Enhancing Respiratory Disease Surveillance to Detect COVID-19 in Shelters for Displaced Persons, Thailand-Myanmar Border, 2020-2021.

We developed surveillance guidance for COVID-19 in 9 temporary camps for displaced persons along the Thailand-Myanmar border. Arrangements were made for testing of persons presenting with acute respiratory infection, influenza-like illness, or who met the Thailand national COVID-19 Person Under Investigation case definition. In addition, testing was performed for persons who had traveled outside of the camps in outbreak-affected areas or who departed Thailand as resettling refugees. During the first 18 months of surveillance, May 2020-October 2021, a total of 6,190 specimens were tested, and 15 outbreaks (i.e., >1 confirmed COVID-19 cases) were detected in 7 camps. Of those, 5 outbreaks were limited to a single case. Outbreaks during the Delta variant surge were particularly challenging to control. Adapting and implementing COVID-19 surveillance measures in the camp setting were successful in detecting COVID-19 outbreaks and preventing widespread disease during the initial phase of the pandemic in Thailand.

Three Years of Progress Toward Achieving Hepatitis C Elimination in the Country of Georgia, April 2015-March 2018.

BACKGROUND: In April 2015, in collaboration with the US Centers for Disease Control and Prevention and Gilead Sciences, the country of Georgia embarked on the world's first hepatitis C elimination program. We aimed to assess progress toward elimination targets 3 years after the start of the elimination program. METHODS: We constructed a hepatitis C virus (HCV) care cascade for adults in Georgia, based on the estimated 150 000 persons aged ≥18 years with active HCV infection. All patients who were screened or entered the treatment program during April 2015-March 2018 were included in the analysis. Data on the number of persons screened for HCV were extracted from the national HCV screening database. For the treatment component, we utilized data from the Georgia National HCV treatment program database. Available treatment options included sofosbuvir and ledipasvir/sofosbuvir-based regimens. RESULTS: Since April 2015, a cumulative 974 817 adults were screened for HCV antibodies; 86 624 persons tested positive, of whom 61 925 underwent HCV confirmatory testing. Among the estimated 150 000 adults living with chronic hepatitis C in Georgia, 52 856 (35.1%) were diagnosed, 45 334 (30.2%) initiated treatment with direct-acting antivirals, and 29 090 (19.4%) achieved a sustained virologic response (SVR). Overall, 37 256 persons were eligible for SVR assessment; of these, only 29 620 (79.5%) returned for evaluation. The SVR rate was 98.2% (29 090/29 620) in the per-protocol analysis and 78.1% (29 090/37 256) in the intent-to-treat analysis. CONCLUSIONS: Georgia has made substantial progress in the path toward eliminating hepatitis C. Scaling up of testing and diagnosis, along with effective linkage to treatment services, is needed to achieve the goal of elimination.

Progress and challenges of a pioneering hepatitis C elimination program in the country of Georgia.

BACKGROUND & AIMS: Georgia, with a high prevalence of HCV infection, launched the world's first national hepatitis C elimination program in April 2015. A key strategy is the identification, treatment, and cure of the estimated 150,000 HCV-infected people living in the country. We report on progress and key challenges from Georgia's experience. METHODS: We constructed a care cascade by analyzing linked data from the national hepatitis C screening registry and treatment databases during 2015-2018. We assessed the impact of reflex hepatitis C core antigen (HCVcAg) testing on rates of viremia testing and treatment initiation (i.e. linkage to care). RESULTS: As of December 31, 2018, 1,101,530 adults (39.6% of the adult population) were screened for HCV antibody, of whom 98,430 (8.9%) tested positive. Of the individuals who tested positive, 78,484 (79.7%) received viremia testing, of whom 66,916 (85.3%) tested positive for active HCV infection. A total of 52,576 people with active HCV infection initiated treatment and 48,879 completed their course of treatment. Of the 35,035 who were tested for cure (i.e., sustained virologic response [SVR]), 34,513 (98.5%) achieved SVR. Reflex HCVcAg testing, implemented in March 2018, increased rates of monthly viremia testing by 97.5% among those who screened positive for anti-HCV, however, rates of treatment initiation decreased by 60.7% among diagnosed viremic patients. CONCLUSIONS: Over one-third of people living with HCV in Georgia have been detected and linked to care and treatment, however, identification and linkage to care of the remaining individuals with HCV infection is challenging. Novel interventions, such as reflex testing with HCVcAg, can improve rates of viremia testing, but may result in unintended consequences, such as decreased rates of treatment initiation. Linked data systems allow for regular review of the care cascade, allowing for identification of deficiencies and development of corrective actions. LAY SUMMARY: This report describes progress in Georgia's hepatitis C elimination program and highlights efforts to promote hepatitis C virus screening and treatment initiation on a national scale. Georgia has made progress towards eliminating hepatitis C, treating over 50,000 people, approximately one-third of the number infected, and achieving cure for 98.5% of those tested. However, identifying infected individuals and linking them to care remains challenging. Novel approaches to increase diagnostic testing can have unintended consequences further down the care cascade.

Blood transfusion safety in the country of Georgia: collateral benefit from a national hepatitis C elimination program.

BACKGROUND: In April 2015, the government of Georgia (country) initiated the world's first national hepatitis C elimination program. An analysis of blood donor infectious screening data was conducted to inform a strategic plan to advance blood transfusion safety in Georgia. STUDY DESIGN AND METHODS: Descriptive analysis of blood donation records (2015-2017) was performed to elucidate differences in demographics, donor type, remuneration status, and seroprevalence for infectious markers (hepatitis C virus antibody [anti-HCV], human immunodeficiency virus [HIV], hepatitis B virus surface antigen [HBsAg], and Treponema pallidum). For regression analysis, final models included all variables associated with the outcome in bivariate analysis (chi-square) with a p value of less than 0.05. RESULTS: During 2015 to 2017, there were 251,428 donations in Georgia, representing 112,093 unique donors; 68.5% were from male donors, and 51.2% of donors were paid or replacement (friends or family of intended recipient). The overall seroprevalence significantly declined from 2015 to 2017 for anti-HCV (2.3%-1.4%), HBsAg (1.5%-1.1%), and T. pallidum (1.1%-0.7%) [p < 0.0001]; the decline was not significant for HIV (0.2%-0.1%). Only 41.0% of anti-HCV seropositive donors underwent additional testing to confirm viremia. Infectious marker seroprevalence varied by age, sex, and geography. In multivariable analysis, first-time and paid donor status were associated with seropositivity for all four infectious markers. CONCLUSION: A decline during the study period in infectious markers suggests improvement in blood safety in Georgia. Areas that need further improvement are donor recruitment, standardization of screening and diagnostic follow-up, quality assurance, and posttransfusion surveillance.

Implementing Laboratory Quality Management Systems in Mozambique: The Becton Dickinson-US President's Emergency Plan for AIDS Relief Public-Private Partnership Initiative.

BACKGROUND: Mozambique's ministry of health (MOH) recognized the need to establish a national laboratory quality assurance (NLQA) program to improve the reliability and accuracy of laboratory testing. The Becton Dickinson-US President's Emergency Plan for AIDS Relief Public-Private Partnership (PPP) was used to garner MOH commitment and train a cadre of local auditors and managers to support sustainability and country ownership of a NLQA program. METHODS: From January 2011 to April 2012, the World Health Organization Regional Office for Africa Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist and the Strengthening Laboratory Management Towards Accreditation (SLMTA) curriculum were used in 6 MOH laboratories. PPP volunteers provided training and mentorship to build the capacity of local auditors and program managers to promote institutionalization and sustainability of the program within the MOH. RESULTS: SLIPTA was launched in 6 MOH laboratories, and final audits demonstrated improvements across the 13 quality system essentials, compared with baseline. Training and mentorship of MOH staff by PPP volunteers resulted in 18 qualified auditors and 28 managers/quality officers capacitated to manage the improvement process in their laboratories. CONCLUSIONS: SLIPTA helps laboratories improve the quality and reliability of their service even in the absence of full accreditation. Local capacity building ensures sustainability by creating country buy-in, reducing costs of audits, and institutionalizing program management.

Combined multichannel intraluminal impedance-pH (MII-pH): multicenter report of normal values from 117 children.

Although combined multichannel intraluminal impedance/esophageal pH monitoring (MII-pH) has replaced prolonged pH monitoring alone for assessing gastroesophageal reflux (GER) in the pediatric population, it does so in the absence of reference values for non-acid GER (NAGER). The purpose of this study was to identify a normal range of NAGER impedance values for infants and children. We evaluated EPM/MII tracings for patients referred for GER assessment to Nationwide Children's Hospital (Columbus, OH), Inova Children's Hospital, and Hospital Italiano (Buenos Aires, Argentina). We excluded tracings from patients who had AGER indices greater than 50 % of the upper end of normal (i.e., >3 % for children >12 months and >6 % for infants ≤ 12 months), had a positive temporal association of GER with symptoms, were on anti-reflux medications at the time of the study, and/or had a fundoplication prior to the study. We also excluded studies with durations shorter than 20 h. Values for NAGER percent time, NAGER episode frequency, frequency of proximal NAGER, and mean NAGER duration were calculated for upright position, recumbent, and total. Study population consisted of 46 infants (20 female [F]/26 male [M], median age 4.8 months [range 3 weeks-11.9 months]) with a median AGER index of 2.2 % (range 0.0-5.9 %) and 71 children (22 F/49 M, median age 7.2 years [range 1.3-17 years]) with a median AGER index of 1.1 % (range 0-3.0 %). Data are presented in tables in the text. The results of this study provide a range of values characteristic of infants and children with normal AGER indices and no positive temporal associations of GER with symptoms. These values may be used as references for comparison to identify infants and/or children who may be at risk of developing serious clinical manifestations due to abnormal patterns of GER.

Children with cystic fibrosis have prolonged chemical clearance of acid reflux compared to symptomatic children without cystic fibrosis.

OBJECTIVES: Few studies compare gastroesophageal reflux (GER) parameters of cystic fibrosis (CF) children and symptomatic non-CF children. We aimed to compare the impedance-pH (IMP-pH) parameters for these two groups and to test the hypothesis that prolonged acid exposure in CF patients is due to delayed chemical clearance (CC). METHODS: IMP-pH tracings from 16 CF children (median 8.2 years) and 16 symptomatic non-CF children (median 8.3 years) were analyzed. Software was used to generate IMP-pH reports and parameter data were extracted. IMP-pH was used to calculate the mean CC for each patient. RESULTS: pH studies showed no difference in acid GER (AGER) frequency (p = 0.587); however, mean AGER duration, duration of longest AGER, AGER index, and DeMeester scores were all significantly higher for CF patients. IMP showed no difference in GER frequency [neither acidic (p = 0.918) nor non-acidic (p = 0.277)], but total bolus clearance was more efficient in CF patients (p = 0.049). A larger percentage of total GER reached the proximal esophagus in non-CF children (p = 0.039). Analyses of two-phase AGER episodes showed that these events were more acidic (p = 0.003) and the CC phase was significantly prolonged in the CF cohort (p = 0.001). CONCLUSIONS: Compared to symptomatic non-CF children, CF children do not have more frequent reflux. Actually, they have better bolus clearance efficiency following reflux and may even have better control over the number of GER episodes that reach the proximal esophagus. CC of AGER, however, is significantly prolonged in the CF cohort, likely due to hyperacidity of refluxed gastric contents.

Characteristics, risk factors, and outcomes related to Zika virus infection during pregnancy in Northeastern Thailand: A prospective pregnancy cohort study, 2018-2020.

BACKGROUND: In response to the 2015-2016 Zika virus (ZIKV) outbreak and the causal relationship established between maternal ZIKV infection and adverse infant outcomes, we conducted a cohort study to estimate the incidence of ZIKV infection in pregnancy and assess its impacts in women and infants. METHODOLOGY/PRINCIPAL FINDINGS: From May 2018-January 2020, we prospectively followed pregnant women recruited from 134 participating hospitals in two non-adjacent provinces in northeastern Thailand. We collected demographic, clinical, and epidemiologic data and blood and urine at routine antenatal care visits until delivery. ZIKV infections were confirmed by real-time reverse transcriptase polymerase chain reaction (rRT-PCR). Specimens with confirmed ZIKV underwent whole genome sequencing. Among 3,312 women enrolled, 12 (0.36%) had ZIKV infections, of which two (17%) were detected at enrollment. Ten (83%, 3 in 2nd and 7 in 3rd trimester) ZIKV infections were detected during study follow-up, resulting in an infection rate of 0.15 per 1,000 person-weeks (95% CI: 0.07-0.28). The majority (11/12, 91.7%) of infections occurred in one province. Persistent ZIKV viremia (42 days) was found in only one woman. Six women with confirmed ZIKV infections were asymptomatic until delivery. Sequencing of 8 ZIKV isolates revealed all were of Asian lineage. All 12 ZIKV infected women gave birth to live, full-term infants; the only observed adverse birth outcome was low birth weight in one (8%) infant. Pregnancies in 3,300 ZIKV-rRT-PCR-negative women were complicated by 101 (3%) fetal deaths, of which 67 (66%) had miscarriages and 34 (34%) had stillbirths. There were no differences between adverse fetal or birth outcomes of live infants born to ZIKV-rRT-PCR-positive mothers compared to live infants born to ZIKV-rRT-PCR-negative mothers. CONCLUSIONS/SIGNIFICANCE: Confirmed ZIKV infections occurred infrequently in this large pregnancy cohort and observed adverse maternal and birth outcomes did not differ between mothers with and without confirmed infections.

Gastroesophageal reflux causing sleep interruptions in infants.

BACKGROUND AND AIM: Little is known about the relation between gastroesophageal reflux (GER) episodes and sleep interruptions in infants. The aim of the study was to evaluate the relationship between GER and the incidence of sleep interruptions in infants. METHODS: Study patients included 24 infants (younger than 1 year) referred for multichannel intraluminal impedance and esophageal pH monitoring with simultaneous polysomnography. Exclusion criteria were a previous fundoplication and studies lasting <20 hours. Tests were clinically indicated to investigate suspicion of GER-related apnea (17, 70.8%), stridor (6, 25%), noisy breathing (2, 8.3%), and cyanotic spells (1, 4.2%). Most patients presented with significant comorbidities (19, 79.2%). RESULTS: The number of nonacid GER (NAGER) per hour was greater during sleep time than during daytime and awakening following sleep onset (median 0.27 vs 1.85 and 1.45, P<0.01). A total of 1204 (range 7-86 per infant) arousals in 24 infants was detected, 165 (13.7%) that followed GER episodes, and 43 (3.6%) that preceded GER episodes. Seven patients presented with a positive symptom association probability for arousals; 5 were exclusively because of NAGER. A positive symptom association probability for awakenings was detected in 9 patients; 4 were because of NAGER, 4 were because of AGER, and 1 was because of both NAGER and GER. Patients with awakenings related to GER presented longer mean clearance time of AGER during sleep (165.5 vs 92.8 seconds, P=0.03). CONCLUSIONS: GER was a frequent cause of interrupting sleep among our infant patients, and NAGER proved to be equally important as AGER for causing arousals and awakenings in infants.

First Round of External Quality Assessment Scheme for SARS-CoV-2 Laboratories During the COVID-19 Pandemic in Thailand.

The emergence of SARS-CoV-2 necessitated the rapid deployment of tests to diagnose COVID-19. To monitor the accuracy of testing across the COVID-19 laboratory network in Thailand, the Department of Medical Sciences under the Ministry of Public Health launched a national external quality assessment (EQA) scheme using samples containing inactivated SARS-CoV-2 culture supernatant from a predominant strain in the early phase of the Thailand outbreak. All 197 laboratories in the network participated; 93% (n=183) of which reported correct results for all 6 EQA samples. Ten laboratories reported false-negative results, mostly for samples with low viral concentrations, and 5 laboratories reported false-positive results (1 laboratory reported false positives and false negatives). An intralaboratory investigation of 14 laboratories reporting incorrect results revealed 2 main causes of error: (1) RNA contamination of the rRT-PCR reaction and (2) poor-quality RNA extraction. Specific reagent combinations were significantly associated with false-negative reports. Thailand's approach to national EQA for SARS-CoV-2 can serve as a roadmap for other countries interested in implementing a national EQA program to ensure laboratories provide accurate testing results, which is crucial in diagnosis, prevention, and control strategies. A national EQA program can be less costly and thus more sustainable than commercial EQA programs. National EQA is recommended to detect and correct testing errors and provide postmarket surveillance for diagnostic test performance.

Evaluation of a high-throughput diagnostic system for detection of HIV-1 in dried blood spot samples from infants in Mozambique.

We performed a comparative analysis between Roche Amplicor HIV-1 DNA test and CAPTAQ assay for the detection of HIV in 830 dried blood spot (DBS) pediatric samples collected in Mozambique. Our results demonstrated no statistical difference between these assays. The CAPTAQ assay approached nearly 100% repeatability/accuracy. The increased throughput of testing with minimal operator interference in performing the CAPTAQ assay clearly demonstrated that this method is an improvement over the Roche Amplicor HIV-1 DNA test, version 1.5.

Effect of amoxicillin/clavulanate on gastrointestinal motility in children.

AIM: The aim of the present study was to evaluate the effect of amoxicillin/clavulanate (A/C) on gastrointestinal motility. METHODS: Twenty consecutive pediatric patients referred for antroduodenal manometry received 20 mg/kg of A/C into the small bowel lumen. In 10 patients (group A), A/C was given 1 hour after and in 10 (group B), 1 hour before ingestion of a meal. Characteristics of the migrating motor complex, including presence, frequency, amplitude, and propagation of duodenal phase III and phase I duration and phase II motility index (MI), were evaluated 30 minutes before and after A/C administration. RESULTS: There were no statistically significant differences in age and sex between the 2 groups. Manometry studies were considered normal in 8 patients in each group. In group A, 2 patients developed duodenal phase III after receiving A/C, and no significant difference was found in the MI before and after the drug administration. In group B, 9 patients developed duodenal phase III (P <0.05 vs group A). All phase III occurred within a few minutes from the medication administration. Most duodenal phase III contractions were preceded by an antral component during fasting but never after the medication was administered in either of the 2 groups (P<0.001 vs fasting). In group B, the duration of duodenal phase I was shorter after drug administration (P<0.05). There was no significant difference in duodenal phase II MI before and after A/C administration for the 2 study groups. CONCLUSIONS: In children, administration of A/C directly into the small bowel before a meal induces phase III-type contractions in the duodenum, with characteristics similar to those present in the fasting state. These data suggest the possible use of A/C as a prokinetic agent. Further studies are needed to clarify its specific mechanism of action and the group of patients most likely to benefit from its use.

Biofilm production and evaluation of antifungal susceptibility amongst clinical Candida spp. isolates, including strains of the Candida parapsilosis complex.

Candida cells can form biofilms that frequently are sources of infections and are less susceptible to antifungal drugs. Some authors have reported that Candida orthopsilosis and Candida metapsilosis isolates are not able to produce biofilms in vitro and there are no studies available on biofilm susceptibility for these species to antifungals. The aims of this study were to (i) quantify Candida spp. biofilms in vitro, and (ii) test the in vitro susceptibilities of Candida spp. biofilms to fluconazole (FLC) and amphotericin B (AMB). Isolates studied included four Candida albicans, six C. tropicalis, seven C. parapsilosis, eight C. orthopsilosis, and five C. metapsilosis. We compared two different methods to evaluate biofilm production, i.e., crystal violet (CV) staining and XTT-reduction assays (XTT). Scanning electron microscopy (SEM) was used to observe high, medium and low biofilm producing isolates screened by these two methods. To determine the minimum biofilm eradication concentration (MBEC) for FLC and AMB, XTT-reduction assay was used to measure cell metabolic activity. Biofilm quantification by CV and XTT showed that C. tropicalis isolates were the highest biofilm producer, followed by C. albicans, C. parapsilosis, C. orthopsilosis and C. metapsilosis. Examination of SEM images revealed that the extent of biofilms formed by high, medium, and low producers was highly correlated to the results generated by CV assay. Biofilm of all the isolates evaluated were resistant to FLC (MBEC(80) ≥ 256 ug/ml) but, in general, susceptible to AMB, except for six C. parapsilosis strains (MBEC(80) ≥ 8 ug/ml).

Esophageal impedance monitoring for gastroesophageal reflux.

Dual pH-multichannel intraluminal impedance (pH-MII) is a sensitive tool for evaluating overall gastroesophageal reflux disease, and particularly for permitting detection of nonacid reflux events. pH-MII technology is especially useful in the postprandial period or at other times when gastric contents are nonacidic.pH-MII was recently recognized by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition as being superior to pH monitoring alone for evaluation of the temporal relation between symptoms and gastroesophageal reflux. In children, pH-MII is useful to correlate symptoms with reflux (particularly nonacid reflux), to quantify reflux during tube feedings and the postprandial period, and to assess efficacy of antireflux therapy. This clinical review is simply an evidence-based overview addressing the indications, limitations, and recommended protocol for the clinical use of pH-MII in children.

Effect of serum and surface characteristics on Candida albicans biofilm formation.

Candida spp. biofilms can be established on a wide range of materials, including implanted medical devices, and can display a resistant phenotype to antifungal drugs. Several factors, including host and surface properties, may influence the establishment and the development of Candida albicans biofilms on biotic and abiotic surfaces. We therefore selected a collection of C. albicans clinical isolates to evaluate the effect of surface and serum on biofilm attachment and development. Disc coupons from the CDC biofilm reactor were used in a well plate assay to study biofilm production on six different surfaces with or without the addition of serum: polycarbonate, polystyrene, stainless steel, Teflon, polyvinyl chloride or hydroxyapatite. Our results showed that serum increases in vitro C. albicans biofilm formation on a wide range of distinct surfaces including metallic and non-metallic materials, and that roughness and hydrophobicity can modulate C. albicans biofilm formation. These findings were also confirmed by scanning electron microscopy and it revealed the deposition of extracellular material on hyphae attached to a solid surface. Interestingly, adhesion can be significantly increased in the early stages of colonisation when serum is provided as a conditioning film in a surface-dependent manner.

Core components of infection prevention and control programs at the facility level in Georgia: key challenges and opportunities.

BACKGROUND: The Georgia Ministry of Labor, Health, and Social Affairs is working to strengthen its Infection Prevention and Control (IPC) Program, but until recently has lacked an assessment of performance gaps and implementation challenges faced by hospital staff. METHODS: In 2018, health care hospitals were assessed using a World Health Organization (WHO) adapted tool aimed at implementing the WHO's IPC Core Components. The study included site assessments at 41 of Georgia's 273 hospitals, followed by structured interviews with 109 hospital staff, validation observations of IPC practices, and follow up document reviews. RESULTS: IPC programs for all hospitals were not comprehensive, with many lacking defined objectives, workplans, targets, and budget. All hospitals had at least one dedicated IPC staff member, 66% of hospitals had IPC staff with some formal IPC training; 78% of hospitals had IPC guidelines; and 55% had facility-specific standard operating procedures. None of the hospitals conducted structured monitoring of IPC compliance and only 44% of hospitals used IPC monitoring results to make unit/facility-specific IPC improvement plans. 54% of hospitals had clearly defined priority healthcare-associated infections (HAIs), standard case definitions and data collection methods in their HAI surveillance systems. 85% hospitals had access to a microbiology laboratory. All reported having posters or other tools to promote hand hygiene, 29% had them for injection safety. 68% of hospitals had functioning hand-hygiene stations available at all points of care. 88% had single patient isolation rooms; 15% also had rooms for cohorting patients. 71% reported having appropriate waste management system. CONCLUSIONS: Among the recommended WHO IPC core components, existing programs, infrastructure, IPC staffing, workload and supplies present within Georgian healthcare hospitals should allow for implementation of effective IPC. Development and dissemination of IPC Guidelines, implementation of an effective IPC training system and systematic monitoring of IPC practices will be an important first step towards implementing targeted IPC improvement plans in hospitals.

Molecular epidemiology of Candida parapsilosis sepsis from outbreak investigations in neonatal intensive care units.

The DNA probe, Cp3-13, was used in a Southern blot assay for genotyping Candida parapsilosis (CP) from 3 fungemia outbreaks in neonatal intensive care units (NICUs) in the southeastern U.S. Genotyping, in 2 outbreaks, supplied evidence of horizontal transmission of CP. In the third outbreak, bloodstream isolates (BSIs) of 2 genotypes circulated in the NICU, one was shared by a BSI and a healthcare worker's hand culture. A fourth cluster of recurrent episodes of fungemia occurred in outpatients of a children's hospital receiving total parenteral nutrition (TPN) at home. Each child was infected with a different CP genotype which persisted during recurrences. These genotypes were included in a dendrogram from a CDC population-based surveillance for candidemia consisting of 73 clone-corrected Cp3-13 genotypes (overall SAB = 0.36). Analysis revealed a cluster of 11 genotypes (mean SAB = 0.66) including 3 pairs with identical hybridization profiles. A second cluster of 8 genotypes contained clones from 3 outbreaks (mean SAB = 0.76) but no clustering of genotypes specific for neonates was identified. No decreased susceptibility to azole and polyene antifungal agents was detected in this collection of CP. The frequent occurrence of transmission of CP in this vulnerable population underlines the relevance of Cp3-13 subtyping to investigate suspected transmission and persistence of CP strains in the NICU.

Cryptococcus gattii infection: characteristics and epidemiology of cases identified in a South African province with high HIV seroprevalence, 2002-2004.

We describe 46 Cryptococcus gattii-infected persons identified by population-based surveillance conducted in South Africa. Most patients with C. gattii infection presented with meningitis. The mortality rate during hospitalization was 36%. We found no significant differences between persons with and persons without C. gattii infection with regard to clinical presentation, acquired immunodeficiency syndrome diagnosis, concomitant conditions, or prior opportunistic infections. C. gattii isolates had low MICs to the tested antifungal drugs.

Epidemiology of community-onset candidemia in Connecticut and Maryland.

BACKGROUND: Almost one-third of patients with bloodstream infections with Candida species (candidemia) have onset of disease that occurs outside of the hospital or < or = 2 days after hospital admission (i.e., community-onset candidemia). We compared the characteristics of patients who developed candidemia by the timing of onset of infection. METHODS: Incident episodes of candidemia were identified through active, population-based surveillance in Connecticut and in Baltimore and Baltimore County, Maryland, during 1 October 1998-30 September 2000. The molecular subtypes of a sample of 45 Candida parapsilosis isolates were evaluated using Southern blots hybridized with the complex probe Cp3-13. RESULTS: Overall, 356 (31%) of the 1143 incident episodes of candidemia were classified as community-onset disease (occurring < or = 2 days after hospital admission), and 132 (37%) were caused by Candida albicans, 89 (25%) were caused by Candida glabrata, 57 (16%) were caused by C. parapsilosis, and 53 (15%) were caused by Candida tropicalis. Community-onset disease was less likely to be associated with concurrent immunosuppressive therapy, recent surgery, or use of a central venous catheter, compared with inpatient disease. Among patients with community-onset disease, the median time from blood culture to initiation of antifungal treatment was 2.7 days, the 30-day case-fatality rate was 26%, and 262 patients (75%) had been hospitalized at least once in the previous 3 months. Although there were few differences between patients with very recent hospitalization (in the previous 1 month), less recent hospitalization (previous 1-3 months), and no documented past hospitalization, C. parapsilosis was more frequently associated with community-onset disease as hospitalization became more distant. C. parapsilosis strains tended to be unique to the patient, with little similarity found between strain types, on the basis of epidemiologic classification of patients. CONCLUSION: We report that community-onset candidemia is common and occurs in patients with extensive contact with the health care system. Disease caused by C. parapsilosis tends to involve unique strains.

Gastroesophageal Reflux Affects Sleep Quality in Snoring Obese Children.

PURPOSE: This study was performed to evaluate the quality of sleep in snoring obese children without obstructive sleep apnea (OSA); and to study the possible relationship between sleep interruption and gastroesophageal reflux (GER) in snoring obese children. METHODS: Study subjects included 13 snoring obese children who were referred to our sleep lab for possible sleep-disordered breathing. Patients underwent multichannel intraluminal impedance and esophageal pH monitoring with simultaneous polysomnography. Exclusion criteria included history of fundoplication, cystic fibrosis, and infants under the age of 2 years. Significant association between arousals and awakenings with previous reflux were defined by symptom-association probability using 2-minute intervals. RESULTS: Sleep efficiency ranged from 67-97% (median 81%). A total of 111 reflux episodes (90% acidic) were detected during sleep, but there were more episodes per hour during awake periods after sleep onset than during sleep (median 2.3 vs. 0.6, p=0.04). There were 279 total awakenings during the sleep study; 56 (20.1%) of them in 9 patients (69.2%) were preceded by reflux episodes (55 acid, 1 non-acid). In 5 patients (38.5%), awakenings were significantly associated with reflux. CONCLUSION: The data suggest that acid GER causes sleep interruptions in obese children who have symptoms of snoring or restless sleep and without evidence of OSA.