Severe Illness Associated with Reported Use of Synthetic Cannabinoids - Mississippi, April 2015.

On April 2, 2015, four patients were evaluated at the University of Mississippi Medical Center (UMMC) in Jackson, Mississippi, for agitated delirium after using synthetic cannabinoids. Over the next 3 days, 24 additional persons went to UMMC with illnesses suspected to be related to synthetic cannabinoid use; one patient died. UMMC notified the Mississippi State Department of Health, which issued a statewide alert via the Health Alert Network on April 5, requesting that health care providers report suspected cases of synthetic cannabinoid intoxication to the Mississippi Poison Control Center (MPCC). A suspected case was defined as the occurrence of at least two of the following symptoms: sweating, severe agitation, or psychosis in a person with known or suspected synthetic cannabinoid use. A second statewide alert was issued on April 13, instructing all Mississippi emergency departments to submit line lists of suspected patients to MPCC each day. By April 21, 16 days after the first alert was issued, MPCC had received reports of approximately 400 cases, including eight deaths possibly linked to synthetic cannabinoid use; in contrast, during April 2012­March 2015, the median number of telephone calls to MPCC regarding synthetic cannabinoid use was one per month (range = 0­11). The Mississippi State Department of Health, with the assistance of CDC, initiated an investigation to better characterize the outbreak, identify risk factors associated with severe illness, and prevent additional illnesses and deaths.

Update of cancer and non-cancer mortality in the Missouri poultry cohort.

BACKGROUND: workers in poultry slaughtering and processing plants have one of the highest human exposures to transmissible agents that cause cancer and other diseases in chickens and turkeys, and also have other occupational carcinogenic exposures. The general population is also exposed to these transmissible agents. METHODS: we investigated mortality in workers who belong to a poultry union in Missouri, and estimated standardized mortality ratios. RESULTS: significantly increased mortality was observed for some leukemias, benign neoplasms, thyroid diseases, bacterial infections, and schizophrenic disorders. The risk of breast cancer and several non-cancer conditions was significantly depressed. CONCLUSION: the findings add to the growing evidence suggesting that workers occupationally exposed to transmissible agents and carcinogens in the poultry industry, are at increased risk of dying from certain chronic diseases, including cancer.

Mortality from malignant diseases-update of the Baltimore union poultry cohort.

We previously studied mortality up to 1989 in 2,639 members of a local union who had ever worked in poultry slaughtering and processing plants, because they were exposed to oncogenic viruses present in poultry. In this report, cancer mortality was updated to the year 2003 for 2,580 of the 2,639 subjects who worked exclusively in poultry plants. Mortality in poultry workers was compared with that in the US general population through the estimation of proportional mortality and standardized mortality ratios separately for each race/sex group and for the whole cohort. Compared to the US general population, an excess of cancers of the buccal and nasal cavities and pharynx (base of the tongue, palate and other unspecified mouth, tonsil and oropharynx, nasal cavity/middle ear/accessory sinus), esophagus, recto-sigmoid/rectum/anus, liver and intrabiliary system, myelofibrosis, lymphoid leukemia and multiple myeloma was observed in particular subgroups or in the entire poultry cohort. We hypothesize that oncogenic viruses present in poultry, and exposure to fumes, are candidates for an etiologic role to explain the excess occurrence of at least some of these cancers in the poultry workers. Larger studies which can control for confounding factors are urgently needed to determine the significance of these findings.

Severe illness associated with reported use of synthetic cannabinoids: a public health investigation (Mississippi, 2015).

STUDY OBJECTIVES: In April 2015, a multistate outbreak of illness linked to synthetic cannabinoid (SC) use was unprecedented in magnitude and severity. We identified Mississippi cases in near-real time, collected information on cases to characterize the outbreak, and identified the causative SC. METHODS: A case was defined as any patient of a Mississippi healthcare facility who was suspected of SC use and presenting with ≥2 of the following symptoms: sweating, severe agitation, or psychosis during April 2-May 3, 2015. Clinicians reported cases to the Mississippi Poison Control Center (MPCC). We used MPCC data to identify cases at the University of Mississippi Medical Center (UMMC) to characterize in further detail, including demographics and clinical findings. Biologic samples were tested for known and unknown SCs by liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF/MS). RESULTS: Clinicians reported 721 cases (11 deaths) statewide; 119 (17%) were UMMC patients with detailed data for further analysis. Twelve (10%) were admitted to an intensive care unit and 2 (2%) died. Aggression (32%), hypertension (33%), and tachycardia (42%) were common. SCs were identified in serum from 39/56 patients (70%); 33/39 patients (85%) tested positive for MAB-CHMINACA (N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide) or its metabolites. Compared to all patients tested for SCs, those positive for MAB-CHMINACA were more likely to have altered mental status on examination (OR = 3.3, p = .05). CONCLUSION: SC use can cause severe health effects. MAB-CHMINACA was the most commonly detected SC in this outbreak. As new SCs are created, new strategies to optimize surveillance and patient care are needed to address this evolving public health threat.

Hospital-based mortality in Federal Capital Territory hospitals--Nigeria, 2005-2008.

BACKGROUND: Cause-specific mortality data are important to monitor trends in mortality over time. Medical records provide reliable documentation of the causes of deaths occurring in hospitals. This study describes all causes of mortality reported at hospitals in the Federal Capital Territory (FCT) of Nigeria. METHODS: Deaths reported in 15 secondary and tertiary FCT hospitals occurring from January 1, 2005 and December 31, 2008 were identified by a retrospective review of hospital records conducted by the Nigeria Field Epidemiology and Laboratory Program (NFELTP). Data extracted from the records included sociodemographics, geographic area of residence and underlying cause-of-death information. RESULTS: A total of 4,623 deaths occurred in the hospitals. Overall, the top five causes of death reported were: HIV 951 (21%), road traffic accidents 422 (9%), malaria 264 (6%), septicemia 206 (5%), and hypertension 194 (4%). The median age at death was 30 years (range: 0-100); 888 (20%) of deaths were among those less than one year of age. Among children < 1 year, low birth weight and infections were responsible for the highest proportion 131 (15%) of reported mortality. CONCLUSION: Many of the leading causes of mortality identified in this study are preventable. Infant mortality is a large public health problem in FCT hospitals. Although these findings are not representative of all FCT deaths, they may be used to quantify mortality in that occurs in FCT hospitals. These data combined with other mortality surveillance data can provide evidence to inform policy on public health strategies and interventions for the FCT.

Influenza preparedness and response: involvement of African Field Epidemiology and Laboratory Training Programs, 2009.

BACKGROUND: The capacity of public health professionals to rapidly detect and respond to disease pandemics is critical to understand and control global disease spread. On June 11, 2009, the World Health Organization (WHO) declared H1N1 virus infection as pandemic. In May 2009, we assessed the participation of Field Epidemiology and Laboratory Training Programs (FELTPs) based in sub-Saharan Africa on pandemic influenza preparedness and response. METHODS: We administered an electronic survey to directors and resident advisors of African Field Epidemiology Network (AFENET) member and associate FELTPs. The survey included questions on the following attributes: program involvement in suspected H1N1 investigations, experience in influenza outbreak investigations, national influenza surveillance and response plans, and H1N1 outbreak preparedness. RESULTS: Nine countries (100%) responded to the survey; all had existing national influenza response plans. Six programs reported their trainees had participated in past pandemic preparedness and response exercise, five (83%) of them were influenza specific. CONCLUSION: FELTPs played an important role in H1N1 surveillance and response in sub-Saharan Africa. Continued technical assistance and support to these programs is vital to foster their capacity to monitor and control public health threats.

A pilot case-cohort study of liver and pancreatic cancers in poultry workers.

PURPOSE: To test the hypothesis that exposure to poultry oncogenic viruses that widely occurs occupationally in poultry workers and in the general population, may be associated with increased risks of deaths from liver and pancreatic cancers, and to identify new risk factors. METHODS: A pilot case-cohort study of both cancers within a combined cohort of 30,411 highly exposed poultry workers and 16,408 control subjects was conducted, and risk assessed by logistic regression odds ratios (OR) and proportional hazards risk ratios. RESULTS: New occupational findings were recorded respectively for pancreatic/liver cancers, for slaughtering of poultry (OR = 8.9, 95% confidence interval [CI]: 2.7-29.3)/OR = 9.1, 95% CI: 1.9-42.9); catching of live chickens (OR = 3.6, 95% CI: 1.2-10.9)/OR = 1.0, 95% CI: 0.1-8.5); killing other types of animals for food (OR = 4.8, 95% CI: 1.5-16.6)/OR = 2.0, 95% CI: 0.2-18.2), and ever worked on a pig raising farm (OR = 3.0, 95% CI: 1.0-8.2) for pancreatic cancer only. New non-occupational findings for liver cancer were for receiving immunization with yellow fever vaccine (OR = 8.7, 95% CI: 1.0-76.3); and vaccination with typhoid vaccine (OR = 6.3, 95% CI: 1.1-37.4). The study also confirmed previously reported risk factors for both diseases. CONCLUSIONS: This study provides preliminary evidence that exposure to poultry oncogenic viruses may possibly be associated with the occurrence of liver and pancreatic cancers. Case-control studies nested within occupational cohorts of highly exposed subjects of sufficient statistical power may provide an efficient and valid method of investigating/confirming these findings.

Field Epidemiology and Laboratory Training Programs in sub-Saharan Africa from 2004 to 2010: need, the process, and prospects.

As of 2010 sub-Saharan Africa had approximately 865 million inhabitants living with numerous public health challenges. Several public health initiatives [e.g., the United States (US) President's Emergency Plan for AIDS Relief and the US President's Malaria Initiative] have been very successful at reducing mortality from priority diseases. A competently trained public health workforce that can operate multi-disease surveillance and response systems is necessary to build upon and sustain these successes and to address other public health problems. Sub-Saharan Africa appears to have weathered the recent global economic downturn remarkably well and its increasing middle class may soon demand stronger public health systems to protect communities. The Epidemic Intelligence Service (EIS) program of the US Centers for Disease Control and Prevention (CDC) has been the backbone of public health surveillance and response in the US during its 60 years of existence. EIS has been adapted internationally to create the Field Epidemiology Training Program (FETP) in several countries. In the 1990s CDC and the Rockefeller Foundation collaborated with the Uganda and Zimbabwe ministries of health and local universities to create 2-year Public Health Schools Without Walls (PHSWOWs) which were based on the FETP model. In 2004 the FETP model was further adapted to create the Field Epidemiology and Laboratory Training Program (FELTP) in Kenya to conduct joint competency-based training for field epidemiologists and public health laboratory scientists providing a master's degree to participants upon completion. The FELTP model has been implemented in several additional countries in sub-Saharan Africa. By the end of 2010 these 10 FELTPs and two PHSWOWs covered 613 million of the 865 million people in sub-Saharan Africa and had enrolled 743 public health professionals. We describe the process that we used to develop 10 FELTPs covering 15 countries in sub-Saharan Africa from 2004 to 2010 as a strategy to develop a locally trained public health workforce that can operate multi-disease surveillance and response systems.