralateral (uninjured) leg as an internal control. RESULTS: Mean rSO2 values taken 48 hours from surgical stabilization from each compartment of the patients' injured legs were significantly higher than the mean values of the contralateral legs (injured = 70, 68, 72, 70; contralateral = 55, 54, 57, 56 for anterior, lateral, deep posterior, and superficial posterior compartments, respectively; p < 0.0001 for all compartments). CONCLUSIONS: These results suggest that the hyperaemic response to injury remains present at 48 hours after surgical stabilization, and that NIRS values in an injured extremity should be expected to remain elevated throughout the window of concern for ACS. NIRS may be a valuable tool in monitoring leg injuries during this critical time period.

Cadaveric Study of Appropriate Screw Length for Distal Radius Stabilization Using Volar Plate Fixation.

We conducted a study to highlight areas of risk with distal radius fixation to prevent occurrence of extensor tendon injury without compromising the security and stability of the fixation. Twelve cadaveric forearms were used. The volar locking plate was placed to best anatomical and radiologic fit on the distal radius of each arm. All 7 holes in the plate were drilled, and bicortical length was measured using a depth gauge under fluoroscopy to estimate screw lengths. Screws were secured into place, and dorsal prominence was measured. The central screw positions had the least dorsal screw prominence, mean (SD) of 0.50 (1.06) mm, and were considered low-risk. The radial and ulnar screw positions had more dorsal screw prominence, 3.38 (1.38) mm and 1.03 (1.30) mm, respectively. Although only radial prominence was statistically significant, both radial and ulnar screw positions were considered high-risk and in need of screw length adjustments. The data suggest that screw length for this plate should be decreased by about 3 mm for the radial positions and by 1 mm for the ulnar positions to decrease the risk for tendon rupture and irritation secondary to dorsal screw prominence.

Subcutaneous depth in a traumatized lower extremity.

BACKGROUND: Acute compartment syndrome is a rare but serious consequence of traumatic leg injury. Near-infrared spectroscopy (NIRS) is able to measure oxygenation to a depth of 2 cm to 3 cm below the skin, raising concerns over the ability of NIRS to accurately determine oxygenation of injured leg compartments in the presence of swelling and in the obese. The purpose of this study was to measure the thickness of the subcutaneous tissue overlying the posterior muscle compartment in subjects with tibia fractures to determine if it might compromise rSO2 measurement in the muscle. METHODS: Data were analyzed on 50 patients with severe leg injuries. Distance from the skin to the fascia in the superficial posterior compartment of both legs was measured on each patient using a portable ultrasound device. RESULTS: Subject age ranged from 18 years to 65 years (mean, 39 years), with 43 male and 7 female patients. The mean (SD) subcutaneous adipose tissue thickness (ATT) was 6.98 (3.17) mm for the injured leg and 7.06 (3.37) mm for the uninjured leg, and the mean body mass index for the group was 27.08 kg/m. No significant correlation was found between the ATT of the injured or uninjured legs and body mass index. Mean comparison testing revealed no difference in ATT between the injured and uninjured legs (null hypothesis: equal means, p > 0.05). Of the 50 subjects analyzed, no subject had a subcutaneous depth of more than 2 cm on the injured or uninjured leg. CONCLUSION: These data suggest that, within this traumatically injured population, symptoms associated with leg injury (such as swelling and edema) do not significantly affect the distance from the skin to the fascia. It is also notable that subcutaneous depth beyond the 2-cm mark (validated in previous studies) is a rare occurrence in this population. These results further support the use of continuous NIRS monitoring for diagnosis of acute compartment syndrome. LEVEL OF EVIDENCE: Therapeutic study, level IV.