Community-Scale Wastewater Surveillance of Candida auris during an Ongoing Outbreak in Southern Nevada.

Candida auris is an opportunistic fungal pathogen and an emerging global public health threat, given its high mortality among infected individuals, antifungal resistance, and persistence in healthcare environments. This study explored the applicability of wastewater surveillance for C. auris in a metropolitan area with reported outbreaks across multiple healthcare facilities. Influent or primary effluent samples were collected over 10 weeks from seven sewersheds in Southern Nevada. Pelleted solids were analyzed using an adapted quantitative polymerase chain reaction (qPCR) assay targeting the ITS2 region of the C. auris genome. Positive detection was observed in 72 of 91 samples (79%), with higher detection frequencies in sewersheds serving healthcare facilities involved in the outbreak (94 vs 20% sample positivity). Influent wastewater concentrations ranged from 2.8 to 5.7 log10 gene copies per liter (gc/L), and primary clarification achieved an average log reduction value (LRV) of 1.24 ± 0.34. Presumptive negative surface water and wastewater controls were non-detect. These results demonstrate that wastewater surveillance may assist in tracking the spread of C. auris and serve as an early warning tool for public health action. These findings provide the foundation for future application of wastewater-based epidemiology (WBE) to community- or facility-level surveillance of C. auris and other high consequence, healthcare-associated infectious agents.

Antifungal Resistance Trends of Candida auris Clinical Isolates in New York and New Jersey from 2016 to 2020.

About 55% of U.S. Candida auris clinical cases were reported from New York and New Jersey from 2016 through 2020. Nearly all New York-New Jersey clinical isolates (99.8%) were fluconazole resistant, and 50% were amphotericin B resistant. Echinocandin resistance increased from 0% to 4% and pan-resistance increased from 0 to <1% for New York C. auris clinical isolates but not for New Jersey, highlighting the regional differences.

The Measurement Error Elephant in the Room: Challenges and Solutions to Measurement Error in Epidemiology.

Measurement error, although ubiquitous, is uncommonly acknowledged and rarely assessed or corrected in epidemiologic studies. This review offers a straightforward guide to common problems caused by measurement error in research studies and a review of several accessible bias-correction methods for epidemiologists and data analysts. Although most correction methods require criterion validation including a gold standard, there are also ways to evaluate the impact of measurement error and potentially correct for it without such data. Technical difficulty ranges from simple algebra to more complex algorithms that require expertise, fine tuning, and computational power. However, at all skill levels, software packages and methods are available and can be used to understand the threat to inferences that arises from imperfect measurements.

External Societal Costs of Antimicrobial Resistance in Humans Attributable to Antimicrobial Use in Livestock.

Antimicrobial use (AMU) in animal agriculture contributes to antimicrobial resistance (AMR) in humans, which imposes significant health and economic costs on society. Economists call these costs negative externalities, societal costs that are not properly reflected in market prices. We review the relevant literature and develop a model to quantify the external costs of AMU in animal agriculture on AMR in humans. Parameters required for this estimate include (a) the health and economic burden of AMR in humans,(b) the impact of AMU in animal agriculture on AMR in animals, (c) the fraction of AMR in humans attributable to animal agriculture, and (d) AMU in animals. We use a well-documented historic case to estimate an externality cost of about US$1,500 per kilogram of fluoroquinolones administered in US broiler chicken production. Enhanced data collection, particularly on the third and fourth parameters, is urgently needed to quantify more fully the externalities of AMU in animal agriculture.

Increase in Hospital-Acquired Carbapenem-Resistant Acinetobacter baumannii Infection and Colonization in an Acute Care Hospital During a Surge in COVID-19 Admissions - New Jersey, February-July 2020.

Carbapenem-resistant Acinetobacter baumannii (CRAB), an opportunistic pathogen primarily associated with hospital-acquired infections, is an urgent public health threat (1). In health care facilities, CRAB readily contaminates the patient care environment and health care providers' hands, survives for extended periods on dry surfaces, and can be spread by asymptomatically colonized persons; these factors make CRAB outbreaks in acute care hospitals difficult to control (2,3). On May 28, 2020, a New Jersey hospital (hospital A) reported a cluster of CRAB infections during a surge in patients hospitalized with coronavirus disease 2019 (COVID-19). Hospital A and the New Jersey Department of Health (NJDOH) conducted an investigation, and identified 34 patients with hospital-acquired multidrug-resistant CRAB infection or colonization during February-July 2020, including 21 (62%) who were admitted to two intensive care units (ICUs) dedicated to caring for COVID-19 patients. In late March, increasing COVID-19-related hospitalizations led to shortages in personnel, personal protective equipment (PPE), and medical equipment, resulting in changes to conventional infection prevention and control (IPC) practices. In late May, hospital A resumed normal operations, including standard IPC measures, as COVID-19 hospitalizations decreased, lessening the impact of personnel and supply chain shortages on hospital functions. CRAB cases subsequently returned to a pre-COVID-19 baseline of none to two cases monthly. The occurrence of this cluster underscores the potential for multidrug-resistant organisms (MDROs) to spread during events when standard hospital practices might be disrupted; conventional IPC strategies should be reinstated as soon as capacity and resources allow.

Assessing the difference in contamination of retail meat with multidrug-resistant bacteria using for-consumer package label claims that indicate on-farm antibiotic use practices- United States, 2016-2019.

BACKGROUND: Antibiotic use in food-producing animals can select for antibiotic resistance in bacteria that can be transmitted to people through contamination of food products during meat processing. Contamination resulting in foodborne illness contributes to adverse health outcomes. Some livestock producers have implemented antibiotic use reduction strategies marketed to consumers on regulated retail meat packaging labels ("label claims"). OBJECTIVE: We investigated whether retail meat label claims were associated with isolation of multidrug-resistant organisms (MDROs, resistant to ≥3 classes of antibiotics) from U.S. meat samples. METHODS: We utilized retail meat data from the U.S. Food and Drug Administration National Antimicrobial Resistance Monitoring System (NARMS) collected during 2016-2019 for bacterial contamination of chicken breast, ground turkey, ground beef, and pork chops. We used modified Poisson regression models to compare the prevalence of MDRO contamination among meat samples with any antibiotic restriction label claims versus those without such claims (i.e., conventionally produced). RESULTS: In NARMS, 62,338 meat samples were evaluated for bacterial growth from 2016-2019. Of these, 24,446 (39%) samples had label claims that indicated antibiotic use was restricted during animal production. MDROs were isolated from 2252 (4%) meat samples, of which 71% (n = 1591) were conventionally produced, and 29% (n = 661) had antibiotic restriction label claims. Compared with conventional samples, meat with antibiotic restriction label claims had a statistically lower prevalence of MDROs (adjusted prevalence ratio: 0.66; 95% CI: 0.61, 0.73). This relationship was consistent for the outcome of any bacterial growth. IMPACT: This repeated cross-sectional analysis of a nationally representative retail meat surveillance database in the United States supports that retail meats labeled with antibiotic restriction claims were less likely to be contaminated with MDROs compared with retail meat without such claims during 2016-2019. These findings indicate the potential for the public to become exposed to bacterial pathogens via retail meat and emphasizes a possibility that consumers could reduce their exposure to environmental reservoirs of foodborne pathogens that are resistant to antibiotics.

Clusters of emerging multidrug-resistant organisms in US health care facilities during the initial months of the SARS-CoV-2 pandemic.

BACKGROUND: Outbreaks of emerging multidrug-resistant organisms (eMDROs), including carbapenem-resistant Enterobacterales, carbapenem-resistant Acinetobacter baumannii, and Candida auris, have been reported among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients. We describe eMDRO clusters in SARS-CoV-2 units and associated infection control (IC) practices early in the SARS-CoV-2 pandemic. METHODS: We conducted a retrospective survey of a convenience sample of health departments in 11 states to describe clusters of eMDROs that began before November 1, 2020 and involved SARS-CoV-2 units. Cluster characteristics and IC practices during the cluster period were assessed using a standardized outbreak report form, and descriptive analyses were performed. RESULTS: Overall, 18 eMDRO clusters (10 carbapenem-resistant Enterobacterales, 6 C auris, 1 carbapenem-resistant Pseudomonas aeruginosa, and 1 carbapenem-resistant A baumannii) in 18 health care facilities involving 397 patients were reported from 10 states. During the cluster period, 60% of facilities reported a shortage of isolation gowns, 69% extended use of gowns, and 67% reported difficulty obtaining preferred disinfectants. Reduced frequency of hand hygiene audits was reported in 85% of acute care hospitals during the cluster period compared with before the pandemic. CONCLUSIONS: Changes in IC practices and supply shortages were identified in facilities with eMDRO outbreaks during the SARS-CoV-2 pandemic and might have contributed to eMDRO transmission.

Animal drug shortages limit veterinary therapeutic options and introduce artifacts in antimicrobial sales reporting.

Supply chain issues disrupt veterinary care and cause downstream consequences that alter the practice of veterinary medicine. Antimicrobials are just 1 class of pharmaceuticals that have been impacted by supply chain issues over the last couple of years. Since February 2021, 2 sponsors/manufacturers of penicillin products have reported shortages in the active pharmaceutical ingredient. With the release of the 2021 Summary Report on Antimicrobials Sold or Distributed for Use in Food-Producing Animals by the FDA, a key finding was a 19% decrease in penicillin sales and distribution from 2020 to 2021. Herein, we provide our clinicians' professional perspective regarding how drug shortages, specifically that of penicillin, might contribute to misconstrued patterns in antimicrobial use and what can be done by veterinarians and the FDA to minimize the impact of an antimicrobial drug shortage on animal health and well-being.

A framework for integrating wastewater-based epidemiology and public health.

Wastewater-based epidemiology (WBE) is an environmental approach to monitor community health through the analysis of sewage. The COVID-19 pandemic catalyzed scientists and public health professionals to revisit WBE as a tool to optimize resource allocation to mitigate disease spread and prevent outbreaks. Some studies have highlighted the value of WBE programs that coordinate with public health professionals; however, the details necessary for implementation are not well-characterized. To respond to this knowledge gap, this article documents the framework of a successful WBE program in Arizona, titled Wastewater Analysis for Tactical Epidemiological Response Systems (WATERS), detailing the developed structure and methods of communication that enabled public health preparedness and response actions. This communication illustrates how program operations were employed to reduce outbreak severity. The structure outlined here is customizable and may guide other programs in the implementation of WBE as a public health tool.

Impact of a Statewide Livestock Antibiotic Use Policy on Resistance in Human Urine Escherichia coli Isolates: A Synthetic Control Analysis.

BACKGROUND: On 1 January 2018, California implemented Senate Bill 27 (SB27), banning, for the first time in the United States, routine preventive use of antibiotics in food-animal production and any antibiotic use without a veterinarian's prescription. OBJECTIVES: Our objective was to assess whether SB27 was associated with decreased antimicrobial resistance among E. coli isolated from human urine. METHODS: We used U.S. nationwide monthly state-level data from BD Insights Research Database (Becton, Dickinson, and Co.) spanning 1 January 2013 to 30 June 2021 on antibiotic-resistance patterns of 30-d nonduplicate E. coli isolated from urine. Tested antibiotic classes included aminoglycosides, extended-spectrum cephalosporins (ESC), fluoroquinolones, and tetracyclines. Counts of tested and not-susceptible (resistant and intermediate, hereafter resistant) urine isolates were available by sex, age group (<65, 65+ year), month, and state. We applied a synthetic control approach to estimate the causal effect of SB27 on resistance patterns. Our approach created a synthetic California based on a composite of other states without the policy change and contrasted its counterfactual postpolicy trends with the observed postpolicy trends in California. FINDINGS: We included 7.1 million E. coli urine isolates, 90% among women, across 33 states. From 2013 to 2017, the median (interquartile range) resistance percentages in California were 11.9% (7.4, 17.6), 13.8% (5.8, 20.0), 24.6% (9.6, 36.4), 7.9% (2.1, 13.1), for aminoglycosides, ESC, fluoroquinolones, and tetracyclines, respectively. SB27 was associated with a 7.1% reduction in ESC resistance (p-value for joint null: <0.01), but no change in resistance to aminoglycosides, fluoroquinolones, or tetracyclines. DISCUSSION: Further research is needed to determine the role of SB27 in the observed reduction in ESC resistance E. coli in human populations, particularly as additional states implement similar legislation. https://doi.org/10.1289/EHP11221.

Distance and destination of retail meat alter multidrug resistant contamination in the United States food system.

Antibiotic-resistant infections are a global concern, especially those caused by multidrug-resistant (MDR) bacteria, defined as those resistant to more than three drug classes. The animal agriculture industry contributes to the antimicrobial resistant foodborne illness burden via contaminated retail meat. In the United States, retail meat is shipped across the country. Therefore, understanding geospatial factors that influence MDR bacterial contamination is vital to protect consumers and inform interventions. Using data available from the United States Food and Drug Administration's National Antimicrobial Resistance Monitoring System (NARMS), we describe retail meat shipping distances using processor and retailer locations and investigated this distance as a risk factor for MDR bacteria meat contamination using log-binomial regression. Meat samples collected during 2012-2014 totaled 11,243, of which 4791 (42.61%) were contaminated with bacteria and 835 (17.43%) of those bacteria were MDR. All examined geospatial factors were associated with MDR bacteria meat contamination. After adjustment for year and meat type, we found higher prevalence of MDR contamination among meat processed in the south (relative adjusted prevalence ratio [aPR] 1.35; 95% CI 1.06-1.73 when compared to the next-highest region), sold in Maryland (aPR 1.12; 95% CI 0.95-1.32 when compared to the next-highest state), and shipped from 194 to 469 miles (aPR 1.59; 95% CI 1.31-1.94 when compared to meats that traveled < 194 miles). However, sensitivity analyses revealed that New York sold the meat with the highest prevalence of MDR Salmonella contamination (4.84%). In this secondary analysis of NARMS data, both geographic location where products were sold and the shipping distance were associated with microbial contamination on retail meat.

Variant-specific SARS-CoV-2 shedding rates in wastewater.

Previous studies show that SARS-CoV-2 waste shedding rates vary by community and are influenced by multiple factors; however, differences in shedding rates across multiple variants have yet to be evaluated. The purpose of this work is to build on previous research that evaluated waste shedding rates for early SARS-CoV-2 and the Delta variant, and update population level waste shedding rates for the more-recent Omicron variant in six communities. Mean SARS-CoV-2 waste shedding rates were found to increase with the predominance of the Delta variant and subsequently decrease with Omicron infections. Interestingly, the Delta stage had the highest mean shedding rates and was associated with the most severe disease symptoms reported in other clinical studies, while Omicron, exhibiting reduced symptoms, had the lowest mean shedding rates. Additionally, shedding rates were most consistent across communities during the Omicron stage. This is the first paper to identify waste shedding rates specific to the Omicron variant and fills a knowledge gap critical to disease prevalence modeling.

Correction: Consumer perceptions of antimicrobial use in animal husbandry: A scoping review.

[This corrects the article DOI: 10.1371/journal.pone.0261010.].

Wastewater-Based Epidemiology Mitigates COVID-19 Outbreaks at a Food Processing Facility near the Mexico-U.S. Border-November 2020-March 2022.

Background: Wastewater-based epidemiology (WBE) has the potential to inform activities to contain infectious disease outbreaks in both the public and private sectors. Although WBE for SARS-CoV-2 has shown promise over short time intervals, no other groups have evaluated how a public-private partnership could influence disease spread through public health action over time. The aim of this study was to characterize and assess the application of WBE to inform public health response and contain COVID-19 infections in a food processing facility. Methods: Over the period November 2020-March 2022, wastewater in an Arizona food processing facility was monitored for the presence of SARS-CoV-2 using Real-Time Quantitative PCR. Upon positive detection, partners discussed public health intervention strategies, including infection control reinforcement, antigen testing, and vaccination. Results: SARS-CoV-2 RNA was detected on 18 of 205 days in which wastewater was sampled and analyzed (8.8%): seven during Wild-type predominance and 11 during Omicron-variant predominance. All detections triggered the reinforcement of infection control guidelines. In five of the 18 events, active antigen testing identified asymptomatic workers. Conclusions: These steps heightened awareness to refine infection control protocols and averted possible transmission events during periods where detection occurred. This public-private partnership has potentially decreased human illness and economic loss during the COVID-19 pandemic.

Enhancing global health security in Thailand: Strengths and challenges of initiating a One Health approach to avian influenza surveillance.

Infectious disease surveillance systems support early warning, promote preparedness, and inform public health response. Pathogens that have human, animal, and environmental reservoirs should be monitored through systems that incorporate a One Health approach. In 2016, Thailand's federal government piloted an avian influenza (AI) surveillance system that integrates stakeholders from human, animal, and environmental sectors, at the central level and in four provinces to monitor influenza A viruses within human, waterfowl, and poultry populations. This research aims to describe and evaluate Thailand's piloted AI surveillance system to inform strategies for strengthening and building surveillance systems relevant to One Health. We assessed this surveillance system using the United States Centers for Disease Control and Prevention's (U.S. CDC) "Guidelines for Evaluating Public Health Surveillance Systems" and added three novel metrics: transparency, interoperability, and security. In-depth key informant interviews were conducted with representatives among six Thai federal agencies and departments, the One Health coordinating unit, a corporate poultry producer, and the Thai Ministry of Public Health-U.S. CDC Collaborating Unit. Thailand's AI surveillance system demonstrated strengths in acceptability, simplicity, representativeness, and flexibility, and exhibited challenges in data quality, stability, security, interoperability, and transparency. System efforts may be strengthened through increasing laboratory integration, improving pathogen detection capabilities, implementing interoperable systems, and incorporating sustainable capacity building mechanisms. This innovative piloted surveillance system provides a strategic framework that can be used to develop, integrate, and bolster One Health surveillance approaches to combat emerging global pathogen threats and enhance global health security.

Population level SARS-CoV-2 fecal shedding rates determined via wastewater-based epidemiology.

Wastewater-based epidemiology (WBE) has been utilized as an early warning tool to anticipate disease outbreaks, especially during the COVID-19 pandemic. However, COVID-19 disease models built from wastewater-collected data have been limited by the complexities involved in estimating SARS-CoV-2 fecal shedding rates. In this study, wastewater from six municipalities in Arizona and Florida with distinct demographics were monitored for SARS-CoV-2 RNA between September 2020 and December 2021. Virus concentrations with corresponding clinical case counts were utilized to estimate community-wide fecal shedding rates that encompassed all infected individuals. Analyses suggest that average SARS-CoV-2 RNA fecal shedding rates typically occurred within a consistent range (7.53-9.29 log10 gc/g-feces); and yet, were unique to each community and influenced by population demographics. Age, ethnicity, and socio-economic factors may have influenced shedding rates. Interestingly, populations with median age between 30 and 39 had the greatest fecal shedding rates. Additionally, rates remained relatively constant throughout the pandemic provided conditions related to vaccination and variants were unchanged. Rates significantly increased in some communities when the Delta variant became predominant. Findings in this study suggest that community-specific shedding rates may be appropriate in model development relating wastewater virus concentrations to clinical case counts.

Consumer perceptions of antimicrobial use in animal husbandry: A scoping review.

Antimicrobial use in animal agriculture is often perceived to play a role in the emerging threat of antimicrobial resistance. Increased consumer awareness of this issue places pressure on animal husbandry to adopt policies to reduce or eliminate antimicrobial use. We use a scoping review methodology to assess research on consumer perceptions of antimicrobial drugs in meat products in the United States, Canada, or the European Union. Evaluating peer-reviewed and grey literature, we included studies for assessment if they met these topical and geographic requirements, involved primary data collection, and were originally published in English. Our screening process identified 124 relevant studies. Three reviewers jointly developed a data charting form and independently charted the contents of the studies. Of the 105 studies that measured consumer concern, 77.1% found that consumers were concerned about antimicrobial use in meat production. A minority of studies (29.8% of all studies) queried why consumers hold these views. These studies found human health and animal welfare were the main reasons for concern. Antimicrobial resistance rarely registered as an explicit reason for concern. A smaller group of studies (23.3%) measured the personal characteristics of consumers that expressed concern about antimicrobials. Among these studies, the most common and consistent features of these consumers were gender, age, income, and education. Regarding the methodology used, studies tended to be dominated by either willingness-to-pay studies or Likert scale questionnaires (73.64% of all studies). We recommend consideration of qualitative research into consumer views on this topic, which may provide new perspectives that explain consumer decision-making and mentality that are lacking in the literature. In addition, more research into the difference between what consumers claim is of concern and their ultimate purchasing decisions would be especially valuable.

Policy implications for awareness gaps in antimicrobial resistance (AMR) and antimicrobial use among commercial Nepalese poultry producers.

BACKGROUND: Nepal's poultry industry has increased with a growing middle class, which has translated to an increase in antimicrobial consumption and thus a rise in antimicrobial resistance (AMR). Describing and understanding antimicrobial use practices among commercial poultry producers in Nepal may help minimize the risks of AMR development in both humans and animals and determine the effectiveness of relevant policies. METHODS: From July to August 2018, poultry farmers were randomly recruited from Nepal's Chitwan District to participate in a cross-sectional study. The lead producer in each poultry operation was administered a quantitative structured-survey via a 30-min interview. Participants were asked to provide demographics, production practices, and knowledge about their antimicrobial use practices. Descriptive data analysis was performed to obtain frequencies and compare practices. RESULTS: In total, 150 commercial poultry producers of whom raised between 300 and 40,000 birds completed the interviews. Only 33% (n = 49) of producers reported knowing what AMR was, and among them only 50% (n = 25) consulted a veterinarian for treatment options. Antimicrobial administration for growth promotion was still employed by 13% of poultry producers. Similarly, critically important antimicrobial drugs, specifically colistin, were identified at 35% of participating operations. Producers reported low overall understanding and compliance of withdrawal periods (n = 41; 27%), which may result in both AMR development and adverse health reactions among consumers who ingest antimicrobial residues. Although Nepal has publicized antimicrobial use policies and awareness campaigns to instill healthy production practices, most producers (82%) were unaware of them. CONCLUSION: Many Nepalese poultry producers lack overall antimicrobial use and AMR awareness, which is evidenced by low antimicrobial withdrawal period compliance, use of antimicrobials for growth promotion, and the sustained use of critically important antimicrobials. Improved outreach and educational capacities, paired with increased veterinary resources and extensive monitoring in operations and retail meat products, may increase AMR awareness and policy enforcement.

Contamination of Retail Meat Samples with Multidrug-Resistant Organisms in Relation to Organic and Conventional Production and Processing: A Cross-Sectional Analysis of Data from the United States National Antimicrobial Resistance Monitoring System, 2012-2017.

BACKGROUND: During food animal production, animals are exposed to, colonized by, and sometimes infected with bacteria that may contaminate animal products with susceptible and multidrug-resistant organisms (MDRO). The United States' Organic Foods Production Act resulted in decreased antibiotic use in some animal production operations. Some studies have reported that decreased antibiotic use is associated with reduced MDRO on meat. OBJECTIVES: The aim of this study was to investigate associations of meat production and processing methods with MDRO and overall bacterial contamination of retail meats. METHODS: Bacterial contamination data from 2012 to 2017 for chicken breast, ground beef, ground turkey, and pork chops were downloaded from the National Antimicrobial Resistance Monitoring System. Poisson regression models with robust variance were used to estimate associations with MDRO contamination and any contamination (adjusted for year and meat type) overall, and according to bacteria genus (Salmonella, Campylobacter, Enterococcus, Escherichia coli) and meat type. RESULTS: A total of 39,349 retail meat samples were linked to 216 conventional, 123 split (conventional and organic), and three organic processing facilities. MDRO contamination was similar in conventionally produced meats processed at split vs. conventional facilities but was significantly lower in organically produced meats processed at split facilities [adjusted prevalance ratio (aPR)=0.43; 95% CI: 0.30, 0.63]. Meat processed by split vs. conventional processors had higher or similar MDRO contamination for all tested bacterial genera except Campylobacter (aPR=0.29; 95% CI: 0.13, 0.64). The prevalence of any contamination was lower in samples processed at split vs. conventional facilities for aggregated samples (aPR=0.70; 95% CI: 0.68, 0.73) and all meat types and bacterial genera. DISCUSSION: Organically produced and processed retail meat samples had a significantly lower prevalence of MDRO than conventionally produced and processed samples had, whereas meat from split processors had a lower prevalence of any contamination than samples from conventional processors had. Additional studies are needed to confirm findings and clarify specific production and processing practices that might explain them. https://doi.org/10.1289/EHP7327.