Zika-Associated Birth Defects Reported in Pregnancies with Laboratory Evidence of Confirmed or Possible Zika Virus Infection - U.S. Zika Pregnancy and Infant Registry, December 1, 2015-March 31, 2018.

Zika virus infection during pregnancy can cause serious birth defects of the brain and eyes, including intracranial calcifications, cerebral or cortical atrophy, chorioretinal abnormalities, and optic nerve abnormalities (1,2). The frequency of these Zika-associated brain and eye defects, based on data from the U.S. Zika Pregnancy and Infant Registry (USZPIR), has been previously reported in aggregate (3,4). This report describes the frequency of individual Zika-associated brain and eye defects among infants from pregnancies with laboratory evidence of confirmed or possible Zika virus infection. Among 6,799 live-born infants in USZPIR born during December 1, 2015-March 31, 2018, 4.6% had any Zika-associated birth defect; in a subgroup of pregnancies with a positive nucleic acid amplification test (NAAT) for Zika virus infection, the percentage was 6.1% of live-born infants. The brain and eye defects most frequently reported included microcephaly, corpus callosum abnormalities, intracranial calcification, abnormal cortical gyral patterns, ventriculomegaly, cerebral or cortical atrophy, chorioretinal abnormalities, and optic nerve abnormalities. Among infants with any Zika-associated birth defect, one third had more than one defect reported. Certain brain and eye defects in an infant might prompt suspicion of prenatal Zika virus infection. These findings can help target surveillance efforts to the most common brain and eye defects associated with Zika virus infection during pregnancy should a Zika virus outbreak reemerge, and might provide a signal to the reemergence of Zika virus, particularly in geographic regions without ongoing comprehensive Zika virus surveillance.

A Preparedness Model for Mother-Baby Linked Longitudinal Surveillance for Emerging Threats.

INTRODUCTION: Public health responses often lack the infrastructure to capture the impact of public health emergencies on pregnant women and infants, with limited mechanisms for linking pregnant women with their infants nationally to monitor long-term effects. In 2019, the Centers for Disease Control and Prevention (CDC), in close collaboration with state, local, and territorial health departments, began a 5-year initiative to establish population-based mother-baby linked longitudinal surveillance, the Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET). OBJECTIVES: The objective of this report is to describe an expanded surveillance approach that leverages and modernizes existing surveillance systems to address the impact of emerging health threats during pregnancy on pregnant women and their infants. METHODS: Mother-baby pairs are identified through prospective identification during pregnancy and/or identification of an infant with retrospective linking to maternal information. All data are obtained from existing data sources (e.g., electronic medical records, vital statistics, laboratory reports, and health department investigations and case reporting). RESULTS: Variables were selected for inclusion to address key surveillance questions proposed by CDC and health department subject matter experts. General variables include maternal demographics and health history, pregnancy and infant outcomes, maternal and infant laboratory results, and child health outcomes up to the second birthday. Exposure-specific modular variables are included for hepatitis C, syphilis, and Coronavirus Disease 2019 (COVID-19). The system is structured into four relational datasets (maternal, pregnancy outcomes and birth, infant/child follow-up, and laboratory testing). DISCUSSION: SET-NET provides a population-based mother-baby linked longitudinal surveillance approach and has already demonstrated rapid adaptation to COVID-19. This innovative approach leverages existing data sources and rapidly collects data and informs clinical guidance and practice. These data can help to reduce exposure risk and adverse outcomes among pregnant women and their infants, direct public health action, and strengthen public health systems.

Burkholderia pseudomallei in Soil, US Virgin Islands, 2019.

The distribution of Burkholderia pseudomallei in the Caribbean is poorly understood. We isolated B. pseudomallei from US Virgin Islands soil. The soil isolate was genetically similar to other isolates from the Caribbean, suggesting that B. pseudomallei might have been introduced to the islands multiple times through severe weather events.

Population-Based Surveillance for Birth Defects Potentially Related to Zika Virus Infection - 22 States and Territories, January 2016-June 2017.

Zika virus infection during pregnancy can cause congenital brain and eye abnormalities and is associated with neurodevelopmental abnormalities (1-3). In areas of the United States that experienced local Zika virus transmission, the prevalence of birth defects potentially related to Zika virus infection during pregnancy increased in the second half of 2016 compared with the first half (4). To update the previous report, CDC analyzed population-based surveillance data from 22 states and territories to estimate the prevalence of birth defects potentially related to Zika virus infection, regardless of laboratory evidence of or exposure to Zika virus, among pregnancies completed during January 1, 2016-June 30, 2017. Jurisdictions were categorized as those 1) with widespread local transmission of Zika virus; 2) with limited local transmission of Zika virus; and 3) without local transmission of Zika virus. Among 2,004,630 live births, 3,359 infants and fetuses with birth defects potentially related to Zika virus infection during pregnancy were identified (1.7 per 1,000 live births, 95% confidence interval [CI] = 1.6-1.7). In areas with widespread local Zika virus transmission, the prevalence of birth defects potentially related to Zika virus infection during pregnancy was significantly higher during the quarters comprising July 2016-March 2017 (July-September 2016 = 3.0; October-December 2016 = 4.0; and January-March 2017 = 5.6 per 1,000 live births) compared with the reference period (January-March 2016) (1.3 per 1,000). These findings suggest a fourfold increase (prevalence ratio [PR] = 4.1, 95% CI = 2.1-8.4) in birth defects potentially related to Zika virus in widespread local transmission areas during January-March 2017 compared with that during January-March 2016, with the highest prevalence (7.0 per 1,000 live births) in February 2017. Population-based birth defects surveillance is critical for identifying infants and fetuses with birth defects potentially related to Zika virus regardless of whether Zika virus testing was conducted, especially given the high prevalence of asymptomatic disease. These data can be used to inform follow-up care and services as well as strengthen surveillance.

Melioidosis after Hurricanes Irma and Maria, St. Thomas/St. John District, US Virgin Islands, October 2017.

We report 2 cases of melioidosis in women with diabetes admitted to an emergency department in the US Virgin Islands during October 2017. These cases emerged after Hurricanes Irma and Maria and did not have a definitively identified source. Poor outcomes were observed when septicemia and pulmonary involvement were present.

Community Assessments for Public Health Emergency Response (CASPERs)-US Virgin Islands, 2017-2018.

Objectives. To assess preparedness levels of communities to help public health and others plan for disasters or emergencies and tailor messaging to increase community preparedness.Methods. US Virgin Islands Department of Health conducted a Community Assessment for Public Health Emergency Response (CASPER) in June 2017, 2 hurricane response CASPERs in November 2017, and a recovery CASPER in February 2018. CASPER is a 2-stage cluster sampling method designed to provide household-based information about a community's needs in a timely, inexpensive, and representative manner.Results. Roughly the same amount of households reported having a 3-day supply of food and water before and 3 months after the hurricanes. During the response, approximately a third of households resupplied between 3 and 6 days and an additional approximately 40% between days 7 and 14.Conclusions. On the basis of the CASPERs, we were able to track whether households had an emergency preparedness kit, whether they used it during the storms (and what was missing), and if they resupplied their kit in recovery.Public Health Implications. CASPER is a promising tool to measure community preparedness to help state, local, tribal, and territorial jurisdictions plan for disasters or emergencies.

Community Assessments for Mosquito Prevention and Control Experiences, Attitudes, and Practices - U.S. Virgin Islands, 2017 and 2018.

Aedes aegypti, the mosquito that carries dengue, chikungunya, and Zika viruses, is present throughout the U.S. Virgin Islands (USVI). To reduce mosquitoborne disease transmission, the USVI Department of Health (VIDOH) is responsible for integrated mosquito management. During January 2016-January 2018, USVI experienced its first Zika outbreak, with most cases reported during January-December 2016, as well as two Category 5 hurricanes (Irma on St. Thomas/St. John on September 6, 2017, and Maria on St. Croix on September 19, 2017). The hurricanes severely damaged mosquito protection-related building structures (e.g., screens, roofs) and infrastructure (e.g., electricity, air conditioning) and might have created an environment more conducive to mosquito breeding. VIDOH, with requested technical assistance from CDC, conducted three Community Assessments for Public Health Emergency Response (CASPERs) to provide rapid community information at the household level. The three CASPERs were conducted to inform 1) the Zika outbreak response, 2) the hurricane response, and 3) the hurricane recovery. The CASPERs assessed mosquito prevention and control-related experiences, attitudes, and practices; household and environmental conditions associated with mosquito breeding, prevention, and control; and other nonmosquito-related information to inform outbreak and disaster response planning. Approximately 40% of households were very concerned about contracting Zika virus during the Zika outbreak and hurricane responses. Environmental conditions were reported to become more favorable for mosquito breeding between the Zika outbreak and hurricane response. Between 75%-80% of the community supported mosquito-spraying in all assessments. VIDOH used these data to support real-time outbreak and hurricane response planning. Mosquito prevention and control community assessments can provide rapid, actionable information to advise both mosquito education and control and emergency response and recovery efforts. The CASPER design can be used by vector control programs to enhance routine and response operations.

Ability To Serologically Confirm Recent Zika Virus Infection in Areas with Varying Past Incidence of Dengue Virus Infection in the United States and U.S. Territories in 2016.

Cross-reactivity within flavivirus antibody assays, produced by shared epitopes in the envelope proteins, can complicate the serological diagnosis of Zika virus (ZIKAV) infection. We assessed the utility of the plaque reduction neutralization test (PRNT) to confirm recent ZIKAV infections and rule out misleading positive immunoglobulin M (IgM) results in areas with various levels of past dengue virus (DENV) infection incidence. We reviewed PRNT results of sera collected for diagnosis of ZIKAV infection from 1 January through 31 August 2016 with positive ZIKAV IgM results, and ZIKAV and DENV PRNTs were performed. PRNT result interpretations included ZIKAV, unspecified flavivirus, DENV infection, or negative. For this analysis, ZIKAV IgM was considered false positive for samples interpreted as a DENV infection or negative. In U.S. states, 208 (27%) of 759 IgM-positive results were confirmed to be ZIKAV compared to 11 (21%) of 52 in the U.S. Virgin Islands (USVI), 15 (15%) of 103 in American Samoa, and 13 (11%) of 123 in Puerto Rico. In American Samoa and Puerto Rico, more than 80% of IgM-positive results were unspecified flavivirus infections. The false-positivity rate was 27% in U.S. states, 18% in the USVI, 2% in American Samoa, and 6% in Puerto Rico. In U.S. states, the PRNT provided a virus-specific diagnosis or ruled out infection in the majority of IgM-positive samples. Almost a third of ZIKAV IgM-positive results were not confirmed; therefore, providers and patients must understand that IgM results are preliminary. In territories with historically higher rates of DENV transmission, the PRNT usually could not differentiate between ZIKAV and DENV infections.

Community and Street-Scale Supports for Walking in the US Virgin Islands Before the 2017 Hurricanes.

OBJECTIVES: To determine the prevalence of community and street-scale design features that promote walking across the US Virgin Islands (USVI). METHODS: In May 2016, the USVI Department of Health, with technical assistance from the Centers for Disease Control and Prevention, conducted a territory-wide audit with a validated tool. We selected street segments (n = 1114) via a 2-stage sampling method, and estimates were weighted to be representative of publicly accessible street length. RESULTS: Overall, 10.7% of the street length contained a transit stop, 11.3% had sidewalks, 21.7% had at least 1 destination (e.g., stores, restaurants), 27.4% had a traffic calming feature (e.g., speed humps), and 53.2% had at least some street lighting. Several features were less prevalent on residential streets compared with commercial streets, including transit stops, sidewalks, destinations, and street lighting (P < .01). CONCLUSIONS: Across the USVI, community and street-scale features supportive of walking were uncommon. Improving community and street-scale design in the USVI, particularly in residential areas, could increase physical activity by enhancing walkability and therefore improve public health. These data can be used to inform community planning in the USVI.

Vital Signs: Zika-Associated Birth Defects and Neurodevelopmental Abnormalities Possibly Associated with Congenital Zika Virus Infection - U.S. Territories and Freely Associated States, 2018.

INTRODUCTION: Zika virus infection during pregnancy causes serious birth defects and might be associated with neurodevelopmental abnormalities in children. Early identification of and intervention for neurodevelopmental problems can improve cognitive, social, and behavioral functioning. METHODS: Pregnancies with laboratory evidence of confirmed or possible Zika virus infection and infants resulting from these pregnancies are included in the U.S. Zika Pregnancy and Infant Registry (USZPIR) and followed through active surveillance methods. This report includes data on children aged ≥1 year born in U.S. territories and freely associated states. Receipt of reported follow-up care was assessed, and data were reviewed to identify Zika-associated birth defects and neurodevelopmental abnormalities possibly associated with congenital Zika virus infection. RESULTS: Among 1,450 children of mothers with laboratory evidence of confirmed or possible Zika virus infection during pregnancy and with reported follow-up care, 76% had developmental screening or evaluation, 60% had postnatal neuroimaging, 48% had automated auditory brainstem response-based hearing screen or evaluation, and 36% had an ophthalmologic evaluation. Among evaluated children, 6% had at least one Zika-associated birth defect identified, 9% had at least one neurodevelopmental abnormality possibly associated with congenital Zika virus infection identified, and 1% had both. CONCLUSION: One in seven evaluated children had a Zika-associated birth defect, a neurodevelopmental abnormality possibly associated with congenital Zika virus infection, or both reported to the USZPIR. Given that most children did not have evidence of all recommended evaluations, additional anomalies might not have been identified. Careful monitoring and evaluation of children born to mothers with evidence of Zika virus infection during pregnancy is essential for ensuring early detection of possible disabilities and early referral to intervention services.

Persistent Arthralgia Associated with Chikungunya Virus Outbreak, US Virgin Islands, December 2014-February 2016.

After the 2014-2015 outbreak of chikungunya virus in the US Virgin Islands, we compared the prevalence of persistent arthralgia among case-patients and controls. Prevalence was higher in case-patients than controls 6 and 12 months after disease onset. Continued vaccine research to prevent acute illness and long-term sequelae is essential.

Awareness, Beliefs, and Actions Concerning Zika Virus Among Pregnant Women and Community Members - U.S. Virgin Islands, November-December 2016.

As of May 2, 2017, the U.S. Virgin Islands (USVI), comprising St. Thomas, St. John, and St. Croix, had reported 1,021 probable or confirmed cases* of Zika virus disease in its population of approximately 100,000 (1); 222 symptomatic and asymptomatic pregnant women in the USVI had tested positive for Zika virus. In January 2016, USVI Department of Health (USVI DOH) initiated Zika response measures, including surveillance, vector control, and a communications program. Interventions included education and outreach, distribution of Zika prevention kits† to pregnant women in the USVI, and provision of free Zika virus laboratory testing and vector control services. In November 2016, USVI DOH staff members conducted interviews with convenience samples of community members and pregnant women to gather feedback about current and proposed interventions (2). Pregnant women reported taking a median of two actions to protect themselves from Zika, with repellent use being the most commonly reported action. Community members reported taking a median of one action and were supportive of several proposed vector control approaches. Whereas multiple pregnant women and community members reported hearing messages about the cause and consequences of Zika virus infections, few recalled messages about specific actions they could take to protect themselves. Integrating evaluation into response measures permits ongoing assessment of intervention effectiveness and supports improvement to serve the population's needs.

Contact investigation of melioidosis cases reveals regional endemicity in Puerto Rico.

BACKGROUND: Melioidosis results from infection with Burkholderia pseudomallei and is associated with case-fatality rates up to 40%. Early diagnosis and treatment with appropriate antimicrobials can improve survival rates. Fatal and nonfatal melioidosis cases were identified in Puerto Rico in 2010 and 2012, respectively, which prompted contact investigations to identify risk factors for infection and evaluate endemicity. METHODS: Questionnaires were administered and serum specimens were collected from coworkers, neighborhood contacts within 250 m of both patients' residences, and injection drug user (IDU) contacts of the 2012 patient. Serum specimens were tested for evidence of prior exposure to B. pseudomallei by indirect hemagglutination assay. Neighborhood seropositivity results guided soil sampling to isolate B. pseudomallei. RESULTS: Serum specimens were collected from contacts of the 2010 (n = 51) and 2012 (n = 60) patients, respectively. No coworkers had detectable anti-B. pseudomallei antibody, whereas seropositive results among neighborhood contacts was 5% (n = 2) for the 2010 patient and 23% (n = 12) for the 2012 patient, as well as 2 of 3 IDU contacts for the 2012 case. Factors significantly associated with seropositivity were having skin wounds, sores, or ulcers (odds ratio [OR], 4.6; 95% confidence interval [CI], 1.2-17.8) and IDU (OR, 18.0; 95% CI, 1.6-194.0). Burkholderia pseudomallei was isolated from soil collected in the neighborhood of the 2012 patient. CONCLUSIONS: Taken together, isolation of B. pseudomallei from a soil sample and high seropositivity among patient contacts suggest at least regional endemicity of melioidosis in Puerto Rico. Increased awareness of melioidosis is needed to enable early case identification and early initiation of appropriate antimicrobial therapy.

Rational design of a live attenuated dengue vaccine: 2'-o-methyltransferase mutants are highly attenuated and immunogenic in mice and macaques.

Dengue virus is transmitted by Aedes mosquitoes and infects at least 100 million people every year. Progressive urbanization in Asia and South-Central America and the geographic expansion of Aedes mosquito habitats have accelerated the global spread of dengue, resulting in a continuously increasing number of cases. A cost-effective, safe vaccine conferring protection with ideally a single injection could stop dengue transmission. Current vaccine candidates require several booster injections or do not provide protection against all four serotypes. Here we demonstrate that dengue virus mutants lacking 2'-O-methyltransferase activity are highly sensitive to type I IFN inhibition. The mutant viruses are attenuated in mice and rhesus monkeys and elicit a strong adaptive immune response. Monkeys immunized with a single dose of 2'-O-methyltransferase mutant virus showed 100% sero-conversion even when a dose as low as 1,000 plaque forming units was administrated. Animals were fully protected against a homologous challenge. Furthermore, mosquitoes feeding on blood containing the mutant virus were not infected, whereas those feeding on blood containing wild-type virus were infected and thus able to transmit it. These results show the potential of 2'-O-methyltransferase mutant virus as a safe, rationally designed dengue vaccine that restrains itself due to the increased susceptibility to the host's innate immune response.

Severe Illness from Methyl Bromide Exposure at a Condominium Resort--U.S. Virgin Islands, March 2015.

On March 22, 2015, the Agency for Toxic Substances and Disease Registry (ATSDR) was notified by the U.S. Environmental Protection Agency (EPA) of four cases of suspected acute methyl bromide toxicity among family members vacationing at a condominium resort in the U.S. Virgin Islands. Methyl bromide is a pesticide that has been banned in the United States for use in homes and other residential settings. An investigation conducted by the U.S. Virgin Islands Department of Health (VIDOH), the U.S. Virgin Islands Department of Planning and Natural Resources (DPNR), and EPA confirmed that methyl bromide had been used as a fumigant on March 18 in the building where the family had been residing, 2 days before they were transported to the hospital; three family members had life-threatening illness. On March 25, 2015, a stop-use order for methyl bromide was issued by DPNR to the pest control company that had performed the fumigation. Subsequent investigation revealed that previous fumigation with methyl bromide had occurred on October 20, 2014, at the same condominium resort. In addition to the four ill family members, 37 persons who might have been exposed to methyl bromide as a result of the October 2014 or March 2015 fumigations were identified by VIDOH and ATSDR. Standardized health questionnaires were administered to 16 of the 20 persons for whom contact information was available; six of 16 had symptoms consistent with methyl bromide exposure, including headache and fatigue. Pest control companies should be aware that use of methyl bromide is banned in homes and other residential settings, and clinicians should be aware of the toxicologic syndrome that exposure to methyl bromide can cause.

Vocal Fatigue Experiences and Mitigation Strategies in the Sacred Harp Singing Community.

OBJECTIVES: Sacred Harp singers sing at a high volume for sustained periods of time without collective warm-up or cool-down exercises, ostensibly putting them at elevated risk for vocal fatigue (VF) and associated vocal pathologies. Participants are also likely to lack formal vocal training. The purpose of this study was to (1) assess singers' experiences with VF, (2) document singers' strategies for mitigating VF, and (3) determine whether vocal training was associated with decreased vocal difficulties. STUDY DESIGN: Self-reporting via online questionnaire containing quantitative and qualitative items. METHODS: This study employed an online questionnaire that combined demographic items, open-ended questions, and the Evaluation of the Ability to Sing Easily (EASE). Participants were recruited at one in-person event and via social media and a mailing list. RESULTS: This study returned 134 valid responses. Singers with formal choral experience scored lower on the EASE and two subscales, but length of experience had no impact. There were no correlations between vocal training and EASE scores. Women scored higher on the EASE than men and nonbinary individuals, while age, length of experience with Sacred Harp singing, and frequency of attendance at annual singing events were all negatively correlated with EASE score. Singers reported a wide range of mitigation strategies, most of which are unique to the Sacred Harp context. CONCLUSIONS: Sacred Harp singers do not appear to struggle more with VF than other populations of singers. However, a few characteristics of their practice put them at risk, and many singers would benefit from professional guidance concerning vocal health.

Population-based denominators matter: Bias in U.S. Virgin Islands COVID-19 vaccination coverage under changing population counts.

PURPOSE: The U.S. Virgin Islands (USVI) receives an updated population count once every 10 years and used 2010 decennial census population counts to estimate COVID-19 vaccination coverage during the COVID-19 emergency response. We investigated whether using outdated (2010) or modeled (2020 international database [IDB]) population counts biased vaccination coverage estimates used to inform public health priorities during the 2020-2022 COVID-19 response. METHODS: We estimated percentage of USVI residents with a completed primary COVID-19 vaccination series during December 16, 2020-September 20, 2022. Vaccination coverage was calculated as number of persons who completed the vaccination series divided by 2010 and 2020 decennial census population counts and 2020 IDB intercensal estimate. RESULTS: COVID-19 vaccination coverage using the 2020 population count was 12 % points higher than coverage using 2010 denominator (2010 denominator: 51 %; 2020 denominator: 63 %). Vaccination coverage estimated using 2020 IDB was approximately equal with the 2010 decennial census estimate (52 %). CONCLUSIONS: Using 2010 and modeled population counts underestimated 2020 USVI COVID-19 vaccination coverage given the 18 % population decline during 2010-2020, potentially limiting USVI's ability to assess vaccination progress. Identifying mechanisms for more reliable population enumeration or improved estimate modeling are essential for accurately guiding USVI public health decision-making.

Evaluation of a new commercially available immunoglobulin M capture enzyme-linked immunosorbent assay for diagnosis of dengue virus infection.

We evaluated the FDA-cleared InBios dengue virus (DENV) IgM capture enzyme-linked immunosorbent assay (ELISA) for qualitative detection of anti-DENV IgM antibodies from 79 serum samples obtained from dengue virus-infected patients or suspected dengue cases. The agreement, sensitivity, and specificity of the InBios assay compared to the gold standard in-house DENV IgM capture ELISA were 94, 92, and 94%, respectively. We conclude that the InBios DENV IgM capture ELISA can be effectively used for rapid diagnosis of acute or recent DENV infection.