Evaluation of Online Risk Assessment To Identify Rabies Exposures Among Health Care Workers - Utah, 2019.

On November 7, 2018, the Utah Department of Health (UDOH) reported the first confirmed human rabies death in the state since 1944 (1). The case occurred in a person who had been treated over a period of 19 days at four health care facilities and an emergency medical transport service across three counties and two states. Human rabies is preventable through preexposure or postexposure vaccination but is invariably fatal upon symptom onset. Timely identification of persons who might have been exposed to rabies virus is therefore crucial to administer postexposure prophylaxis (PEP). Because of the large number of health care workers who had been involved in the patient's care, a standardized online risk assessment survey was developed by UDOH based on Advisory Committee on Immunization Practices recommendations (2). This online tool was evaluated for accuracy, acceptability, and administrative obligation by reviewing the results from the tool and conducting focus group discussions and a follow-up survey. Among 90 health care workers initially identified by the online risk assessment as being potentially exposed to infectious material, 74 were classified as exposed. All 74 health care workers received PEP following consultation with occupational health staff members, indicating a positive predictive value of the assessment tool of 82%. In a follow-up survey, 42 (76%) of the 55 respondents reported that they were satisfied with the assessment process. In focus group discussions, participants suggested that the survey could be improved by providing additional information about rabies exposures because many of them were unfamiliar with human-to-human rabies transmission. This evaluation highlighted the importance of adopting clear communication strategies, demonstrated the benefits of using an online risk assessment during a mass rabies exposure, and provided specific feedback for CDC to improve resources available for states and health care facilities after mass rabies exposures.

Human Rabies - Utah, 2018.

On November 3, 2018, the Utah Department of Health (UDOH) was notified of a suspected human rabies case in a man aged 55 years. The patient's symptoms had begun 18 days earlier, and he was hospitalized for 15 days before rabies was suspected. As his symptoms worsened, he received supportive care, but he died on November 4. On November 7, a diagnosis of rabies was confirmed by CDC. This was the first documented rabies death in a Utah resident since 1944. This report summarizes the patient's clinical course and the subsequent public health investigation, which determined that the patient had handled several bats in the weeks preceding symptom onset. Public health agencies, in partnership with affected health care facilities, identified and assessed the risk to potentially exposed persons, facilitated receipt of postexposure prophylaxis (PEP), and provided education to health care providers and the community about the risk for rabies associated with bats. Human rabies is rare and almost always fatal. The findings from this investigation highlight the importance of early recognition of rabies, improved public awareness of rabies in bats, and the use of innovative tools after mass rabies exposure events to ensure rapid and recommended risk assessment and provision of PEP.

Enhanced Surveillance for Coccidioidomycosis, 14 US States, 2016.

Although coccidioidomycosis in Arizona and California has been well-characterized, much remains unknown about its epidemiology in states where it is not highly endemic. We conducted enhanced surveillance in 14 such states in 2016 by identifying cases according to the Council of State and Territorial Epidemiologists case definition and interviewing patients about their demographic characteristics, clinical features, and exposures. Among 186 patients, median time from seeking healthcare to diagnosis was 38 days (range 1-1,654 days); 70% had another condition diagnosed before coccidioidomycosis testing occurred (of whom 83% were prescribed antibacterial medications); 43% were hospitalized; and 29% had culture-positive coccidioidomycosis. Most (83%) patients from nonendemic states had traveled to a coccidioidomycosis-endemic area. Coccidioidomycosis can cause severe disease in residents of non-highly endemic states, a finding consistent with previous studies in Arizona, and less severe cases likely go undiagnosed or unreported. Improved coccidioidomycosis awareness in non-highly endemic areas is needed.

Infection control response to an outbreak of OXA-23 carbapenemase-producing carbapenem-resistant Acinetobacter baumannii in a skilled nursing facility in Utah.

BACKGROUND: Antibiotic-resistant Acinetobacter species are a growing public health threat, yet are not nationally notifiable, and most states do not mandate reporting. Additionally, there are no standardized methods to detect Acinetobacter species colonization. METHODS: An outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) was identified at a Utah ventilator unit in a skilled nursing facility. An investigation was conducted to identify transmission modes in order to control spread of CRAB. Culture-based methods were used to identify patient colonization and environmental contamination in the facility. RESULTS: Of the 47 patients screened, OXA-23-producing CRAB were detected in 10 patients (21%), with 7 patients (15%) having been transferred from out-of-state facilities. Of patients who screened positive, 60% did not exhibit any signs or symptoms of active infection by chart review. A total of 38 environmental samples were collected and CRAB was recovered from 37% of those samples. Whole genome sequencing analyses of patient and environmental isolates suggested repeated CRAB introduction into the facility and highlighted the role of shared equipment in transmission. CONCLUSIONS: The investigation demonstrated this ventilated skilled nursing facility was an important reservoir for CRAB in the community and highlights the need for improved surveillance, strengthened infection control and inter-facility communication within and across states.

Socioeconomic Determinants of Cipro-floxacin-Resistant Shigella Infections in Bangladeshi Children.

BACKGROUND: Shigella species (spp.) are a leading cause of moderate to severe diarrhea in children worldwide. The recent emergence of quinolone-resistant Shigella spp. gives cause for concern, and South Asia has been identified as a reservoir for global spread. The influence of socioeconomic status on antimicrobial resistance in developing countries, such as those in South Asia, remains unknown. METHODS: We used data collected from 2009 to 2014 from a hospital specializing in the treatment of diarrhea in Dhaka, Bangladesh, to determine the relationship between Ciprofloxacin-resistant Shigella spp. isolates and measures of socioeconomic status in Bangladeshi children less than 5 years of age. RESULTS: We found 2.7% (230/8,672) of children who presented with diarrhea had Shigella spp. isolated from their stool, and 50% (115/230) had resistance to Ciprofloxacin. Using multivariable logistic regression analysis, we found that children from families where the father's income was in the highest quintile had significantly higher odds of having Ciprofloxacin-resistant Shigella spp. compared to children in the lowest quintile (OR = 6.1, CI 1.9-19). Factors protective against the development of resistance included access to improved sanitation (OR = 0.27, CI 0.11-0.7), and improved water sources (OR = 0.48, CI 0.25-0.92). We did not find a relationship between Ciprofloxacin resistance and other proxies for socioeconomic status, including the presence of animals in the home, nutritional status, paternal education level, and the number of family members in the home. CONCLUSIONS: Although the associations between wealth and antimicrobial resistance are not fully understood, possible explanations include increased access and use of antibiotics, greater access to healthcare facilities and thus resistant pathogens, or greater consumption of commercially produced foods prepared with antibiotics.

Immune Responses to an Oral Cholera Vaccine in Internally Displaced Persons in South Sudan.

Despite recent large-scale cholera outbreaks, little is known about the immunogenicity of oral cholera vaccines (OCV) in African populations, particularly among those at highest cholera risk. During a 2015 preemptive OCV campaign among internally displaced persons in South Sudan, a year after a large cholera outbreak, we enrolled 37 young children (1-5 years old), 67 older children (6-17 years old) and 101 adults (≥18 years old), who received two doses of OCV (Shanchol) spaced approximately 3 weeks apart. Cholera-specific antibody responses were determined at days 0, 21 and 35 post-immunization. High baseline vibriocidal titers (>80) were observed in 21% of the participants, suggesting recent cholera exposure or vaccination. Among those with titers ≤80, 90% young children, 73% older children and 72% adults seroconverted (≥4 fold titer rise) after the 1st OCV dose; with no additional seroconversion after the 2nd dose. Post-vaccination immunological endpoints did not differ across age groups. Our results indicate Shanchol was immunogenic in this vulnerable population and that a single dose alone may be sufficient to achieve similar short-term immunological responses to the currently licensed two-dose regimen. While we found no evidence of differential response by age, further immunologic and epidemiologic studies are needed.