Coccidioidomycosis outbreak among inmate wildland firefighters: California, 2017.

BACKGROUND: In California, state prison inmates are employed to fight wildfires, which involves performing soil-disrupting work. Wildfires have become more common, including areas where Coccidioides, the soil-dwelling fungus that causes coccidioidomycosis, proliferates. However, work practices that place wildland firefighters at risk for coccidioidomycosis have not been investigated. METHODS: On August 17, 2017, the California Department of Public Health was notified of a cluster of coccidioidomycosis cases among Wildfire A inmate wildland firefighters. We collected data through medical record abstraction from suspected case-patients and mailed a survey assessing potential job task risk factors to Wildfire A inmate firefighters. We described respondent characteristics and conducted a retrospective case-control investigation to assess coccidioidomycosis risk factors. RESULTS: Among 198 inmate firefighters who worked on Wildfire A, 112 (57%) completed the survey. Of 10 case-patients (four clinical and six laboratory-confirmed), two were hospitalized. In the case-control analysis of 71 inmate firefighters, frequently cutting fire lines with a McLeod tool (odds ratio [OR]: 5.5; 95% confidence interval [CI]: 1.1-37.2) and being in a dust cloud or storm (OR: 4.3; 95% CI: 1.1-17.4) were associated with illness. Two of 112 inmate firefighters reported receiving coccidioidomycosis training; none reported wearing respiratory protection on this wildfire. CONCLUSIONS: Wildland firefighters who use hand tools and work in dusty conditions where Coccidioides proliferates are at risk for coccidioidomycosis. Agencies that employ them should provide training about coccidioidomycosis and risk reduction, limit dust exposure, and implement respiratory protection programs that specify where respirator use is feasible and appropriate.

California's Prisoner Protections for Family and Community Health Act : Implementing a Mandated Condom Access Program in State Prisons, 2015-2016.

In 2014, California passed Assembly Bill 966, which required condom access for persons incarcerated in all 35 California state prisons (33 men's and 2 women's prisons). The California Correctional Health Care Services and the Sexually Transmitted Disease Control Branch and the Office of AIDS of the California Department of Public Health collaborated in a prison administration-led multidisciplinary implementation workgroup. Our workgroup, representing public health, correctional health, legal and legislative affairs, labor relations, and prison staff members, participated in 4 planning meetings during May-September 2015. We surveyed prison staff members and incarcerated men to identify and address potential challenges; conceptualized a tamper-resistant condom dispenser; developed educational materials, frequently asked questions for staff members, and fact sheets for the public; and conducted forums for custody and medical staff members at each prison. Key lessons learned included the need for high-level custody support, engagement of labor unions early in the decision-making process, and flexibility within defined parameters for sites to determine best practices given their unique institutional population, culture, and physical layout. Condom access was initiated at 4 prisons in July 2015 and expanded incrementally to the remaining 29 men's prisons through July 2016. A total of 243 563 condoms were accessed in the men's prisons, for an average of 354 condoms per 1000 population per month. The start-up dispenser cost was $69 825 (735 dispensers at $95 each). We estimated an annual condom cost of $0.60 per person. Although staff members and incarcerated men expressed concern that this legislation would condone sex and provide repositories for contraband, no serious adverse incidents involving condoms were reported. California demonstrated that condom access is a safe, low-cost intervention with high uptake for a large correctional system and provided a replicable implementation model for other states. Prison condom programs have the potential to decrease transmission of sexually transmitted infections (STIs) among incarcerated persons and their communities, which are often disproportionately affected by STIs, HIV, and other chronic diseases.

Completion Rates, Adverse Effects, and Costs of a 3-Month and 9-Month Treatment Regimen for Latent Tuberculosis Infection in California Inmates, 2011-2014.

OBJECTIVES: In California, about 80% of tuberculosis disease is caused by untreated latent tuberculosis infection (LTBI), and the rate of LTBI is higher among incarcerated persons (16%) than among nonincarcerated persons (6%). We compared 2 regimens to treat LTBI in an adult prison population in California: 9 months of twice-weekly isoniazid (9H; previous standard of care) and 12 once-weekly doses of isoniazid and rifapentine (3HP; introduced in 2011). METHODS: We evaluated the rates of completion and discontinuation caused by hepatotoxicity among randomly selected patients with LTBI prescribed the 9H regimen in 2011 and among patients with LTBI prescribed the 3HP regimen who entered California prisons during September 2013-March 2014. We compared the cost per fully treated patient for the 2 regimens. RESULTS: Of 92 patients treated with the 9H regimen, the treatment completion rate was 42% and discontinuation due to hepatotoxicity was 14%. Of 122 patients who accepted the 3HP regimen, the completion rate was 90% and discontinuation due to hepatotoxicity was 2%. The cost per fully treated patient for the 9H regimen was $981 and for 3HP was $652. CONCLUSIONS: In an incarcerated population, the 3HP regimen had a higher completion rate, lower hepatotoxicity, and lower cost per fully treated patient than the 9H regimen. If coupled with a high treatment initiation rate, the high rate of LTBI treatment completion with 3HP may contribute to reducing tuberculosis morbidity in California.

Update on the Epidemiology of coccidioidomycosis in the United States.

The incidence of reported coccidioidomycosis in the past two decades has increased greatly; monitoring its changing epidemiology is essential for understanding its burden on patients and the healthcare system and for identifying opportunities for prevention and education. We provide an update on recent coccidioidomycosis trends and public health efforts nationally and in Arizona, California, and Washington State. In Arizona, enhanced surveillance shows that coccidioidomycosis continues to be associated with substantial morbidity. California reported its highest yearly number of cases ever in 2016 and has implemented interventions to reduce coccidioidomycosis in the prison population by excluding certain inmates from residing in prisons in high-risk areas. Coccidioidomycosis is emerging in Washington State, where phylogenetic analyses confirm the existence of a unique Coccidioides clade. Additional studies of the molecular epidemiology of Coccidioides will improve understanding its expanding endemic range. Ongoing public health collaborations and future research priorities are focused on characterizing geographic risk, particularly in the context of environmental change; identifying further risk reduction strategies for high-risk groups; and improving reporting of cases to public health agencies.

Risk Stratification With Coccidioidal Skin Test to Prevent Valley Fever Among Inmates, California, 2015.

Two California state prisons (A and B) have very high rates of coccidioidomycosis (Valley Fever). The prison health care service sought to improve their prevention strategy by risk stratification with a newly available spherulin-based Coccidioides delayed-type hypersensitivity test. Of the 36,789 voluntarily screened inmates, 4.7% experienced adverse reactions. A positive test (8.6% of those tested) was independently associated with (1) incarceration at prisons A and B, (2) admission to prison from a Coccidioides-endemic county, (3) length of stay at prisons A and B, and (4) increasing age. These findings suggest that the test is safe and performing well at risk stratification; the prison system now restricts inmates with negative tests from prisons A and B. This novel use of the test might benefit other coccidioidomycosis prevention programs.

Increased Coccidioidomycosis Among Inmates at a California Prison: Initial Investigation in 2005 to 2006.

Since 2005, coccidioidomycosis has increased among inmates at a California prison. Our initial investigation found an incidence of 3,323 cases/100,000 persons. Black race, age ≥41 years, and residence on Yard C were significantly associated with coccidioidomycosis ( p < .05). Inmates at this prison have continued to be at risk for coccidioidomycosis.

Awareness and Environmental Exposures Related to Coccidioidomycosis Among Inmates at Two California Prisons, 2013.

Coccidioidomycosis (Valley fever) is a major cause of illness in inmates in some California prisons. This article discusses an investigation conducted at two prisons to describe potential environmental exposures. The study did not identify modifiable risk factors; limiting the type or duration of outdoor activity in these prisons may not decrease coccidioidomycosis morbidity.

Evaluation of Routine HIV Opt-Out Screening and Continuum of Care Services Following Entry into Eight Prison Reception Centers--California, 2012.

Early diagnosis of human immunodeficiency virus (HIV) infection and initiation of antiretroviral treatment (ART) improves health outcomes and prevents HIV transmission. Before 2010, HIV testing was available to inmates in the California state prison system upon request. In 2010, the California Correctional Health Care Services (CCHCS) integrated HIV opt-out screening into the health assessment for inmates entering California state prisons. Under this system, a medical care provider informs the inmate that an HIV test is routinely done, along with screening for sexually transmitted, communicable, and vaccine-preventable diseases, unless the inmate specifically declines the test. During 2012-2013, CCHCS, the California Department of Public Health, and CDC evaluated HIV screening, rates of new diagnoses, linkage to and retention in care, ART response, and post-release linkage to care among California prison inmates. All prison inmates are processed through one of eight specialized reception center facilities, where they undergo a comprehensive evaluation of their medical needs, mental health, and custody requirements for placement in one of 35 state prisons. Among 17,436 inmates who entered a reception center during April-September 2012, 77% were screened for HIV infection; 135 (1%) tested positive, including 10 (0.1%) with newly diagnosed infections. Among the 135 HIV-positive patient-inmates, 134 (99%) were linked to care within 90 days of diagnosis, including 122 (91%) who initiated ART. Among 83 who initiated ART and remained incarcerated through July 2013, 81 (98%) continued ART; 71 (88%) achieved viral suppression (<200 HIV RNA copies/mL). Thirty-nine patient-inmates were released on ART; 12 of 14 who were linked to care within 30 days of release were virally suppressed at that time. Only one of nine persons with a viral load test conducted between 91 days and 1 year post-release had viral suppression. Although high rates of viral suppression were achieved in prison, continuity of care in the community remains a challenge. An infrastructure for post-release linkage to care is needed to help ensure sustained HIV disease control.

Rates and risk factors for Coccidioidomycosis among prison inmates, California, USA, 2011.

In California, coccidioidomycosis is a disease acquired by inhaling spores of Coccidioides immitis, a fungus found in certain arid regions, including the San Joaquin Valley, California, USA, where 8 state prisons are located. During 2011, we reviewed coccidioidomycosis rates at 2 of the prisons that consistently report >80% of California's inmate cases and determined inmate risk factors for primary, severe (defined as pulmonary coccidioidomycosis requiring >10 hospital days), and disseminated coccidioidomycosis (defined by hospital discharge International Classification of Disease, Ninth Revision code). Inmates of African American ethnicity who were >40 years of age were at significantly higher risk for primary coccidioidomycosis than their white counterparts (odds ratio = 2.0, 95% CI 1.5-2.8). Diabetes was a risk factor for severe pulmonary coccidioidomycosis, and black race a risk factor for disseminated disease. These findings contributed to a court decision mandating exclusion of black inmates and inmates with diabetes from the 2 California prisons with the highest rates of coccidioidomycosis.

Challenges with controlling varicella in prison settings: experience of California, 2010 to 2011.

This article describes the epidemiology of varicella in one state prison in California during 2010 and 2011, control measures implemented, and associated costs. Eleven varicella cases were reported, of which nine were associated with two outbreaks. One outbreak consisted of three cases and the second consisted of six cases with two generations of spread. Among exposed inmates serologically tested, 98% (643/656) were varicella-zoster virus seropositive. The outbreaks resulted in > 1,000 inmates exposed, 444 staff exposures, and > $160,000 in costs. The authors documented the challenges and costs associated with controlling and managing varicella in a prison setting. A screening policy for evidence of varicella immunity for incoming inmates and staff and vaccination of susceptible persons has the potential to mitigate the impact of future outbreaks and reduce resources necessary to manage cases and outbreaks.

Risk, Feasibility, and Cost Evaluation of a Prisoner Condom Access Pilot Program in One California State Prison.

This study evaluated the safety and security impact, feasibility, and cost of a program to provide condoms to inmates. A 1-year pilot study of wall-mounted condom dispensing machines in one California state prison compared pre- and post-intervention rates of penal code violations related to sexual misconduct, contraband, controlled substances, and violence. The rates of penal code violations were unchanged or decreased compared to the pre-pilot year. Discreetly located condom dispensers were vandalized less frequently than those in plain view (p < .05). Distributing condoms using the pilot model would cost less than $2 per inmate annually. Results suggest that the use of discreetly located dispensing machines is an acceptable, feasible, low-cost option to prevent the transmission of sexually transmitted diseases and poses no safety or security risk in a typical medium-security prison setting.

Syphilis outbreak at a California men's prison, 2007-2008: propagation by lapses in clinical management, case management, and public health surveillance.

This field report describes an investigation to identify cases to control a syphilis outbreak in a prison and determine whether clinical, case management, and surveillance practices influenced the outbreak occurrence, detection, or management. Key performance measures were assessed to evaluate timeliness and quality of clinical and case management activities and surveillance practices. Thirty cases were found. Prior to the investigation, median times for clinical and reporting/surveillance measures were 15 days from primary and secondary (P&S) symptom onset to exam, 7 days from P&S exam to treatment, and 63 days from serologic test to the state's receipt of case. After the investigation, these measures improved to 8, 4.5, and 28 days, respectively. Lack of adherence to surveillance and clinical management protocols likely contributed to this outbreak, which was curtailed by aggressive control measures.

Using major outer membrane protein typing as an epidemiological tool to investigate outbreaks caused by milk-borne Campylobacter jejuni isolates in California.

We describe using major outer membrane protein (MOMP) typing as a screen to compare the Campylobacter jejuni porA gene sequences of clinical outbreak strains from human stool with the porA sequences of dairy farm strains isolated during two milk-borne campylobacteriosis outbreak investigations in California. The genetic relatedness of clinical and environmental strains with identical or closely related porA sequences was confirmed by multilocus sequence typing and pulsed-field gel electrophoresis analysis. The first outbreak involved 1,644 C. jejuni infections at 11 state correctional facilities and was associated with consumption of pasteurized milk supplied by an on-site dairy (dairy A) at a prison in the central valley. The second outbreak involved eight confirmed and three suspect C. jejuni cases linked to consumption of commercial raw milk and raw chocolate colostrum at another central valley dairy (dairy B). Both dairies bottled fluid milk on the farm and distributed the finished product to off-site locations. Altogether, C. jejuni was isolated from 7 of 15 (46.7%) bovine fecal, 12 of 20 (60%) flush alley water, and 1 of 20 (5%) lagoon samples collected on dairy A. At dairy B, C. jejuni was cultured from 9 of 26 (34.6%) bovine fecal samples. Environmental strains indistinguishable from the clinical outbreak strains were found in five flush alley water samples (dairy A) and four bovine fecal samples (dairy B). The findings demonstrate that MOMP typing is a useful tool to triage environmental isolates prior to conducting more labor-intensive molecular typing methods.

Occupational coccidioidomycosis in California: outbreak investigation, respirator recommendations, and surveillance findings.

OBJECTIVE: To describe the investigation of a 2007 occupational coccidioidomycosis outbreak in California, recommend prevention measures, and assess statewide disease burden. METHODS: We evaluated the worksite, observed work practices, interviewed the workers and employer, reviewed medical records, provided prevention recommendations including risk-based respirator selection, and analyzed statewide workers' compensation claims. RESULTS: Ten of 12 workers developed acute pulmonary coccidioidomycosis; none used respiratory protection. We recommended engineering, work practice, and administrative controls, powered air-purifying respirator use, and medical care. Occupational coccidioidomycosis incidence nearly quadrupled in California from 2000 to 2006, with the highest rates in construction and agricultural workers. CONCLUSIONS: Construction workers are at risk for occupational coccidioidomycosis. The high attack rate in this outbreak was due to lack of awareness, rainfall patterns, soil disruption, and failure to use appropriate controls. Multiple risk-based measures are needed to control occupational coccidioidomycosis in endemic areas.

Recurrent wound botulism among injection drug users in California.

BACKGROUND: Botulism is an acute neurologic illness characterized by cranial nerve palsies and descending flaccid paralysis. Botulism is a rare disease and recurrent botulism even more rare. We review cases of recurrent wound botulism (WB) among injection drug users (IDUs) in California from 1993 through 2006 and describe 2 case patients. METHODS: From botulism surveillance data for 1993-2006, we identified patients with >1 episode of clinical WB, defined as acute descending paralysis with a visible wound or recent history of injection drug use. For each patient, ≥1 of their WB episodes was laboratory confirmed. We extracted demographic, clinical, and laboratory information from case and laboratory reports and compared clinical characteristic frequency of initial and second WB episodes. RESULTS: During 1993-2006, 17 IDUs had recurrent WB, 14 with 1 recurrence and 3 with 2 recurrences. Of 25 laboratory-confirmed episodes, 22 were confirmed through serum testing and 3 through wound testing. Patients were 32-61 years old, and 94% were male. All patients reported heroin injections; 88% specified black tar heroin use and 76% reported subcutaneous injection. The most common presentations were having a visible wound, speech difficulty, double vision, respiratory difficulty, and trouble swallowing. There were no significant differences in clinical presentation between initial and second episodes. CONCLUSIONS: As the California epidemic of WB among IDUs continues, WB episodes are recurring. Both clinicians and IDUs should be aware of the potential for WB to recur among IDUs to enable timely diagnosis and early botulinum antitoxin administration and supportive care.

Increasing burden of invasive group B streptococcal disease in nonpregnant adults, 1990-2007.

BACKGROUND: Group B Streptococcus (GBS), traditionally considered to be a neonatal pathogen, is an important cause of morbidity and mortality among older adults and among those with underlying medical conditions. We used population-based surveillance to examine trends in adult GBS disease during the period 1990-2007 and to describe the epidemiology of adult GBS disease to guide prevention efforts. METHODS: Active Bacterial Core surveillance was conducted in selected counties in 10 US states. A case was defined as isolation of GBS from a normally sterile site in a nonpregnant resident of a surveillance area who was 18 years of age. Rates were calculated using US Census data. Demographic and clinical information was abstracted from medical records. Serotyping and susceptibility testing were performed on isolates collected from a subset of case patients. RESULTS: A total of 19,512 GBS cases were identified in nonpregnant adults during 1990-2007 (median patient age, 63 years); the incidence of adult GBS disease doubled from 3.6 cases per 100,000 persons during 1990 to 7.3 cases per 100,000 persons during 2007 (P < .001). The mean difference in incidence between black and white persons was 4.6 cases per 100,000 persons (range, 3.1 cases per 100,000 persons during 1991 to 5.8 cases per 100,000 persons during 1999). Common clinical syndromes in 2007 included bacteremia without focus (39.3%), skin and/or soft-tissue infection (25.6%), and pneumonia (12.6%). Most (88.0%) GBS cases in adults had 1 underlying condition; diabetes was present in 44.4% of cases. Serotypes V, Ia, II, and III accounted for 80.8% of infections during 1998-1999 and 78.5% of infections during 2005-2006. CONCLUSIONS: Invasive GBS disease in nonpregnant adults represents a substantial and increasing burden, particularly among older persons, black persons, and adults with diabetes. Prevention strategies are needed.

Evaluation of universal antenatal screening for group B streptococcus.

BACKGROUND: Group B streptococcal disease is one of the most common infections in the first week after birth. In 2002, national guidelines recommended universal late antenatal screening of pregnant women for colonization with group B streptococcus to identify candidates for intrapartum chemoprophylaxis. METHODS: We evaluated the implementation of the guidelines in a multistate, retrospective cohort selected from the Active Bacterial Core surveillance, a 10-state, population-based system that monitors invasive group B streptococcal disease. We abstracted data from the labor and delivery records of a stratified random sample of live births and of all cases in which the newborn had early-onset group B streptococcal disease (i.e., disease in infants <7 days of age) in 2003 and 2004. We compared our results with those from a study with a similar design that evaluated screening practices in 1998 and 1999. RESULTS: We abstracted records of 254 births in which the infant had group B streptococcal disease and 7437 births in which the infant did not. The rate of screening for group B streptococcus before delivery increased from 48.1% in 1998-1999 to 85.0% in 2003-2004; the percentage of infants exposed to intrapartum antibiotics increased from 26.8% to 31.7%. Chemoprophylaxis was administered in 87.0% of the women who were positive for group B streptococcus and who delivered at term, but in only 63.4% of women with unknown colonization status who delivered preterm. The overall incidence of early-onset group B streptococcal disease was 0.32 cases per 1000 live births. Preterm infants had a higher incidence of early-onset group B streptococcal disease than did term infants (0.73 vs. 0.26 cases per 1000 live births); however, 74.4% of the cases of group B streptococcal disease (189 of 254) occurred in term infants. Missed screening among mothers who delivered at term accounted for 34 of the 254 cases of group B streptococcal disease (13.4%). A total of 61.4% of the term infants with group B streptococcal disease were born to women who had tested negative for group B streptococcus before delivery. CONCLUSIONS: Recommendations for universal screening were rapidly adopted. Improved management of preterm deliveries and improved collection, processing, and reporting of culture results may prevent additional cases of early-onset group B streptococcal disease.

Sensitivity of mouse bioassay in clinical wound botulism.

BACKGROUND: California has an ongoing epidemic of wound botulism (WB) among injection drug users (IDUs). We retrospectively studied a cohort of patients with WB and determined the sensitivity of the mouse bioassay-the gold standard laboratory test for confirmation of botulism-in verifying WB. METHODS: We defined a clinical case of WB as an acute, bilateral, descending, flaccid paralysis starting with 1 cranial nerve palsies in an IDU with no other explainable diagnosis. We calculated the sensitivity of the mouse bioassay as the proportion of clinical WB cases that had positive serum toxin test results by mouse bioassay. We compared serum toxin-positive with serum toxin-negative patients. RESULTS: Of 73 patients with WB, 50 tested serum toxin positive, yielding a sensitivity of 68%. Serum toxin-positive patients did not differ significantly from serum toxin-negative patients with respect to demographic characteristics or injection drug use practices or in days from patient symptom onset to collection of specimens for testing. Patients did not differ significantly by clinical characteristics, except that serum toxin-positive patients were more likely than serum toxin-negative patients to have required mechanical ventilation during their hospital courses (74% vs. 43%; P = .01). CONCLUSIONS: In this study, the mouse bioassay failed to detect botulinum toxin in the serum samples of nearly one-third of IDUs with characteristic WB. Such patients should be considered to have probable WB. Physicians should be aware of the test's limitations and base their final diagnosis of suspected WB on clinical criteria when the mouse bioassay produces negative results.

Revisiting the need for vaccine prevention of late-onset neonatal group B streptococcal disease: a multistate, population-based analysis.

BACKGROUND: Intrapartum antibiotic prophylaxis for neonatal group B streptococcal disease (GBS) effectively prevents disease among infants <7 days old, but there are no prevention strategies for late-onset GBS disease (onset on days 7-89 of life). We describe trends in late-onset GBS over a 16-year period to characterize disease burden and estimate vaccine preventability. METHODS: We conducted active, population-based surveillance for invasive late-onset GBS disease in 10 states from 1990 to 2005. A case was defined by GBS isolation from a normally sterile site on day 7-89 of life in a surveillance area resident. Incidence rates were calculated per 1000 resident live births. RESULTS: We identified 1726 cases; 26% presented with meningitis, and the case fatality ratio was 4.3%. Incidence was similar throughout the study period. Incidence among black infants was approximately 3 times that among non-black infants; the disparity persisted when data were stratified by gestational age. We estimate approximately 1300 cases of late-onset GBS occur annually in the United States. Birth at <37 weeks gestation was common among case-infants (49%) and was associated with elevated case fatality (relative risk: 3.8; 95% confidence interval: 1.1-13.2). Of 653 serotyped isolates, serotypes III (53%), IA (24%), and V (13%) predominated. During 2003-2005, 81 (36%) of the 227 cases caused by serotypes III, IA, and V were born before 34 weeks gestation. CONCLUSIONS: The late-onset GBS disease burden remains substantial. A trivalent vaccine could be an effective prevention strategy. Because many cases were born preterm, reducing the opportunity for transplacental antibody transfer, adolescent immunization should be considered.

Epidemiology of invasive group B streptococcal disease in the United States, 1999-2005.

CONTEXT: Group B streptococcus is a leading infectious cause of morbidity in newborns and causes substantial disease in elderly individuals. Guidelines for prevention of perinatal disease through intrapartum chemoprophylaxis were revised in 2002. Candidate vaccines are under development. OBJECTIVE: To describe disease trends among populations that might benefit from vaccination and among newborns during a period of evolving prevention strategies. DESIGN AND SETTING: Analysis of active, population-based surveillance in 10 states participating in the Active Bacterial Core surveillance/Emerging Infections Program Network. MAIN OUTCOME MEASURES: Age- and race-specific incidence of invasive group B streptococcal disease. RESULTS: There were 14,573 cases of invasive group B streptococcal disease during 1999-2005, including 1348 deaths. The incidence of invasive group B streptococcal disease among infants from birth through 6 days decreased from 0.47 per 1000 live births in 1999-2001 to 0.34 per 1000 live births in 2003-2005 (P < .001), a relative reduction of 27% (95% confidence interval [CI], 16%-37%). Incidence remained stable among infants aged 7 through 89 days (mean, 0.34 per 1000 live births) and pregnant women (mean, 0.12 per 1000 live births). Among persons aged 15 through 64 years, disease incidence increased from 3.4 per 100,000 population in 1999 to 5.0 per 100,000 in 2005 (chi2(1) for trend, 57; P < .001), a relative increase of 48% (95% CI, 32%-65%). Among adults 65 years or older, incidence increased from 21.5 per 100,000 to 26.0 per 100,000 (chi2(1) for trend, 15; P < .001), a relative increase of 20% (95% CI, 8%-35%). All 4882 isolates tested were susceptible to penicillin, ampicillin, and vancomycin, but 32% and 15% were resistant to erythromycin and clindamycin, respectively. Serotypes Ia, Ib, II, III, and V accounted for 96% of neonatal cases and 88% of adult cases. CONCLUSIONS: Among infants from birth through 6 days, the incidence of group B streptococcal disease was lower in 2003-2005 relative to 1999-2001. This reduction coincided with the release of revised disease prevention guidelines in 2002. However, the disease burden in adults is substantial and increased significantly during the study period.