Development and Evaluation of Surveillance System for Identifying Jail-Associated COVID-19 Cases in Minnesota, USA, 2022.

Confinement facilities are high-risk settings for the spread of infectious disease, necessitating timely surveillance to inform public health action. To identify jail-associated COVID-19 cases from electronic laboratory reports maintained in the Minnesota Electronic Disease Surveillance System (MEDSS), Minnesota, USA, the Minnesota Department of Health developed a surveillance system that used keyword and address matching (KAM). The KAM system used a SAS program (SAS Institute Inc., https://www.sas.com) and an automated program within MEDSS to identify confinement keywords and addresses. To evaluate KAM, we matched jail booking data from the Minnesota Statewide Supervision System by full name and birthdate to the MEDSS records of adults with COVID-19 for 2022. The KAM system identified 2,212 cases in persons detained in jail; sensitivity was 92.40% and specificity was 99.95%. The success of KAM demonstrates its potential to be applied to other diseases and congregate-living settings for real-time surveillance without added reporting burden.

Outbreaks Associated with Untreated Recreational Water - California, Maine, and Minnesota, 2018-2019.

Outbreaks associated with fresh or marine (i.e., untreated) recreational water can be caused by pathogens or chemicals, including toxins. Voluntary reporting of these outbreaks to CDC's National Outbreak Reporting System (NORS) began in 2009. NORS data for 2009-2017 are finalized, and data for 2018-2019 are provisional. During 2009-2019 (as of May 13, 2020), public health officials from 31 states voluntarily reported 119 untreated recreational water-associated outbreaks, resulting at least 5,240 cases; 103 of the outbreaks (87%) started during June-August. Among the 119 outbreaks, 88 (74%) had confirmed etiologies. The leading etiologies were enteric pathogens: norovirus (19 [22%] outbreaks; 1,858 cases); Shiga toxin-producing Escherichia coli (STEC) (19 [22%]; 240), Cryptosporidium (17 [19%]; 237), and Shigella (14 [16%]; 713). This report highlights three examples of outbreaks that occurred during 2018-2019, were caused by leading etiologies (Shigella, norovirus, or STEC), and demonstrate the wide geographic distribution of such outbreaks across the United States. Detection and investigation of untreated recreational water-associated outbreaks are challenging, and the sources of these outbreaks often are not identified. Tools for controlling and preventing transmission of enteric pathogens through untreated recreational water include epidemiologic investigations, regular monitoring of water quality (i.e., testing for fecal indicator bacteria), microbial source tracking, and health policy and communications (e.g., observing beach closure signs and not swimming while ill with diarrhea).

Evaluation of an ensemble-based distance statistic for clustering MLST datasets using epidemiologically defined clusters of cyclosporiasis.

Outbreaks of cyclosporiasis, a food-borne illness caused by the coccidian parasite Cyclospora cayetanensis have increased in the USA in recent years, with approximately 2300 laboratory-confirmed cases reported in 2018. Genotyping tools are needed to inform epidemiological investigations, yet genotyping Cyclospora has proven challenging due to its sexual reproductive cycle which produces complex infections characterized by high genetic heterogeneity. We used targeted amplicon deep sequencing and a recently described ensemble-based distance statistic that accommodates heterogeneous (mixed) genotypes and specimens with partial genotyping data, to genotype and cluster 648 C. cayetanensis samples submitted to CDC in 2018. The performance of the ensemble was assessed by comparing ensemble-identified genetic clusters to analogous clusters identified independently based on common food exposures. Using these epidemiologic clusters as a gold standard, the ensemble facilitated genetic clustering with 93.8% sensitivity and 99.7% specificity. Hence, we anticipate that this procedure will greatly complement epidemiologic investigations of cyclosporiasis.

Multicenter Evaluation of Clinical Diagnostic Methods for Detection and Isolation of Campylobacter spp. from Stool.

The use of culture-independent diagnostic tests (CIDTs), such as stool antigen tests, as standalone tests for the detection of Campylobacter in stool is increasing. We conducted a prospective, multicenter study to evaluate the performance of stool antigen CIDTs compared to culture and PCR for Campylobacter detection. Between July and October 2010, we tested 2,767 stool specimens from patients with gastrointestinal illness with the following methods: four types of Campylobacter selective media, four commercial stool antigen assays, and a commercial PCR assay. Illnesses from which specimens were positive by one or more culture media or at least one CIDT and PCR were designated "cases." A total of 95 specimens (3.4%) met the case definition. The stool antigen CIDTs ranged from 79.6% to 87.6% in sensitivity, 95.9 to 99.5% in specificity, and 41.3 to 84.3% in positive predictive value. Culture alone detected 80/89 (89.9% sensitivity) Campylobacter jejuni/Campylobacter coli-positive cases. Of the 209 noncases that were positive by at least one CIDT, only one (0.48%) was positive by all four stool antigen tests, and 73% were positive by just one stool antigen test. The questionable relevance of unconfirmed positive stool antigen CIDT results was supported by the finding that noncases were less likely than cases to have gastrointestinal symptoms. Thus, while the tests were convenient to use, the sensitivity, specificity, and positive predictive value of Campylobacter stool antigen tests were highly variable. Given the relatively low incidence of Campylobacter disease and the generally poor diagnostic test characteristics, this study calls into question the use of commercially available stool antigen CIDTs as standalone tests for direct detection of Campylobacter in stool.

Two concurrent enteric disease outbreaks among men who have sex with men, minneapolis-st paul area.

Between 1 November 2013 and 31 March 2014, concurrent shigellosis and cryptosporidiosis outbreaks occurred among men who have sex with men in the Minneapolis-St. Paul area, 75% of whom were HIV-infected. Current HIV/AIDS strategy emphasizing treatment as prevention may effectively decrease HIV transmission, but raises concerns about other diseases if safer sex messages are de-emphasized.

Raw milk consumption among patients with non-outbreak-related enteric infections, Minnesota, USA, 2001-2010.

Raw milk has frequently been identified as the source of foodborne illness outbreaks; however, the number of illnesses ascertained as part of documented outbreaks likely represents a small proportion of the actual number of illnesses associated with this food product. Analysis of routine surveillance data involving illnesses caused by enteric pathogens that were reportable in Minnesota during 2001-2010 revealed that 3.7% of patients with sporadic, domestically acquired enteric infections had reported raw milk consumption during their exposure period. Children were disproportionately affected, and 76% of those <5 years of age were served raw milk from their own or a relative's farm. Severe illness was noted, including hemolytic uremic syndrome among 21% of Escherichia coli O157-infected patients reporting raw milk consumption, and 1 death was reported. Raw milk consumers, potential consumers, and policy makers who might consider relaxing regulations regarding raw milk sales should be educated regarding illnesses associated with raw milk consumption.

Campylobacter prosthetic joint infection.

A 75-year-old man was diagnosed with probable Campylobacter jejuni prosthetic knee infection after a diarrheal illness. Joint aspirate and operative cultures were negative, but PCR of prosthesis sonicate fluid was positive, as was stool culture. Nineteen additional cases of Campylobacter prosthetic joint infection reported in the literature are reviewed.

Epidemiology and antimicrobial resistance of international travel-associated Campylobacter infections in the United States, 2005-2011.

OBJECTIVES: The objective of this study was to determine the role international travel plays in US Campylobacter epidemiology and antimicrobial resistance. METHODS: In this study, epidemiological and antimicrobial resistance data, encompassing the years 2005 to 2011, from 10 sites participating in the Foodborne Diseases Active Surveillance Network were linked. The 10 sites are represented by 7 states that conducted surveillance on a statewide level, and 3 states which conducted county-level surveillance. Cases of Campylobacter among persons with history of international travel in the week prior to illness were compared with cases among individuals with no international travel. RESULTS: Approximately 18% of Campylobacter infections were estimated to be associated with international travel, and 60% of international travel-associated infections had a quinolone-resistant Campylobacter isolate. CONCLUSIONS: We confirm that international travel plays a significant role in campylobacteriosis diagnosed in the United States. Recognizing this is important to both medical management decisions and understanding burden and attribution estimates of US campylobacteriosis and antibiotic-resistant campylobacteriosis.

Pool chemical-associated health events in public and residential settings - United States, 2003-2012, and Minnesota, 2013.

Pool chemicals are added to treated recreational water venues (e.g., pools, hot tubs/spas, and interactive fountains) primarily to protect public health by inactivating pathogens and maximizing the effectiveness of disinfection by controlling pH. However, pool chemicals also can cause injuries when handled or stored improperly. To estimate the number of emergency department (ED) visits for injuries associated with pool chemicals in the United States per year during 2003-2012, CDC analyzed data from the U.S. Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS). This report summarizes the results of that analysis. In 2012 alone, an estimated 4,876 persons (95% confidence interval [CI] = 2,821-6,930) visited an ED for injuries associated with pool chemicals. Almost half of the patients were aged <18 years. This report also describes a pool chemical-associated health event that occurred in Minnesota in 2013, which sent seven children and one adult to an ED. An investigation by the Minnesota Department of Health (MDH) determined the cause to be poor monitoring of or response to pool chemistry. Pool chemical-associated health events are preventable. CDC's Model Aquatic Health Code (MAHC) (1) is a resource that state and local agencies can use to optimize prevention of injuries and illnesses associated with public treated recreational water venues, including pool chemical-associated health events.

Impacts of culture-independent diagnostic practices on public health surveillance for bacterial enteric pathogens.

For decades, culture has been the mainstay of diagnostic testing for bacterial enteric pathogens. This paradigm is changing as clinical laboratories adopt culture-independent methods, such as antigen-based tests and nucleic acid-based assays. Public health surveillance for enteric infections addresses 4 interrelated but distinct objectives: case investigation for localized disease control; assessment of disease burden and trends to prioritize and assess impact of population-based control measures; outbreak detection; and microbiologic characterization to improve understanding of pathogens, their virulence mechanisms, and epidemiology. We summarize the challenges and opportunities that culture-independent tests present and suggest strategies, such as validation studies and development of culture-independent tests compatible with subtyping, that could be adopted to ensure that surveillance remains robust. Many of these approaches will require time and resources to implement, but they will be necessary to maintain a strong surveillance system. Public health practitioners must clearly explain the value of surveillance, especially how outbreak detection benefits the public, and collaborate with all stakeholders to develop solutions.

Clinical laboratory practices for the isolation and identification of Campylobacter in Foodborne Diseases Active Surveillance Network (FoodNet) sites: baseline information for understanding changes in surveillance data.

BACKGROUND: Campylobacter is a leading cause of foodborne illness in the United States. Understanding laboratory practices is essential to interpreting incidence and trends in reported campylobacteriosis over time and provides a baseline for evaluating the increasing use of culture-independent diagnostic methods for Campylobacter infection. METHODS: The Foodborne Diseases Active Surveillance Network (FoodNet) conducts surveillance for laboratory-confirmed Campylobacter infections. In 2005, FoodNet conducted a survey of clinical laboratories to describe routine practices used for isolation and identification of Campylobacter. A profile was assigned to laboratories based on complete responses to key survey questions that could impact the recovery and isolation of Campylobacter from stool specimens. RESULTS: Of 411 laboratories testing on-site for Campylobacter, 97% used only culture methods. Among those responding to the individual questions, nearly all used transport medium (97%) and incubated at 42°C (94%); however, most deviated from existing guidelines in other areas: 68% held specimens in transport medium at room temperature before plating, 51% used Campy blood agar plate medium, 52% read plates at <72 hours of incubation, and 14% batched plates before placing them in a microaerobic environment. In all, there were 106 testing algorithms among 214 laboratories with a complete profile; only 16 laboratories were fully adherent to existing guidelines. CONCLUSIONS: Although most laboratories used culture-based methods, procedures differed widely and most did not adhere to existing guidelines, likely resulting in underdiagnosis. Given the availability of new culture-independent testing methods, these data highlight a clear need to develop best practice recommendations for Campylobacter infection diagnostic testing.

Estimates of enteric illness attributable to contact with animals and their environments in the United States.

BACKGROUND: Contact with animals and their environment is an important, and often preventable, route of transmission for enteric pathogens. This study estimated the annual burden of illness attributable to animal contact for 7 groups of pathogens: Campylobacter species, Cryptosporidium species, Shiga toxin-producing Escherichia coli (STEC) O157, STEC non-O157, Listeria monocytogenes, nontyphoidal Salmonella species, and Yersinia enterocolitica. METHODS: By using data from the US Foodborne Diseases Active Surveillance Network and other sources, we estimated the proportion of illnesses attributable to animal contact for each pathogen and applied those proportions to the estimated annual number of illnesses, hospitalizations, and deaths among US residents. We established credible intervals (CrIs) for each estimate. RESULTS: We estimated that 14% of all illnesses caused by these 7 groups of pathogens were attributable to animal contact. This estimate translates to 445 213 (90% CrI, 234 197-774 839) illnesses annually for the 7 groups combined. Campylobacter species caused an estimated 187 481 illnesses annually (90% CrI, 66 259-372 359), followed by nontyphoidal Salmonella species (127 155; 90% CrI, 66 502-219 886) and Cryptosporidium species (113 344; 90% CrI, 22 570-299 243). Of an estimated 4933 hospitalizations (90% CrI, 2704-7914), the majority were attributable to nontyphoidal Salmonella (48%), Campylobacter (38%), and Cryptosporidium (8%) species. Nontyphoidal Salmonella (62%), Campylobacter (22%), and Cryptosporidium (9%) were also responsible for the majority of the estimated 76 deaths (90% CrI, 5-211). CONCLUSIONS: Animal contact is an important transmission route for multiple major enteric pathogens. Continued efforts are needed to prevent pathogen transmission from animals to humans, including increasing awareness and encouraging hand hygiene.

Evaluation of the positive predictive value of rapid assays used by clinical laboratories in Minnesota for the diagnosis of cryptosporidiosis.

We evaluated the positive predictive value (PPV) of rapid assays used by clinical laboratories in Minnesota to diagnose cryptosporidiosis. The overall PPV was 56% for rapid assays versus 97% for nonrapid assays; clinicians and laboratorians need to be aware of the low PPV of rapid assays when diagnosing cryptosporidiosis.

Hospital Water Management Programs for Legionella Prevention, Minnesota, 2017.

Infection preventionists at Minnesota hospitals were surveyed to determine whether they had Legionella water management plans. Of 137 hospitals, 84 (61%) responded. Among them, 27% hospitals had a water management plan, 21% regularly sampled for Legionella, and 51% had knowledge of ASHRAE Legionella prevention standards. Significant changes are needed to protect patients from nosocomial infection. Infect Control Hosp Epidemiol 2018;39:336-338.

Community Laboratory Testing for Cryptosporidium: Multicenter Study Retesting Public Health Surveillance Stool Samples Positive for Cryptosporidium by Rapid Cartridge Assay with Direct Fluorescent Antibody Testing.

Cryptosporidium is a common cause of sporadic diarrheal disease and outbreaks in the United States. Increasingly, immunochromatography-based rapid cartridge assays (RCAs) are providing community laboratories with a quick cryptosporidiosis diagnostic method. In the current study, the Centers for Disease Control and Prevention (CDC), the Association of Public Health Laboratories (APHL), and four state health departments evaluated RCA-positive samples obtained during routine Cryptosporidium testing. All samples underwent "head to head" re-testing using both RCA and direct fluorescence assay (DFA). Community level results from three sites indicated that 54.4% (166/305) of Meridian ImmunoCard STAT! positives and 87.0% (67/77) of Remel Xpect positives were confirmed by DFA. When samples were retested by RCA at state laboratories and compared with DFA, 83.3% (155/186) of Meridian ImmunoCard STAT! positives and 95.2% (60/63) of Remel Xpect positives were confirmed. The percentage of confirmed community results varied by site: Minnesota, 39.0%; New York, 63.9%; and Wisconsin, 72.1%. The percentage of confirmed community results decreased with patient age; 12.5% of community positive tests could be confirmed by DFA for patients 60 years of age or older. The percentage of confirmed results did not differ significantly by sex, storage temperature, time between sample collection and testing, or season. Findings from this study demonstrate a lower confirmation rate of community RCA positives when compared to RCA positives identified at state laboratories. Elucidating the causes of decreased test performance in order to improve overall community laboratory performance of these tests is critical for understanding the epidemiology of cryptosporidiosis in the United States (US).

Use of global trade item numbers in the investigation of a salmonella newport outbreak associated with blueberries in Minnesota, 2010.

In August 2010, the Minnesota Department of Agriculture and Minnesota Department of Health investigated an outbreak of six cases of Salmonella Newport infection occurring in northwestern Minnesota, which identified fresh blueberries as the cause. Initially, traditional traceback methods involving the review of invoices and bills of lading were used to attempt to identify the source of the outbreak. When these methods failed, novel traceback methods were used. Specifically, supplier-specific 12-digit Global Trade Item Numbers (GTINs) and shopper-card information were used to identify a single blueberry grower linked to cases, corroborating the results of a case-control study in which consuming fresh blueberries was statistically associated with illness (5 of 5 cases versus 8 of 19 controls, matched odds ratio [MOR] undefined, P = 0.02). Consuming fresh blueberries from retailer A was also statistically associated with illness (3 of 3 cases versus 3 of 18 controls, MOR undefined, P = 0.03). Based on initially incomplete evidence in this investigation, the invoices pointed to wholesaler A and grower A, based on first-in-first-out product rotation. However, when point-of-sale data were analyzed and linked to shopper-card information, a common GTIN was identified. This information led to an on-site record evaluation at retailer A, and the discovery of additional records at this location documented the supply chain from grower B to wholesaler C to retailer A, shifting the focus of the investigation from grower A to grower B. This investigation demonstrates the emerging concepts of Critical Tracking Events (CTEs) and Key Data Elements (KDE) related to food product tracing. The use of these shopper-cased data and the event data that were queried by investigators demonstrates the potential utility of consciously designed CTEs and KDEs at critical points in the supply chain to better facilitate product tracing.