Epidemiologic and Clinical Features of Children and Adolescents Aged <18 Years with Monkeypox - United States, May 17-September 24, 2022.

Data on monkeypox in children and adolescents aged <18 years are limited (1,2). During May 17­September 24, 2022, a total of 25,038 monkeypox cases were reported in the United States,† primarily among adult gay, bisexual, and other men who have sex with men (3). During this period, CDC and U.S. jurisdictional health departments identified Monkeypox virus (MPXV) infections in 83 persons aged <18 years, accounting for 0.3% of reported cases. Among 28 children aged 0­12 years with monkeypox, 64% were boys, and most had direct skin-to-skin contact with an adult with monkeypox who was caring for the child in a household setting. Among 55 adolescents aged 13­17 years, most were male (89%), and male-to-male sexual contact was the most common presumed exposure route (66%). Most children and adolescents with monkeypox were non-Hispanic Black or African American (Black) (47%) or Hispanic or Latino (Hispanic) (35%). Most (89%) were not hospitalized, none received intensive care unit (ICU)­level care, and none died. Monkeypox in children and adolescents remains rare in the United States. Ensuring equitable access to monkeypox vaccination, testing, and treatment is a critical public health priority. Vaccination for adolescents with risk factors and provision of prevention information for persons with monkeypox caring for children might prevent additional infections.

Assessment of Knowledge, Attitudes, and Practices Toward Ticks and Tickborne Disease among Healthcare Professionals Working in Schools in New York and Maryland.

Healthcare Professionals Working in Schools (HPWS) are responsible for providing health services to students and play a role in providing education to prevent illnesses, including tickborne diseases (TBD). Providing TBD education to children has been shown to increase prevention behaviors and knowledge of TBD symptoms, but little is known regarding the current state of TBD awareness among HPWS. In spring 2019 we conducted a cross-sectional knowledge, attitudes, and practices (KAP) survey of HPWS in two states with a high incidence of Lyme disease (LD) to inform design of TBD prevention programs. The survey queried general knowledge of TBDs, school practices regarding TBDs, and availability of TBD resources. Overall, higher confidence, experience, risk perception, prior training on TBD, and more years employed as a HPWS were independently associated with knowledge of LD transmission, symptoms, and correct tick removal practices. State and local health departments should consider prioritizing engagement with HPWS to provide educational opportunities about tickborne diseases.

Human Melioidosis Caused by Novel Transmission of Burkholderia pseudomallei from Freshwater Home Aquarium, United States1.

Nearly all cases of melioidosis in the continental United States are related to international travel to areas to which Burkholderia pseudomallei, the bacterium that causes melioidosis, is endemic. We report the diagnosis and clinical course of melioidosis in a patient from the United States who had no international travel history and the public health investigation to determine the source of exposure. We tested environmental samples collected from the patient's home for B. pseudomallei by PCR and culture. Whole-genome sequencing was conducted on PCR-positive environmental samples, and results were compared with sequences from the patient's clinical specimen. Three PCR-positive environmental samples, all collected from a freshwater home aquarium that had contained imported tropical fish, were a genetic match to the clinical isolate from the patient. This finding suggests a novel route of exposure and a potential for importation of B. pseudomallei, a select agent, into the United States from disease-endemic areas.

Coronavirus Disease among Workers in Food Processing, Food Manufacturing, and Agriculture Workplaces.

We describe coronavirus disease (COVID-19) among US food manufacturing and agriculture workers and provide updated information on meat and poultry processing workers. Among 742 food and agriculture workplaces in 30 states, 8,978 workers had confirmed COVID-19; 55 workers died. Racial and ethnic minority workers could be disproportionately affected by COVID-19.

Factors That Might Affect SARS-CoV-2 Transmission Among Foreign-Born and U.S.-Born Poultry Facility Workers - Maryland, May 2020.

Numerous recent assessments indicate that meat and poultry processing facility workers are at increased risk for infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1-4). Physical proximity to other workers and shared equipment can facilitate disease transmission in these settings (2-4). The disproportionate number of foreign-born workers employed in meat and poultry processing reflects structural, social, and economic inequities that likely contribute to an increased COVID-19 incidence in this population* (5). In May 2020, the Maryland Department of Health and CDC investigated factors that might affect person-to-person SARS-CoV-2 transmission among persons who worked at two poultry processing facilities.† A survey administered to 359 workers identified differences in risk factors for SARS-CoV-2 infection between workers born outside the United States and U.S.-born workers. Compared with U.S.-born workers, foreign-born workers had higher odds of working in fixed locations on the production floor (odds ratio [OR] for cutup and packaging jobs = 4.8), of having shared commutes (OR = 1.9), and of living with other poultry workers (OR = 6.0). They had lower odds of participating in social gatherings (OR for visits to family = 0.2; OR for visits to friends = 0.4), and they visited fewer businesses in the week before the survey than did their U.S.-born coworkers. Some workplace risk factors can be mitigated through engineering and administrative controls focused on the production floor, and this will be of particular benefit to the foreign-born workers concentrated in these areas. Employers and health departments can also partner with local organizations to disseminate culturally and linguistically tailored messages about risk reduction behaviors in community settings, including shared transportation§ and household members dwelling in close quarters.¶.

Update: COVID-19 Among Workers in Meat and Poultry Processing Facilities - United States, April-May 2020.

Meat and poultry processing facilities face distinctive challenges in the control of infectious diseases, including coronavirus disease 2019 (COVID-19) (1). COVID-19 outbreaks among meat and poultry processing facility workers can rapidly affect large numbers of persons. Assessment of COVID-19 cases among workers in 115 meat and poultry processing facilities through April 27, 2020, documented 4,913 cases and 20 deaths reported by 19 states (1). This report provides updated aggregate data from states regarding the number of meat and poultry processing facilities affected by COVID-19, the number and demographic characteristics of affected workers, and the number of COVID-19-associated deaths among workers, as well as descriptions of interventions and prevention efforts at these facilities. Aggregate data on confirmed COVID-19 cases and deaths among workers identified and reported through May 31, 2020, were obtained from 239 affected facilities (those with a laboratory-confirmed COVID-19 case in one or more workers) in 23 states.* COVID-19 was confirmed in 16,233 workers, including 86 COVID-19-related deaths. Among 14 states reporting the total number of workers in affected meat and poultry processing facilities (112,616), COVID-19 was diagnosed in 9.1% of workers. Among 9,919 (61%) cases in 21 states with reported race/ethnicity, 87% occurred among racial and ethnic minority workers. Commonly reported interventions and prevention efforts at facilities included implementing worker temperature or symptom screening and COVID-19 education, mandating face coverings, adding hand hygiene stations, and adding physical barriers between workers. Targeted workplace interventions and prevention efforts that are appropriately tailored to the groups most affected by COVID-19 are critical to reducing both COVID-19-associated occupational risk and health disparities among vulnerable populations. Implementation of these interventions and prevention efforts† across meat and poultry processing facilities nationally could help protect workers in this critical infrastructure industry.

Influenza A(H3N2) Variant Virus Outbreak at Three Fairs - Maryland, 2017.

On September 17, 2017, the Maryland Department of Agriculture (MDA) was notified by fair and 4-H officials of ill swine at agricultural fair A, held September 14-17. That day, investigation of the 107 swine at fair A revealed five swine with fever and signs of upper respiratory tract illness. All five respiratory specimens collected from these swine tested positive for influenza A virus at the MDA Animal Health Laboratory, and influenza A(H3N2) virus was confirmed in all specimens by the U.S. Department of Agriculture National Veterinary Services Laboratory (NVSL). On September 18, MDA was notified by fair and 4-H officials that swine exhibitors were also ill. MDA alerted the Maryland Department of Health (MDH). A joint investigation with MDH and the local health department was started and later broadened to Maryland agricultural fairs B (September 13-17) and C (September 15-23). In total, 76 persons underwent testing for variant influenza, and influenza A(H3N2) variant (A(H3N2)v) virus infection was identified in 40 patients with exposure to swine at these fairs (Figure), including 30 (75%) who had more than one characteristic putting them at high risk for serious influenza complications; 24 (60%) of these were children aged <5 years. Twenty-six (65%) patients reported direct contact with swine (i.e., touching swine or swine enclosure), but 14 (35%) reported only indirect contact (e.g., walking through a swine barn). Two children required hospitalization; all patients recovered. This outbreak highlights the risk, particularly among children, for contracting variant influenza virus at agricultural fairs after direct or indirect swine contact. Publicizing CDC's recommendation that persons at high risk for serious influenza complications avoid pigs and swine barns might help prevent future variant influenza outbreaks among vulnerable groups (1).

Rabies in a Dog Imported from Egypt - Connecticut, 2017.

In 2007, the United States successfully eliminated canine rabies virus variant. Globally, however, dogs remain the principal source of human rabies infections. Since 2007, three cases of canine rabies virus variant were reported in dogs imported into the United States, one each from India (2007), Iraq (2008), and Egypt (2015) (1-3). On December 20, 2017, a dog imported into the United States from Egypt was identified with rabies, representing the second case from Egypt in 3 years. An Egyptian-based animal rescue organization delivered four dogs from Cairo, Egypt, to a flight parent (a person solicited through social media, often not affiliated with the rescue organization, and usually compensated with an airline ticket), who transported the dogs to the United States. The flight parent arrived at John F. Kennedy International Airport (JFK) in New York City and, via transporters (persons who shuttle dogs from one state to another), transferred the dogs to foster families; the dogs ultimately were adopted in three states. The Connecticut Department of Public Health Laboratory (CDPHL) confirmed the presence of a canine rabies virus variant in one of the dogs, a male aged 6 months that was adopted by a Connecticut family. An investigation revealed the possibility of falsified rabies vaccination documentation presented on entry at JFK, allowing the unvaccinated dog entry to the United States. This report highlights the continuing risk posed by the importation of dogs inadequately vaccinated against rabies from high-risk countries and the difficulties in verifying any imported dog's health status and rabies vaccination history.

Knowledge and practices related to louse- and flea-borne diseases among staff providing services to people experiencing homelessness in the United States.

BACKGROUND AND AIMS: Louse-borne Bartonella quintana infection and flea-borne murine typhus are two potentially serious vector-borne diseases that have led to periodic outbreaks among people experiencing homelessness in the United States. Little is known about louse- and flea-borne disease awareness and prevention among staff who provide services to the population. We surveyed staff in seven US states to identify gaps in knowledge and prevention practices for these diseases. METHODS AND RESULTS: Surveys were administered to 333 staff at 89 homeless shelters and outreach teams in California, Colorado, Georgia, Maryland, Minnesota, New York and Washington from August 2022 to April 2023. Most participants (>68%) agreed that body lice and fleas are a problem for people experiencing homelessness. About half were aware that diseases could be transmitted by these vectors; however, most could not accurately identify which diseases. Less than a quarter of staff could describe an appropriate protocol for managing body lice or fleas. Misconceptions included that clients must isolate or be denied services until they are medically cleared. CONCLUSIONS: Our findings reveal significant knowledge gaps among staff who provide services to people experiencing homelessness in the prevention and control of louse- and flea-borne diseases. This demonstrates an urgent need for staff training to both reduce disease and prevent unnecessary restrictions on services and housing.

Potential quantitative effect of a laboratory-based approach to Lyme disease surveillance in high-incidence states.

Historically, public health surveillance for Lyme disease has required clinical follow-up on positive laboratory reports for the purpose of case classification. In areas with sustained high incidence of the disease, this resource-intensive activity yields a limited benefit to public health practice. A range of burden-reducing strategies have been implemented in many states, creating inconsistencies that limit the ability to decipher trends. Laboratory-based surveillance, or surveillance based solely on positive laboratory reports without follow-up for clinical information on positive laboratory reports, emerged as a feasible alternative to improve standardization in already high-incidence areas. To inform expectations of a laboratory-based surveillance model, we conducted a retrospective analysis of Lyme disease data collected during 2012-2018 from 10 high-incidence states. The number of individuals with laboratory evidence of infection ranged from 1302 to 20,994 per state and year. On average, 55% of those were ultimately classified as confirmed or probable cases (range: 29%-86%). Among all individuals with positive laboratory evidence, 18% (range: 2%-37%) were determined to be 'not a case' upon investigation and 23% (range: 2%-52%) were classified as suspect cases due to lack of associated clinical information and thus were not reported to the Centers for Disease Control and Prevention (CDC). The number of reported cases under a laboratory-based approach to surveillance in high-incidence states using recommended two-tier testing algorithms is likely to be, on average, 1.2 times higher (range: 0.6-1.8 times) than what was reported to CDC during 2012-2018. A laboratory-based surveillance approach for high-incidence states will improve standardization and reduce burden on public health systems, allowing public health resources to focus on prevention messaging, exploration of novel prevention strategies and alternative data sources to yield information on the epidemiology of Lyme disease.