Seroprevalence, distribution, and risk factors for human leptospirosis in the United States Virgin Islands.

BACKGROUND: The first documented human leptospirosis cases in the U.S. Virgin Islands (USVI) occurred following 2017 Hurricanes Irma and Maria. We conducted a representative serosurvey in USVI to estimate the seroprevalence and distribution of human leptospirosis and evaluate local risk factors associated with seropositivity. METHODOLOGY/PRINCIPAL FINDINGS: A stratified, two-stage cluster sampling design was used and consisted of three island strata and random selection of census blocks and then households. All eligible members of selected households were invited to participate (≥5 years old, resided in USVI ≥6 months and ≥6 months/year). Household and individual-level questionnaires were completed, and serum collected from each enrolled individual. Microscopic agglutination test serology was conducted, and bivariate and logistic regression analyses completed to identify risk factors for seropositivity. In March 2019, 1,161 individuals were enrolled from 918 households in St. Croix, St. Thomas, and St. John. The territory-wide weighted seroprevalence was 4.0% (95% CI:2.3-5.7). Characteristics/exposures independently associated with seropositivity using logistic regression included contact with cows (OR: 39.5; 95% CI: 9.0-172.7), seeing rodents/rodent evidence or contact with rodents (OR: 2.6; 95% CI: 1.1-5.9), and increasing age (OR: 1.02; 95% CI: 1.002-1.04); full or partial Caucasian/White race was negatively correlated with seropositivity (OR: 0.02, 95% CI: 0.04-0.7). Bivariate analysis showed self-reported jaundice since the 2017 hurricanes (pRR: 5.7; 95% CI: 1.0-33.4) was associated with seropositivity and using a cover/lid on cisterns/rainwater collection containers (pRR: 0.3; 95% CI: 0.08-0.8) was protective against seropositivity. CONCLUSIONS/SIGNIFICANCE: Leptospirosis seropositivity of 4% across USVI demonstrates an important human disease that was previously unrecognized and emphasizes the importance of continued leptospirosis surveillance and investigation. Local risk factors identified may help guide future human and animal leptospirosis studies in USVI, strengthen leptospirosis public health surveillance and treatment timeliness, and inform targeted education, prevention, and control efforts.

Risk factors for Brucellosis and knowledge-attitude practice among pastoralists in Afar and Somali regions of Ethiopia.

BACKGROUND: Brucellosis is a neglected bacterial zoonotic disease with substantial economic impact on households. Pastoral communities are a potential risk group due to their way of life being closely interlinked with their large livestock herds. METHODOLOGY: A semi-structured questionnaire survey was conducted in households in the pastoral Afar and Somali (SRS) regions. All households had people and animals serologically tested for brucellosis. Questions were related to husbandry, consumption habits, and knowledge-attitude-practice towards the disease and zoonoses. Descriptive statistics and logistic analysis were performed to assess potential risk factors for having households with positive humans and/or animals. RESULT: 647 households were included in the survey. Herd brucellosis prevalence was 40.3 % (15.9-86.3 % in Afar; 4-72.2 % in SRS). Over half (56.3 %) of the households in Afar and 41.8 % in SRS had at least one human reactor. Nearly a quarter of the households (22.8 %), recalled abortions in goats in the last 12 months, whereas 52.5 % and 50.3 % recalled stillborn in all species and membrane retentions respectively. All respondents drank raw milk and discarded animal afterbirths in the direct surroundings with minimal protection. Risk factors for animal reactors were goat herd size, and goat abortion. There was no identified risk factor for having human reactors in households. None of the households knew about brucellosis. CONCLUSION: Although being endemic in Afar and SRS, Brucellosis is not known by the pastoralists. Brucellosis control programs will have to be tailored to the pastoral context, accounting for their mobility, large, multi-species herds and habits.

Integrated human-animal sero-surveillance of Brucellosis in the pastoral Afar and Somali regions of Ethiopia.

BACKGROUND: Brucellosis is widespread in Ethiopia with variable reported prevalence depending on the geographical area, husbandry practices and animal species. However, there is limited information on the disease prevalence amongst pastoral communities, whose life is intricately linked with their livestock. METHODOLOGY: We conducted an integrated human-animal brucellosis sero-surveillance study in two adjacent pastoral regions, Afar and Somali region (SRS). This cross-sectional study included 13 woredas (districts) and 650 households. Blood samples were collected from people and livestock species (cattle, camel, goats and sheep). Sera were analyzed with C-ELISA for camels and shoats (sheep and goats), with I-ELISA for cattle and IgG ELISA for humans. Descriptive and inferential statistics analyses were performed. RESULTS: A total of 5469 sera were tested by ELISA. Prevalence of livestock was 9.0% in Afar and 8.6% in SRS (ranging from 0.6 to 20.2% at woreda level). In humans, prevalence was 48.3% in Afar and 34.9% in SRS (ranging from 0.0 to 74.5% at woreda level). 68.4% of all households in Afar and 57.5% of households in SRS had at least one animal reactor. Overall, 4.1% of animals had a history of abortion. The proportion of animals with abortion history was higher in seropositive animals than in seronegative animals. Risk factor analysis showed that female animals were significantly at higher risk of being reactors (p = 0.013). Among the species, cattle had the least risk of being reactors (p = 0.014). In humans, there was a clear regional association of disease prevalence (p = 0.002). The older the people, the highest the odds of being seropositive. CONCLUSION: Brucellosis is widespread in humans and animals in pastoral communities of Afar and SRS with the existence of geographical hotspots. No clear association was seen between human and particular livestock species prevalence, hence there was no indication as whether B. abortus or B. melitensis are circulating in these areas, which warrants further molecular research prior to embarking on a national control programs. Such programs will need to be tailored to the pastoral context.

Evidence, Experience, Expertise, and the US Coronavirus Disease 2019 Public Health Response.

The U.S. Centers for Disease Control and Prevention (CDC), state, tribal, and local health departments assess available and promising interventions and individual and population health outcomes when crafting public health recommendations. This supplement provides a snapshot of some of the science, experience, and expertise supporting the COVID-19 response.

Death Certificate-Based ICD-10 Diagnosis Codes for COVID-19 Mortality Surveillance - United States, January-December 2020.

Approximately 375,000 deaths during 2020 were attributed to COVID-19 on death certificates reported to CDC (1). Concerns have been raised that some deaths are being improperly attributed to COVID-19 (2). Analysis of International Classification of Diseases, Tenth Revision (ICD-10) diagnoses on official death certificates might provide an expedient and efficient method to demonstrate whether reported COVID-19 deaths are being overestimated. CDC assessed documentation of diagnoses co-occurring with an ICD-10 code for COVID-19 (U07.1) on U.S. death certificates from 2020 that had been reported to CDC as of February 22, 2021. Among 378,048 death certificates listing U07.1, a total of 357,133 (94.5%) had at least one other ICD-10 code; 20,915 (5.5%) had only U07.1. Overall, 97.3% of 357,133 death certificates with at least one other diagnosis (91.9% of all 378,048 death certificates) were noted to have a co-occurring diagnosis that was a plausible chain-of-event condition (e.g., pneumonia or respiratory failure), a significant contributing condition (e.g., hypertension or diabetes), or both. Overall, 70%-80% of death certificates had both a chain-of-event condition and a significant contributing condition or a chain-of-event condition only; this was noted for adults aged 18-84 years, both males and females, persons of all races and ethnicities, those who died in inpatient and outpatient or emergency department settings, and those whose manner of death was listed as natural. These findings support the accuracy of COVID-19 mortality surveillance in the United States using official death certificates. High-quality documentation of co-occurring diagnoses on the death certificate is essential for a comprehensive and authoritative public record. Continued messaging and training (3) for professionals who complete death certificates remains important as the pandemic progresses. Accurate mortality surveillance is critical for understanding the impact of variants of SARS-CoV-2, the virus that causes COVID-19, and of COVID-19 vaccination and for guiding public health action.

COVID-19 Case Investigation and Contact Tracing Efforts from Health Departments - United States, June 25-July 24, 2020.

Case investigation and contact tracing are core public health tools used to interrupt transmission of pathogens, including SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19); timeliness is critical to effectiveness (1,2). In May 2020, CDC funded* 64 state, local, and territorial health departments† to support COVID-19 response activities. As part of the monitoring process, case investigation and contact tracing metrics for June 25-July 24, 2020, were submitted to CDC by 62 health departments. Descriptive analyses of case investigation and contact tracing load, timeliness, and yield (i.e., the number of contacts elicited divided by the number of patients prioritized for interview) were performed. A median of 57% of patients were interviewed within 24 hours of report of the case to a health department (interquartile range [IQR] = 27%-82%); a median of 1.15 contacts were identified per patient prioritized for interview§ (IQR = 0.62-1.76), and a median of 55% of contacts were notified within 24 hours of identification by a patient (IQR = 32%-79%). With higher caseloads, the percentage of patients interviewed within 24 hours of case report was lower (Spearman coefficient = -0.68), and the number of contacts identified per patient prioritized for interview also decreased (Spearman coefficient = -0.60). The capacity to conduct timely contact tracing varied among health departments, largely driven by investigators' caseloads. Incomplete identification of contacts affects the ability to reduce transmission of SARS-CoV-2. Enhanced staffing capacity and ability and improved community engagement could lead to more timely interviews and identification of more contacts.

Summary of Guidance for Public Health Strategies to Address High Levels of Community Transmission of SARS-CoV-2 and Related Deaths, December 2020.

In the 10 months since the first confirmed case of coronavirus disease 2019 (COVID-19) was reported in the United States on January 20, 2020 (1), approximately 13.8 million cases and 272,525 deaths have been reported in the United States. On October 30, the number of new cases reported in the United States in a single day exceeded 100,000 for the first time, and by December 2 had reached a daily high of 196,227.* With colder weather, more time spent indoors, the ongoing U.S. holiday season, and silent spread of disease, with approximately 50% of transmission from asymptomatic persons (2), the United States has entered a phase of high-level transmission where a multipronged approach to implementing all evidence-based public health strategies at both the individual and community levels is essential. This summary guidance highlights critical evidence-based CDC recommendations and sustainable strategies to reduce COVID-19 transmission. These strategies include 1) universal face mask use, 2) maintaining physical distance from other persons and limiting in-person contacts, 3) avoiding nonessential indoor spaces and crowded outdoor spaces, 4) increasing testing to rapidly identify and isolate infected persons, 5) promptly identifying, quarantining, and testing close contacts of persons with known COVID-19, 6) safeguarding persons most at risk for severe illness or death from infection with SARS-CoV-2, the virus that causes COVID-19, 7) protecting essential workers with provision of adequate personal protective equipment and safe work practices, 8) postponing travel, 9) increasing room air ventilation and enhancing hand hygiene and environmental disinfection, and 10) achieving widespread availability and high community coverage with effective COVID-19 vaccines. In combination, these strategies can reduce SARS-CoV-2 transmission, long-term sequelae or disability, and death, and mitigate the pandemic's economic impact. Consistent implementation of these strategies improves health equity, preserves health care capacity, maintains the function of essential businesses, and supports the availability of in-person instruction for kindergarten through grade 12 schools and preschool. Individual persons, households, and communities should take these actions now to reduce SARS-CoV-2 transmission from its current high level. These actions will provide a bridge to a future with wide availability and high community coverage of effective vaccines, when safe return to more everyday activities in a range of settings will be possible.

CDC Deployments to State, Tribal, Local, and Territorial Health Departments for COVID-19 Emergency Public Health Response - United States, January 21-July 25, 2020.

Coronavirus disease 2019 (COVID-19) is a viral respiratory illness caused by SARS-CoV-2. During January 21-July 25, 2020, in response to official requests for assistance with COVID-19 emergency public health response activities, CDC deployed 208 teams to assist 55 state, tribal, local, and territorial health departments. CDC deployment data were analyzed to summarize activities by deployed CDC teams in assisting state, tribal, local, and territorial health departments to identify and implement measures to contain SARS-CoV-2 transmission (1). Deployed teams assisted with the investigation of transmission in high-risk congregate settings, such as long-term care facilities (53 deployments; 26% of total), food processing facilities (24; 12%), correctional facilities (12; 6%), and settings that provide services to persons experiencing homelessness (10; 5%). Among the 208 deployed teams, 178 (85%) provided assistance to state health departments, 12 (6%) to tribal health departments, 10 (5%) to local health departments, and eight (4%) to territorial health departments. CDC collaborations with health departments have strengthened local capacity and provided outbreak response support. Collaborations focused attention on health equity issues among disproportionately affected populations (e.g., racial and ethnic minority populations, essential frontline workers, and persons experiencing homelessness) and through a place-based focus (e.g., persons living in rural or frontier areas). These collaborations also facilitated enhanced characterization of COVID-19 epidemiology, directly contributing to CDC data-informed guidance, including guidance for serial testing as a containment strategy in high-risk congregate settings, targeted interventions and prevention efforts among workers at food processing facilities, and social distancing.

COVID-19 Contact Tracing in Two Counties - North Carolina, June-July 2020.

Contact tracing is a strategy implemented to minimize the spread of communicable diseases (1,2). Prompt contact tracing, testing, and self-quarantine can reduce the transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (3,4). Community engagement is important to encourage participation in and cooperation with SARS-CoV-2 contact tracing (5). Substantial investments have been made to scale up contact tracing for COVID-19 in the United States. During June 1-July 12, 2020, the incidence of COVID-19 cases in North Carolina increased 183%, from seven to 19 per 100,000 persons per day* (6). To assess local COVID-19 contact tracing implementation, data from two counties in North Carolina were analyzed during a period of high incidence. Health department staff members investigated 5,514 (77%) persons with COVID-19 in Mecklenburg County and 584 (99%) in Randolph Counties. No contacts were reported for 48% of cases in Mecklenburg and for 35% in Randolph. Among contacts provided, 25% in Mecklenburg and 48% in Randolph could not be reached by telephone and were classified as nonresponsive after at least one attempt on 3 consecutive days of failed attempts. The median interval from specimen collection from the index patient to notification of identified contacts was 6 days in both counties. Despite aggressive efforts by health department staff members to perform case investigations and contact tracing, many persons with COVID-19 did not report contacts, and many contacts were not reached. These findings indicate that improved timeliness of contact tracing, community engagement, and increased use of community-wide mitigation are needed to interrupt SARS-CoV-2 transmission.

Trends in Number and Distribution of COVID-19 Hotspot Counties - United States, March 8-July 15, 2020.

The geographic areas in the United States most affected by the coronavirus disease 2019 (COVID-19) pandemic have changed over time. On May 7, 2020, CDC, with other federal agencies, began identifying counties with increasing COVID-19 incidence (hotspots) to better understand transmission dynamics and offer targeted support to health departments in affected communities. Data for January 22-July 15, 2020, were analyzed retrospectively (January 22-May 6) and prospectively (May 7-July 15) to detect hotspot counties. No counties met hotspot criteria during January 22-March 7, 2020. During March 8-July 15, 2020, 818 counties met hotspot criteria for ≥1 day; these counties included 80% of the U.S. population. The daily number of counties meeting hotspot criteria peaked in early April, decreased and stabilized during mid-April-early June, then increased again during late June-early July. The percentage of counties in the South and West Census regions* meeting hotspot criteria increased from 10% and 13%, respectively, during March-April to 28% and 22%, respectively, during June-July. Identification of community transmission as a contributing factor increased over time, whereas identification of outbreaks in long-term care facilities, food processing facilities, correctional facilities, or other workplaces as contributing factors decreased. Identification of hotspot counties and understanding how they change over time can help prioritize and target implementation of U.S. public health response activities.

Potential distributions of Bacillus anthracis and Bacillus cereus biovar anthracis causing anthrax in Africa.

BACKGROUND: Bacillus cereus biovar anthracis (Bcbva) is an emergent bacterium closely related to Bacillus anthracis, the etiological agent of anthrax. The latter has a worldwide distribution and usually causes infectious disease in mammals associated with savanna ecosystems. Bcbva was identified in humid tropical forests of Côte d'Ivoire in 2001. Here, we characterize the potential geographic distributions of Bcbva in West Africa and B. anthracis in sub-Saharan Africa using an ecological niche modeling approach. METHODOLOGY/PRINCIPAL FINDINGS: Georeferenced occurrence data for B. anthracis and Bcbva were obtained from public data repositories and the scientific literature. Combinations of temperature, humidity, vegetation greenness, and soils values served as environmental variables in model calibrations. To predict the potential distribution of suitable environments for each pathogen across the study region, parameter values derived from the median of 10 replicates of the best-performing model for each pathogen were used. We found suitable environments predicted for B. anthracis across areas of confirmed and suspected anthrax activity in sub-Saharan Africa, including an east-west corridor from Ethiopia to Sierra Leone in the Sahel region and multiple areas in eastern, central, and southern Africa. The study area for Bcbva was restricted to West and Central Africa to reflect areas that have likely been accessible to Bcbva by dispersal. Model predicted values indicated potential suitable environments within humid forested environments. Background similarity tests in geographic space indicated statistical support to reject the null hypothesis of similarity when comparing environments associated with B. anthracis to those of Bcbva and when comparing humidity values and soils values individually. We failed to reject the null hypothesis of similarity when comparing environments associated with Bcbva to those of B. anthracis, suggesting that additional investigation is needed to provide a more robust characterization of the Bcbva niche. CONCLUSIONS/SIGNIFICANCE: This study represents the first time that the environmental and geographic distribution of Bcbva has been mapped. We document likely differences in ecological niche-and consequently in geographic distribution-between Bcbva and typical B. anthracis, and areas of possible co-occurrence between the two. We provide information crucial to guiding and improving monitoring efforts focused on these pathogens.

One Field Epidemiologist per 200,000 Population: Lessons Learned from Implementing a Global Public Health Workforce Target.

The World Health Organization monitoring and evaluation framework for the International Health Regulations (IHR, 2005) describes the targets for the Joint External Evaluation (JEE) indicators. For workforce development, the JEE defines the optimal target for attaining and complying with the IHR (2005) as 1 trained field epidemiologist (or equivalent) per 200,000 population. We explain the derivation and use of the current field epidemiology workforce development target and identify the limitations and lessons learned in applying it to various countries' public health systems. This article also proposes a way forward for improvements and implementation of this workforce development target.

First Reported Human Cases of Leptospirosis in the United States Virgin Islands in the Aftermath of Hurricanes Irma and Maria, September-November 2017.

OBJECTIVE: Following Hurricanes Irma and Maria, the first case of human leptospirosis ever identified in the US Virgin Islands (USVI) was reported to the Virgin Islands Department of Health. Leptospirosis is a potentially fatal bacterial disease caused by Leptospira species found in animal urine and urine-contaminated water and soil. Outbreaks can occur following extreme weather events. METHOD: Additional cases of leptospirosis were identified in the 2.5 months post-hurricanes by reviewing emergency department (ED) records from territorial hospitals for patients demonstrating leptospirosis-consistent symptoms, testing symptomatic patients previously enrolled in the USVI arbovirus surveillance system (VIASS), and adding leptospirosis testing prospectively to VIASS. Available patient sera underwent local rapid diagnostic testing for anti-Leptospira IgM followed by confirmatory microscopic agglutination testing at the US Centers for Disease Control and Prevention. Water was collected from cisterns with epidemiologic links to confirmed cases and tested by real-time PCR (qPCR) for pathogenic Leptospira spp. RESULTS: Sixteen retrospectively identified symptomatic patients were enrolled in VIASS; 15 with available samples tested negative. Based on review of 5226 ED charts, 6 patients were further investigated; of these, 5 were tested of which 1 was positive. Prospective leptospirosis surveillance tested 57 additional patients; of these, 1 was positive. Water from 1 of 5 tested cisterns was found positive by qPCR. CONCLUSIONS: This investigation documents the first 3 cases of leptospirosis reported in the USVI and demonstrates how VIASS successfully was adapted to establish leptospirosis surveillance. Contaminated cistern water was identified as a potential source for Leptospira spp. transmission, highlighting the need for additional post-hurricane remediation and disinfection guidance.

Anthrax Epizootic in Wildlife, Bwabwata National Park, Namibia, 2017.

In late September 2017, Bwabwata National Park in Namibia experienced a sudden die-off of hippopotamuses and Cape buffalo. A multiorganizational response was initiated, involving several ministries within Namibia and the US Centers for Disease Control and Prevention. Rapid interventions resulted in zero human or livestock cases associated with this epizootic.

Initial Public Health Laboratory Response After Hurricane Maria - Puerto Rico, 2017.

Hurricane Maria made landfall in Puerto Rico on September 20, 2017, causing major damage to infrastructure and severely limiting access to potable water, electric power, transportation, and communications. Public services that were affected included operations of the Puerto Rico Department of Health (PRDOH), which provides critical laboratory testing and surveillance for diseases and other health hazards. PRDOH requested assistance from CDC for the restoration of laboratory infrastructure, surveillance capacity, and diagnostic testing for selected priority diseases, including influenza, rabies, leptospirosis, salmonellosis, and tuberculosis. PRDOH, CDC, and the Association of Public Health Laboratories (APHL) collaborated to conduct rapid needs assessments and, with assistance from the CDC Foundation, implement a temporary transport system for shipping samples from Puerto Rico to the continental United States for surveillance and diagnostic and confirmatory testing. This report describes the initial laboratory emergency response and engagement efforts among federal, state, and nongovernmental partners to reestablish public health laboratory services severely affected by Hurricane Maria. The implementation of a sample transport system allowed Puerto Rico to reinitiate priority infectious disease surveillance and laboratory testing for patient and public health interventions, while awaiting the rebuilding and reinstatement of PRDOH laboratory services.

Enhancing Surveillance and Diagnostics in Anthrax-Endemic Countries.

Naturally occurring anthrax disproportionately affects the health and economic welfare of poor, rural communities in anthrax-endemic countries. However, many of these countries have limited anthrax prevention and control programs. Effective prevention of anthrax outbreaks among humans is accomplished through routine livestock vaccination programs and prompt response to animal outbreaks. The Centers for Disease Control and Prevention uses a 2-phase framework when providing technical assistance to partners in anthrax-endemic countries. The first phase assesses and identifies areas for improvement in existing human and animal surveillance, laboratory diagnostics, and outbreak response. The second phase provides steps to implement improvements to these areas. We describe examples of implementing this framework in anthrax-endemic countries. These activities are at varying stages of completion; however, the public health impact of these initiatives has been encouraging. The anthrax framework can be extended to other zoonotic diseases to build on these efforts, improve human and animal health, and enhance global health security.