Estimate of Burden and Direct Healthcare Cost of Infectious Waterborne Disease in the United States.

Provision of safe drinking water in the United States is a great public health achievement. However, new waterborne disease challenges have emerged (e.g., aging infrastructure, chlorine-tolerant and biofilm-related pathogens, increased recreational water use). Comprehensive estimates of the health burden for all water exposure routes (ingestion, contact, inhalation) and sources (drinking, recreational, environmental) are needed. We estimated total illnesses, emergency department (ED) visits, hospitalizations, deaths, and direct healthcare costs for 17 waterborne infectious diseases. About 7.15 million waterborne illnesses occur annually (95% credible interval [CrI] 3.88 million-12.0 million), results in 601,000 ED visits (95% CrI 364,000-866,000), 118,000 hospitalizations (95% CrI 86,800-150,000), and 6,630 deaths (95% CrI 4,520-8,870) and incurring US $3.33 billion (95% CrI 1.37 billion-8.77 billion) in direct healthcare costs. Otitis externa and norovirus infection were the most common illnesses. Most hospitalizations and deaths were caused by biofilm-associated pathogens (nontuberculous mycobacteria, Pseudomonas, Legionella), costing US $2.39 billion annually.

Preliminary Incidence and Trends of Infections with Pathogens Transmitted Commonly Through Food - Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 2015-2018.

Foodborne diseases represent a major health problem in the United States. The Foodborne Diseases Active Surveillance Network (FoodNet) of CDC's Emerging Infections Program monitors cases of laboratory-diagnosed infection caused by eight pathogens transmitted commonly through food in 10 U.S. sites.* This report summarizes preliminary 2018 data and changes since 2015. During 2018, FoodNet identified 25,606 infections, 5,893 hospitalizations, and 120 deaths. The incidence of most infections is increasing, including those caused by Campylobacter and Salmonella, which might be partially attributable to the increased use of culture-independent diagnostic tests (CIDTs). The incidence of Cyclospora infections increased markedly compared with 2015-2017, in part related to large outbreaks associated with produce (1). More targeted prevention measures are needed on produce farms, food animal farms, and in meat and poultry processing establishments to make food safer and decrease human illness.

Preliminary Incidence and Trends of Infections with Pathogens Transmitted Commonly Through Food - Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 2006-2017.

Despite ongoing food safety measures in the United States, foodborne illness continues to be a substantial health burden. The 10 U.S. sites of the Foodborne Diseases Active Surveillance Network (FoodNet)* monitor cases of laboratory-diagnosed infections caused by nine pathogens transmitted commonly through food. This report summarizes preliminary 2017 data and describes changes in incidence since 2006. In 2017, FoodNet reported 24,484 infections, 5,677 hospitalizations, and 122 deaths. Compared with 2014-2016, the 2017 incidence of infections with Campylobacter, Listeria, non-O157 Shiga toxin-producing Escherichia coli (STEC), Yersinia, Vibrio, and Cyclospora increased. The increased incidences of pathogens for which testing was previously limited might have resulted from the increased use and sensitivity of culture-independent diagnostic tests (CIDTs), which can improve incidence estimates (1). Compared with 2006-2008, the 2017 incidence of infections with Salmonella serotypes Typhimurium and Heidelberg decreased, and the incidence of serotypes Javiana, Infantis, and Thompson increased. New regulatory requirements that include enhanced testing of poultry products for Salmonella† might have contributed to the decreases. The incidence of STEC O157 infections during 2017 also decreased compared with 2006-2008, which parallels reductions in isolations from ground beef.§ The declines in two Salmonella serotypes and STEC O157 infections provide supportive evidence that targeted control measures are effective. The marked increases in infections caused by some Salmonella serotypes provide an opportunity to investigate food and nonfood sources of infection and to design specific interventions.

Multidrug-Resistant Campylobacter jejuni Outbreak Linked to Puppy Exposure - United States, 2016-2018.

Campylobacter causes an estimated 1.3 million diarrheal illnesses in the United States annually (1). In August 2017, the Florida Department of Health notified CDC of six Campylobacter jejuni infections linked to company A, a national pet store chain based in Ohio. CDC examined whole-genome sequencing (WGS) data and identified six isolates from company A puppies in Florida that were highly related to an isolate from a company A customer in Ohio. This information prompted a multistate investigation by local and state health and agriculture departments and CDC to identify the outbreak source and prevent additional illness. Health officials from six states visited pet stores to collect puppy fecal samples, antibiotic records, and traceback information. Nationally, 118 persons, including 29 pet store employees, in 18 states were identified with illness onset during January 5, 2016-February 4, 2018. In total, six pet store companies were linked to the outbreak. Outbreak isolates were resistant by antibiotic susceptibility testing to all antibiotics commonly used to treat Campylobacter infections, including macrolides and quinolones. Store record reviews revealed that among 149 investigated puppies, 142 (95%) received one or more courses of antibiotics, raising concern that antibiotic use might have led to development of resistance. Public health authorities issued infection prevention recommendations to affected pet stores and recommendations for testing puppies to veterinarians. This outbreak demonstrates that puppies can be a source of multidrug-resistant Campylobacter infections in humans, warranting a closer look at antimicrobial use in the commercial dog industry.

Chicken Liver-Associated Outbreaks of Campylobacteriosis and Salmonellosis, United States, 2000-2016: Identifying Opportunities for Prevention.

Chicken liver has been implicated in several reported U.S. illness outbreaks, probably caused by inadequate cooking and pathogen contamination. To identify commonalities among these outbreaks that could represent targets for prevention, we describe chicken liver-associated U.S. outbreaks during 2000-2016 reported to the Food Safety and Inspection Service, to the Centers for Disease Control and Prevention, and in published literature. We identified 28 outbreaks (23 [82.1%] were campylobacteriosis only, 3 [10.7%] were salmonellosis only, and 2 [7.1%] were caused by both pathogens), with 18 (64.3%) occurring during 2014-2016. Common outbreak features included blended chicken liver dishes (e.g., pâté; 24 [85.7%]), inadequate cooking (26 [92.8%]), and preparation in foodservice settings (e.g., sit-down restaurants; 25 [89.3%]). The increasing frequency of reported outbreaks highlights chicken liver as an important food safety problem. Public health partners should collaborate on prevention measures, including education on proper foodservice preparation of blended chicken liver dishes.

Increasing Campylobacter Infections, Outbreaks, and Antimicrobial Resistance in the United States, 2004-2012.

BACKGROUND: Campylobacteriosis, a leading cause of foodborne illness in the United States, was not nationally notifiable until 2015. Data describing national patterns and trends are limited. We describe the epidemiology of Campylobacter infections in the United States during 2004-2012. METHODS: We summarized laboratory-confirmed campylobacteriosis data from the Nationally Notifiable Disease Surveillance System, National Outbreak Reporting System, National Antimicrobial Resistance Monitoring System, and Foodborne Diseases Active Surveillance Network. RESULTS: During 2004-2012, 303520 culture-confirmed campylobacteriosis cases were reported. Average annual incidence rate (IR) was 11.4 cases/100000 persons, with substantial variation by state (range, 3.1-47.6 cases/100000 persons). IRs among patients aged 0-4 years were more than double overall IRs. IRs were highest among males in all age groups. IRs in western states and rural counties were higher (16.2/100000 and 14.2/100000, respectively) than southern states and metropolitan counties (6.8/100000 and 11.0/100000, respectively). Annual IRs increased 21% from 10.5/100000 during 2004-2006 to 12.7/100000 during 2010-2012, with the greatest increases among persons aged >60 years (40%) and in southern states (32%). The annual median number of Campylobacter outbreaks increased from 28 in 2004-2006 to 56 in 2010-2012; in total, 347 were reported. Antimicrobial susceptibility testing of isolates from 4793 domestic and 1070 travel-associated infections revealed that, comparing 2004-2009 to 2010-2012, ciprofloxacin resistance increased among domestic infections (12.8% vs 16.1%). CONCLUSIONS: During 2004-2012, incidence of campylobacteriosis, outbreaks, and clinically significant antimicrobial resistance increased. Marked demographic and geographic differences exist. Our findings underscore the importance of national surveillance and understanding of risk factors to guide and target control measures.

Incidence and Trends of Infections with Pathogens Transmitted Commonly Through Food and the Effect of Increasing Use of Culture-Independent Diagnostic Tests on Surveillance - Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 2013-2016.

Foodborne diseases represent a substantial public health concern in the United States. CDC's Foodborne Diseases Active Surveillance Network (FoodNet) monitors cases reported from 10 U.S. sites* of laboratory-diagnosed infections caused by nine enteric pathogens commonly transmitted through food. This report describes preliminary surveillance data for 2016 on the nine pathogens and changes in incidences compared with 2013-2015. In 2016, FoodNet identified 24,029 infections, 5,512 hospitalizations, and 98 deaths caused by these pathogens. The use of culture-independent diagnostic tests (CIDTs) by clinical laboratories to detect enteric pathogens has been steadily increasing since FoodNet began surveying clinical laboratories in 2010 (1). CIDTs complicate the interpretation of FoodNet surveillance data because pathogen detection could be affected by changes in health care provider behaviors or laboratory testing practices (2). Health care providers might be more likely to order CIDTs because these tests are quicker and easier to use than traditional culture methods, a circumstance that could increase pathogen detection (3). Similarly, pathogen detection could also be increasing as clinical laboratories adopt DNA-based syndromic panels, which include pathogens not often included in routine stool culture (4,5). In addition, CIDTs do not yield isolates, which public health officials rely on to distinguish pathogen subtypes, determine antimicrobial resistance, monitor trends, and detect outbreaks. To obtain isolates for infections identified by CIDTs, laboratories must perform reflex culture†; if clinical laboratories do not, the burden of culturing falls to state public health laboratories, which might not be able to absorb that burden as the adoption of these tests increases (2). Strategies are needed to preserve access to bacterial isolates for further characterization and to determine the effect of changing trends in testing practices on surveillance.

Tickborne relapsing fever - United States, 1990-2011.

Tickborne relapsing fever (TBRF) is a zoonosis caused by spirochetes of the genus Borrelia and transmitted to humans by ticks of the genus Ornithodoros. TBRF is endemic in the western United States, predominately in mountainous regions. Clinical illness is characterized by recurrent bouts of fever, headache, and malaise. Although TBRF is usually a mild illness, severe sequelae and death can occur. This report summarizes the epidemiology of 504 TBRF cases reported from 12 western states during 1990-2011. Cases occurred most commonly among males and among persons aged 10‒14 and 40‒44 years. Most reported infections occurred among nonresident visitors to areas where TBRF is endemic. Clinicians and public health practitioners need to be familiar with current epidemiology and features of TBRF to adequately diagnose and treat patients and recognize that any TBRF case might indicate an ongoing source of potential exposure that needs to be investigated and eliminated.

Assessment of vaccine exemptions among Wyoming school children, 2009 and 2011.

During 2010-2011, varicella vaccination was an added requirement for school entrance in Wyoming. Vaccination exemption rates were compared during the 2009-2010 and 2011-2012 school years, and impacts of implementing a new childhood vaccine requirement were evaluated. All public schools, grades K-12, were required to report vaccination status of enrolled children for the 2009-2010 and 2011-2012 school years to the Wyoming Department of Health. Exemption data were analyzed by exemption category, vaccine, county, grade, and rurality. The proportion of children exempt for ≥ 1 vaccine increased from 1.2% (1,035/87,398) during the 2009-2010 school year to 1.9% (1,678/89,476) during 2011-2012. In 2011, exemptions were lowest (1.5%) in urban areas and highest (2.6%) in the most rural areas, and varicella vaccine exemptions represented 67.1% (294/438) of single vaccination exemptions. Implementation of a new vaccination requirement for school admission led to an increased exemption rate across Wyoming.

Clinic- and hospital-based sentinel influenza surveillance, Uganda 2007-2010.

BACKGROUND: To assess the epidemiology and seasonality of influenza in Uganda, we established a sentinel surveillance system for influenza in 5 hospitals and 5 outpatient clinics in 4 geographically distinct regions, using standard case definitions for influenzalike illness (ILI) and severe acute respiratory illness (SARI). METHODS: Nasopharyngeal and oropharyngeal specimens were collected from April 2007 through September 2010 from patients with ILI and SARI aged ≥ 2 months, tested for influenza A and B with real-time reverse-transcription polymerase chain reaction, and subtyped for seasonal A/H1, A/H3, A/H5, and 2009 pandemic influenza A (pH1N1). RESULTS: Among the 2758 patients sampled, 2656 (96%) enrolled with ILI and 101 (4%) with SARI. Specimens from 359 (13.0%) were positive for influenza; 267 (74.4%) were influenza A, and 92 (25.6%) were influenza B. The median age of both patients with ILI and patients with SARI was 4 years (range, 2 months to 67 years); patients aged 5-14 years had the highest influenza-positive percentage (19.6%), and patients aged 0-4 years had the lowest percentage (9.1%). Influenza circulated throughout the year, but the percentage of influenza-positive specimens peaked during June-November, coinciding with the second rainy season. CONCLUSIONS: Continued and increased surveillance is needed to better understand the morbidity and mortality of influenza in Uganda.

Ongoing Outbreak of Extensively Drug-Resistant Campylobacter jejuni Infections Associated With US Pet Store Puppies, 2016-2020.

Importance: Extensively drug-resistant Campylobacter jejuni infections cannot be treated with any commonly recommended antibiotics and pose an increasing public health threat. Objectives: To investigate cases of extensively drug-resistant C jejuni associated with pet store puppies and describe the epidemiologic and laboratory characteristics of these infections. Design, Setting, and Participants: In August 2017, health officials identified, via survey, patients with C jejuni infections who reported contact with puppies sold by pet stores. In conjunction with state and federal partners, the Centers for Disease Control and Prevention investigated cases of culture-confirmed C jejuni infections in US patients with an epidemiologic or molecular association with pet store puppies between January 1, 2016, and February 29, 2020. Available records from cases occurring before 2016 with genetically related isolates were also obtained. Main Outcomes and Measures: Patients were interviewed about demographic characteristics, health outcomes, and dog exposure during the 7 days before illness onset. Core genome multilocus sequence typing was used to assess isolate relatedness, and genomes were screened for resistance determinants to predict antibiotic resistance. Isolates resistant to fluoroquinolones, macrolides, and 3 or more additional antibiotic classes were considered to be extensively drug resistant. Cases before 2016 were identified by screening all sequenced isolates submitted for surveillance using core genome multilocus sequence typing. Results: A total of 168 patients (median [interquartile range] age, 37 [19.5-51.0] years; 105 of 163 female [64%]) with an epidemiologic or molecular association with pet store puppies were studied. A total of 137 cases occurred from January 1, 2016, to February 29, 2020, with 31 additional cases dating back to 2011. Overall, 117 of 121 patients (97%) reported contact with a dog in the week before symptom onset, of whom 69 of 78 (88%) with additional information reported contact with a pet store puppy; 168 isolates (88%) were extensively drug resistant. Traceback investigation did not implicate any particular breeder, transporter, distributer, store, or chain. Conclusions and Relevance: Strains of extensively drug-resistant C jejuni have been circulating since at least 2011 and are associated with illness among pet store customers, employees, and others who come into contact with pet store puppies. The results of this study suggest that practitioners should ask about puppy exposure when treating patients with Campylobacter infection, especially when they do not improve with routine antibiotics, and that the commercial dog industry should take action to help prevent the spread of extensively drug-resistant C jejuni from pet store puppies to people.

Infection with Colorado tick fever virus among humans and ticks in a national park and forest, Wyoming, 2010.

BACKGROUND: Colorado tick fever (CTF) is an underreported tick-borne viral disease occurring in the western United States. CTF illness includes fever, headache, and severe myalgia lasting for weeks. Wyoming has one of the highest CTF incidence rates with approximately 30% of infected persons reporting tick exposure in a Wyoming National Park or Forest before symptom onset. We assessed CTF virus infections among humans and Dermacentor andersoni ticks in Grand Teton National Park (GRTE) and Bridger-Teton National Forest (BTNF). METHODS: In June of 2010, 526 eligible employees were approached to participate in a baseline and 3-month follow-up serosurvey and risk behavior survey. Seropositivity was defined as antibody titers against CTF virus ≥10, as measured by the plaque reduction neutralization test. Ticks were collected at 27 sites within GRTE/BTNF and tested by RT-PCR for the CTF virus. RESULTS: A total of 126 (24%) employees participated in the baseline and follow-up study visits. Three (2%) employees were seropositive for CTF virus infection at baseline. During the study, 47 (37%) participants found unattached ticks on themselves, and 12 (10%) found attached ticks; however, no participants seroconverted against CTF virus. Walking through sagebrush (p=0.04) and spending time at ≥7000 feet elevation (p<0.01) were significantly associated with tick exposure. Ninety-nine percent (174/176) of ticks were D. andersoni, and all were found at ≥7000 feet elevation in sagebrush areas; 37 (21%) ticks tested positive for CTF virus and were found at 10 (38%) of 26 sites sampled. CONCLUSIONS: Although no GRTE or BTNF employees were infected with CTF virus during the study period, high rates of infected ticks were identified in areas with sagebrush at ≥7000 feet. CTF education and personal protection measures against tick exposure should be targeted to visitors and employees traveling to the high-risk environs identified in this study.