Pregnancy, Labor, and Delivery after Ebola Virus Disease and Implications for Infection Control in Obstetric Services, United States.

Many of the survivors of the 2014-2015 epidemic of Ebola virus disease (EVD) in western Africa were women of childbearing age. Limited clinical and laboratory data exist that describe these women's pregnancies and outcomes. We report the case of an EVD survivor who became pregnant and delivered her child in the United States, and we discuss implications of this case for infection control practices in obstetric services. Hospitals in the United States must be prepared to care for EVD survivors.

Measles in a Patient with Presumed Immunity - Los Angeles County, 2015.

On February 14, 2015, patient A, aged 17 years, was seen in an emergency department for evaluation of reactive airway disease. In the waiting room at the same time were two siblings, aged 6 months, presenting with fever and rash; these two children (patients B and C) were later confirmed to have measles. Patient A began a 5-day course of oral prednisone (50 mg per day); however, symptoms continued, and patient A returned to the emergency department the next day and received 125 mg of intravenous (IV) methylprednisolone. Patient A had documentation of receipt of 2 doses of measles, mumps, and rubella (MMR) vaccine at ages 12 months and 4 years.

Meningococcal disease among men who have sex with men - United States, January 2012-June 2015.

Since 2012, three clusters of serogroup C meningococcal disease among men who have sex with men (MSM) have been reported in the United States. During 2012, 13 cases of meningococcal disease among MSM were reported by the New York City Department of Health and Mental Hygiene (1); over a 5-month period during 2012­2013, the Los Angeles County Department of Public Health reported four cases among MSM; and during May­June 2015, the Chicago Department of Public Health reported seven cases of meningococcal disease among MSM in the greater Chicago area. MSM have not previously been considered at increased risk for meningococcal disease. Determining outbreak thresholds* for special populations of unknown size (such as MSM) can be difficult. The New York City health department declared an outbreak based on an estimated increased risk for meningococcal infection in 2012 among MSM and human immunodeficiency virus (HIV)­infected MSM compared with city residents who were not MSM or for whom MSM status was unknown (1). The Chicago Department of Public Health also declared an outbreak based on an increase in case counts and thresholds calculated using population estimates of MSM and HIV-infected MSM. Local public health response included increasing awareness among MSM, conducting contact tracing and providing chemoprophylaxis to close contacts, and offering vaccination to the population at risk (1­3). To better understand the epidemiology and burden of meningococcal disease in MSM populations in the United States and to inform recommendations, CDC analyzed data from a retrospective review of reported cases from January 2012 through June 2015.

School-located influenza vaccination decreases laboratory-confirmed influenza and improves school attendance.

BACKGROUND: School-located influenza vaccination (SLV) programs can efficiently immunize large numbers of school-aged children. We evaluated the impact of SLV on laboratory-confirmed influenza and absenteeism. METHODS: Active surveillance for influenza-like illness (ILI) was conducted on 4455 children in 4 SLV intervention and 4 control elementary schools (grades K-6) matched for sociodemographic characteristics during the 2010-2011 influenza season in Los Angeles County, California. Combined nose/throat swabs were collected from febrile children with ILI at presentation to the school nurse or during absenteeism. RESULTS: In SLV schools, 26.9%-46.6% of enrolled students received at least 1 dose of either inactivated or live attenuated influenza vaccine compared with 0.8%-4.3% in control schools. Polymerase chain reaction for respiratory viruses (PCR) was performed on 1021 specimens obtained from 898 children. Specimens were positive for influenza in 217 (21.3%), including 2009 H1N1 (30.9%), H3 (9.2%), and B (59.9%). Children attending SLV schools, regardless of vaccination status, were 30.8% (95% confidence interval, 10.1%-46.8%) less likely to acquire influenza compared with children at control schools. Unvaccinated children were indirectly protected in the school with nearly 50% vaccination coverage compared with control schools (influenza rate, 27.1 vs 60.0 per 1000 children; P = .023). Unvaccinated children missed more school days than vaccinated children (4.3 vs 2.8 days per 100 school days; P < .001). CONCLUSIONS: Vaccination of at least a quarter of the school population resulted in decreased influenza rates and improved school attendance. Herd immunity for unvaccinated children may occur in schools with vaccination coverage approaching 50%.

Fungal endophthalmitis associated with compounded products.

Fungal endophthalmitis is a rare but serious infection. In March 2012, several cases of probable and laboratory-confirmed fungal endophthalmitis occurring after invasive ocular procedures were reported nationwide. We identified 47 cases in 9 states: 21 patients had been exposed to the intraocular dye Brilliant Blue G (BBG) during retinal surgery, and the other 26 had received an intravitreal injection containing triamcinolone acetonide. Both drugs were produced by Franck's Compounding Lab (Ocala, FL, USA). Fusarium incarnatum-equiseti species complex mold was identified in specimens from BBG-exposed case-patients and an unopened BBG vial. Bipolaris hawaiiensis mold was identified in specimens from triamcinolone-exposed case-patients. Exposure to either product was the only factor associated with case status. Of 40 case-patients for whom data were available, 39 (98%) lost vision. These concurrent outbreaks, associated with 1 compounding pharmacy, resulted in a product recall. Ensuring safety and integrity of compounded medications is critical for preventing further outbreaks associated with compounded products.

Strengthening Pediatric and Public Health Collaboration to Protect Children's Health During a Pandemic.

This article examines lessons learned from previous pandemics, including the 2009 H1N1 influenza and the coronavirus disease 2019 pandemic. Pediatric providers have a unique and important role and strategies to improve collaboration and communication between public health and pediatric providers are essential during public health emergencies. A robust network of communication channels, effective public health messaging, and pediatric-focused disease related, and program outcome data are key to supporting a coordinated response to future pandemics. Critical issues include real-time communication with and engagement of pediatric providers as well as optimizing best evidence approaches for pediatric care while considering the distinct challenges facing children and their families.

Global Implications for COVID-19 Vaccine Series Completion: Insights from Real-World Data from the United States.

This retrospective cohort analysis leveraged vaccination data for BNT162b2, mRNA-1273, and Ad26.COV2.S in the United States from the Komodo Healthcare Map database, the TriNetX Dataworks USA Network, and Cerner Real-World EHR (electronic health record) Data to evaluate rates of adherence to and completion of COVID-19 vaccination series (November 2020 through June 2021). Individuals were indexed on the date they received the first dose of a COVID-19 vaccine, with an adherence follow-up window of 42 days. Adherence/completion rates were calculated in the overall cohort of each database and by month of initiation and stratified by age, race/ethnicity, and urban/rural status. Overall adherence and completion to 2-dose COVID-19 mRNA vaccine schedules ranged from 79.4% to 87.4% and 81.0% to 89.2%, respectively. In TriNetX and Cerner, mRNA-1273 recipients were generally less adherent compared with BNT162b2 across sociodemographic groups. In Komodo, rates of adherence/completion between mRNA-1273 and BNT162b2 were similar. Adherence/completion were generally lower in younger (<65 years) versus older recipients (≥65 years), particularly for mRNA-1273. No other sociodemographic-based gaps in vaccine adherence/completion were identified. These data demonstrate high but incomplete adherence to/completion of multidose COVID-19 vaccines during initial vaccine rollout in the United States. Multidose schedules may contribute to challenges associated with successful global vaccination.

Loss of vaccine-induced immunity to varicella over time.

BACKGROUND: The introduction of universal varicella vaccination in 1995 has substantially reduced varicella-related morbidity and mortality in the United States. However, it remains unclear whether vaccine-induced immunity wanes over time, a condition that may result in increased susceptibility later in life, when the risk of serious complications may be greater than in childhood. METHODS: We examined 10 years (1995 to 2004) of active surveillance data from a sentinel population of 350,000 subjects to determine whether the severity and incidence of breakthrough varicella (with an onset of rash >42 days after vaccination) increased with the time since vaccination. We used multivariate logistic regression to adjust for the year of disease onset (calendar year) and the subject's age at both disease onset and vaccination. RESULTS: A total of 11,356 subjects were reported to have varicella during the surveillance period, of whom 1080 (9.5%) had breakthrough disease. Children between the ages of 8 and 12 years who had been vaccinated at least 5 years previously were significantly more likely to have moderate or severe disease than were those who had been vaccinated less than 5 years previously (risk ratio, 2.6; 95% confidence interval [CI], 1.2 to 5.8). The annual rate of breakthrough varicella significantly increased with the time since vaccination, from 1.6 cases per 1000 person-years (95% CI, 1.2 to 2.0) within 1 year after vaccination to 9.0 per 1000 person-years (95% CI, 6.9 to 11.7) at 5 years and 58.2 per 1000 person-years (95% CI, 36.0 to 94.0) at 9 years. CONCLUSIONS: A second dose of varicella vaccine, now recommended for all children, could improve protection from both primary vaccine failure and waning vaccine-induced immunity.

Risk factors for mortality among patients with nonperinatal listeriosis in Los Angeles County, 1992-2004.

BACKGROUND: Listeriosis is a relatively rare foodborne disease with significant public health implications. The causative pathogen, Listeria monocytogenes, grows well in refrigeration, is associated with a case-fatality rate of 20%, and causes an estimated 28% of all foodborne disease-related deaths. Nevertheless, data on the risk factors for listeriosis mortality are limited. METHODS: Using the passive surveillance listeriosis database of the County of Los Angeles Department of Public Health, we conducted a 13-year retrospective cohort study to describe nonperinatal listeriosis mortality in Los Angeles County during the period 1992-2004. A nonperinatal listeriosis case was defined as one occurring in a nonpregnant person >42 days of age who resided in Los Angeles County and had a culture positive for L. monocytogenes. RESULTS: Unconditional multivariable logistic regression analysis of 281 nonperinatal listeriosis cases with 29 main effects variables resulted in finding nonhematological malignancy (odds ratio [OR], 5.92; 95% confidence interval [CI], 1.85-18.9), alcoholism (OR, 4.63; 95% CI, 1.36-15.8), age 70 years (OR, 3.44; 95% CI, 1.50-7.87), steroid medication (OR, 3.34; 95% CI, 1.38-8.08), and kidney disease (OR, 2.94; 95% CI, 1.18-7.31) to be statistically significant risk factors for mortality. Other listeriosis mortality risk factors with adjusted odds ratios >1.5 included blood transfusion, asthma, black race, Asian race, use of antibiotics, hypertension, receipt of chemotherapy, and Hispanic race. Patients admitted to the hospital with a diagnosis of sepsis alone had the highest mortality (23.7%), whereas patients with cases of meningitis alone had the lowest mortality (3.13%). CONCLUSIONS: The findings of this study should be used to help researchers and clinicians focus on specific risk factors to prevent nonperinatal listeriosis-related deaths.

Transmission of Trypanosoma cruzi by heart transplantation.

BACKGROUND: Trypanosoma cruzi infection (i.e., Chagas disease) is an unusual complication that can occur after solid-organ transplantation and that can result in severe illness or death. In 2006, there were 2 heart transplant recipients in Los Angeles, California, reported to have acute trypanosomiasis during the same month. We conducted an investigation to determine the source of these infections. METHODS: We reviewed the medical, organ procurement, and donor transfusion and transplantation records of these 2 heart transplant recipients. The 2 heart transplant recipients were interviewed regarding any kind of natural exposure and were screened for parasites by obtaining blood and other tissue samples for buffy coat, culture, and polymerase chain reaction. Serum samples from the heart transplant recipients, organ donors, and blood donors were tested for T. cruzi antibodies by use of immunofluorescence assay and radioimmunoprecipitation assay. Tissue samples from the organ donors were examined by use of polymerase chain reaction and immunohistochemical staining. Other recipients of organs from the same donors were monitored for T. cruzi infection by use of polymerase chain reaction and immunofluorescence assay. RESULTS: Both heart transplant recipients had no apparent risk factors for preexisting T. cruzi infection. Both were seronegative but tested positive for the parasite, indicating recent infection. Both recipients died despite medical treatment. The organ donors tested positive for T. cruzi antibodies by use of radioimmunoprecipitation assay; the blood donors were seronegative. Six other patients had received a liver or kidney from these organ donors. None showed evidence of T. cruzi infection. CONCLUSIONS: To our knowledge, this is the first report of T. cruzi transmission associated with heart transplantation. Clinicians and public health authorities should be aware that manifestations of Chagas disease can occur after transplantation, requiring rapid evaluation, diagnosis, and treatment.

Responding to suspected smallpox cases in the Los Angeles County from 2002 to 2006: identifying areas for education.

INTRODUCTION: Although smallpox has been eradicated, health care providers in emergency departments (EDs) need to remain vigilant to its recognition. Smallpox can be confused with chickenpox. We describe suspected smallpox cases reported in Los Angeles County from 2002 to 2006 and highlight areas for education. METHODS: We retrospectively reviewed suspected smallpox reports from 2002 to 2006. Laboratory testing was performed. Photographs of rashes were taken. RESULTS: Five suspected smallpox cases were reported. Two presented first to an ED. Smallpox was suspected based on rash features. Previous history of chickenpox or varicella vaccination may have caused increased suspicion for smallpox. All 5 were determined to have a final diagnosis of chickenpox. Health care providers notified public health appropriately and responses were immediate. CONCLUSIONS: Public health investigated 5 suspected smallpox cases in the past 5 years. Two presented initially to EDs. Education differentiating smallpox from chickenpox and collaboration between public health, EDs, and health care providers remains important. The ability to respond rapidly to a potential bioterrorism emergency was tested.

Decreasing listeriosis mortality in the United States, 1990-2005.

BACKGROUND: Listeria monocytogenes is among the most virulent foodborne pathogens, with 20% of clinical infections resulting in death. To explore listeriosis-associated mortality in the United States and to evaluate prevention efforts, we reviewed vital records over a 16-year period to assess demographic, temporal, and seasonal trends. METHODS: Nonperinatal listeriosis-associated deaths from 1990 through 2005 were identified from multiple-cause-coded death records and were combined with US census data to calculate mortality rates. Poisson regression was used to model time trends, and logistic regression was used to identify comorbid conditions associated with listeriosis on the death record. RESULTS: Of the 37,267,946 deaths occurring in the United States during the 16-year study period, 1178 included listeriosis on the death record. Listeriosis-related mortality rates decreased annually by 10.74% from 1990 through 1996 and by 4.26% from 1996 through 2005. Seasonal trends show a distinct peak in mortality from July through October. After adjustment for age, sex, and race/ethnicity, listeriosis was positively associated with human immunodeficiency virus (HIV) infection (odds ratio, 4.19; 95% confidence interval, 3.06-5.73), lymphoid and hematopoietic cancers (odds ratio, 5.27; 95% confidence interval, 4.47-6.22), and liver disease (odds ratio, 2.05; 95% confidence interval, 1.54-2.73) on the death record. CONCLUSIONS: Nonperinatal listeriosis-associated deaths in the United States have decreased, paralleling a decreasing trend in incidence. Strict monitoring of food manufacturing processes, as well as improved treatment for HIV infection, may have played influential roles in preventing human infections. Health care providers should be aware of seasonal listeriosis patterns, as well as conditions predisposing individuals to severe infection and death due to L. monocytogenes infection, to guide strategies for disease management and prevention.

Pediatricians and Public Health: Optimizing the Health and Well-Being of the Nation's Children.

Ensuring optimal health for children requires a population-based approach and collaboration between pediatrics and public health. The prevention of major threats to children's health (such as behavioral health issues) and the control and management of chronic diseases, obesity, injury, communicable diseases, and other problems cannot be managed solely in the pediatric office. The integration of clinical practice with public health actions is necessary for multiple levels of disease prevention that involve the child, family, and community. Although pediatricians and public health professionals interact frequently to the benefit of children and their families, increased integration of the 2 disciplines is critical to improving child health at the individual and population levels. Effective collaboration is necessary to ensure that population health activities include children and that the child health priorities of the American Academy of Pediatrics (AAP), such as poverty and child health, early brain and child development, obesity, and mental health, can engage federal, state, and local public health initiatives. In this policy statement, we build on the 2013 AAP Policy Statement on community pediatrics by identifying specific opportunities for collaboration between pediatricians and public health professionals that are likely to improve the health of children in communities. In the statement, we provide recommendations for pediatricians, public health professionals, and the AAP and its chapters.

Risk factors for neonatal methicillin-resistant Staphylococcus aureus infection in a well-infant nursery.

OBJECTIVE: To determine risk factors for neonatal methicillin-resistant Staphylococcus aureus (MRSA) skin and soft-tissue infection in a well-infant nursery. DESIGN: Case-control studies. SETTING: A well-infant nursery in a nonteaching, community hospital. METHODS: Case infants were newborns in the nursery who were born in the period November 2003 through June 2004 and had onset of MRSA skin and soft-tissue infection within 21 days after discharge from the nursery. Site inspections were conducted. Control infants were randomly selected male infants in the nursery during the outbreak periods. MRSA isolates were characterized with pulsed-field gel electrophoresis. RESULTS: Eleven case infants were identified in 2 outbreaks: outbreak 1 occurred from November 18 through December 24, 2003, and outbreak 2 occurred from May 26 through June 5, 2004. All were full-term male infants with pustular-vesicular lesions in the groin. Inspection revealed uncovered circumcision equipment, multiple-dose lidocaine vials, and inadequate hand hygiene practices. In outbreak 1, case infants (n=6) had a significantly higher mean length of stay than control infants (3.7 vs 2.5 days; P=.01). In outbreak 2, case infants (n=5) were more likely to have been circumcised in the nursery (OR, undefined [95% CI, 1.7 to undefined]) and to have received lidocaine injections (OR, undefined [95% CI, 2.6 to undefined]). Controlling for length of stay, case infants were more likely to have been circumcised in the nursery (OR, 12.2 [95% CI, 1.5 to undefined]). Pulsed-field gel electrophoresis showed that 7 available isolates were indistinguishable from a community-associated MRSA strain (USA300-0114). CONCLUSIONS: Newborns in well-infant nurseries are at risk for nosocomial infection with community-associated MRSA strains. Reducing length of stay, improving circumcision and hand hygiene practices, and eliminating use of multiple-dose lidocaine vials should decrease transmission of community-associated MRSA strains in nurseries.

Validity of self-reported varicella disease history in pregnant women attending prenatal clinics.

OBJECTIVE: The purpose of this study was to assess the validity of self-reported history for varicella disease relative to serological evidence of varicella immunity in pregnant women attending antenatal care at clinics located in two diverse geographical locations in the U.S. (Antelope Valley, California, and Philadelphia) with high varicella vaccination coverage. METHODS: Pregnant women attending prenatal care appointments who needed blood drawn as part of their routine care were eligible to participate. Self-reported varicella disease history was obtained via questionnaire. Varicella serostatus was determined using a whole-cell enzyme-linked immunosorbent assay to test for varicella zoster virus-specific immunoglobulin G (VZV IgG) antibodies. RESULTS: Of the 309 study participants from Antelope Valley and the 528 participants from Philadelphia who self-reported having had chickenpox disease, 308 (99.7%; 95% confidence interval [CI]: 98.2, 100) and 517 (97.9%; 95% CI: 96.3, 99.0), respectively, had serological evidence of immunity to varicella. Only 6.8% (95% CI: 3.9, 11.0) and 17.4% (95% CI: 13.1, 22.5) of women who self-reported having a negative or uncertain varicella disease history in Antelope Valley and Philadelphia, respectively, were seronegative for varicella antibodies. CONCLUSION: Despite the dramatic changes in the epidemiology of varicella that have occurred since 1995 due to the introduction and subsequent widespread use of the varicella vaccine, self-reported history of varicella continues to be a strong predictor of VZV IgG antibodies in pregnant women. Negative or uncertain history remains poorly predictive of negative serostatus.

Harnessing Syndromic Surveillance Emergency Department Data to Monitor Health Impacts During the 2015 Special Olympics World Games.

INTRODUCTION: Mass gatherings that attract a large international presence may cause or amplify point-source outbreaks of emerging infectious disease. The Los Angeles County Department of Public Health customized its syndromic surveillance system to detect increased syndrome-specific utilization of emergency departments (EDs) and other medical encounters coincident to the 2015 Special Olympics World Games. MATERIALS AND METHODS: We queried live databases containing data on ED visits, California Poison Control System calls, and Los Angeles County coroner-investigated deaths for increases in daily counts from July 19 to August 6, 2015. We chose syndrome categories based on the potential for disease outbreaks common to international travel and dormitory settings, morbidity amplified by high temperatures, and bioterrorism threats inherent to mass gatherings. We performed line-list reviews and trend analyses of total, syndrome-specific, and region-specific daily counts, using cumulative sum-based signals. We also piloted a novel strategy of requesting that ED registrars proactively tag Special Olympics attendees in chief complaint data fields. RESULTS: The syndromic surveillance system showed that the 2015 Special Olympics did not generate large-scale acute morbidities leading to detectable stress on local EDs. We recruited 10 hospitals for proactive patient tagging, from which 16 Special Olympics attendees were detected; these patients reported various symptoms, such as injury, vomiting, and syncope. PRACTICE IMPLICATIONS: As an enhancement to traditional syndromic surveillance, proactive patient tagging can illuminate potential epidemiologic links among patients in challenging syndromic surveillance applications, such as mass gatherings. Syndromic surveillance has the potential to enhance ED patient polling and reporting of exposure, symptom, and other epidemiologic case definition criteria to public health agencies in near-real time.

Generalisability of vaccine effectiveness estimates: an analysis of cases included in a postlicensure evaluation of 13-valent pneumococcal conjugate vaccine in the USA.

OBJECTIVES: External validity, or generalisability, is the measure of how well results from a study pertain to individuals in the target population. We assessed generalisability, with respect to socioeconomic status, of estimates from a matched case-control study of 13-valent pneumococcal conjugate vaccine effectiveness for the prevention of invasive pneumococcal disease in children in the USA. DESIGN: Matched case-control study. SETTING: Thirteen active surveillance sites for invasive pneumococcal disease in the USA. PARTICIPANTS: Cases were identified from active surveillance and controls were age and zip code matched. OUTCOME MEASURES: Socioeconomic status was assessed at the individual level via parent interview (for enrolled individuals only) and birth certificate data (for both enrolled and unenrolled individuals) and at the neighbourhood level by geocoding to the census tract (for both enrolled and unenrolled individuals). Prediction models were used to determine if socioeconomic status was associated with enrolment. RESULTS: We enrolled 54.6% of 1211 eligible cases and found a trend toward enrolled cases being more affluent than unenrolled cases. Enrolled cases were slightly more likely to have private insurance at birth (p=0.08) and have mothers with at least some college education (p<0.01). Enrolled cases also tended to come from more affluent census tracts. Despite these differences, our best predictive model for enrolment yielded a concordance statistic of only 0.703, indicating mediocre predictive value. Variables retained in the final model were assessed for effect measure modification, and none were found to be significant modifiers of vaccine effectiveness. CONCLUSIONS: We conclude that although enrolled cases are somewhat more affluent than unenrolled cases, our estimates are externally valid with respect to socioeconomic status. Our analysis provides evidence that this study design can yield valid estimates and the assessing generalisability of observational data is feasible, even when unenrolled individuals cannot be contacted.

Population-based analysis of meningococcal disease mortality in the United States: 1990-2002.

BACKGROUND: Neisseria meningitidis is a leading cause of bacterial meningitis and septicemia in the United States. Approximately 10-15% of meningococcal patients died despite antimicrobial therapies. METHODS: We used vital records to assess meningococcal disease mortality in the United States during 1990-2002. Meningococcal cases were defined as reported deaths with recorded International Classification of Diseases, 9th revision (ICD-9) codes 036.0-036.9 or ICD-10 codes A39.0-A39.9. Denominator data were obtained from population estimates published by the U.S. Census Bureau. We analyzed the effects of age, sex, race/ethnicity and season of the year on meningococcal disease mortality. RESULTS: We identified 3335 meningococcal deaths. Both the crude and age-adjusted mortality rates were 0.10 death per 100,000 population per year (95% confidence interval, 0.09-0.10). Fifty-eight percent of deaths occurred among persons younger than 25 years old. Mortality was elevated in infants, young adults (15-24 years old), and older adults (older than 74 years old). Mortality rates in African-Americans were 1.45 and 3.32 times higher than mortality rates in whites and Asians/Pacific Islanders, respectively. Mortality caused by meningococcal disease rose in winter months and declined during the summer. Observed mortality rates increased from 1990 to 1997 and decreased from 1997 to 2002. CONCLUSIONS: Meningococcal disease continues to be an important, vaccine-preventable cause of death in the United States. Vaccination and other disease prevention efforts should be augmented for higher risk groups. Meningococcal mortality data can be used to assess the effectiveness of these efforts.

West Nile virus infection in the pediatric population.

In 2004, Los Angeles County confirmed 11 cases of symptomatic West Nile virus (WNV) infections in children younger than 18 years of age. Eight had WNV fever, 2 had meningitis and 1 had encephalitis. Fever, rash, nausea and vomiting were the most prominent symptoms at presentation; median duration of illness was 7 days. Clinicians should be aware of the risk of WNV illness, confirm this diagnosis and report suspected WNV cases to their local health department.

Update on Incidence of Herpes Zoster Among Children and Adolescents After Implementation of Varicella Vaccination, Antelope Valley, CA, 2000 to 2010.

BACKGROUND: Changes in herpes zoster (HZ) epidemiology are expected with childhood varicella vaccination. We reported previously that during 2000 to 2006 HZ incidence decreased 55% in children <10 years of age, while among 10- to 19-year olds it increased by 63%. We update the analysis with 4 additional years of data. METHODS: Population-based active surveillance was conducted for HZ in Antelope Valley, California. Structured telephone interviews and medical chart reviews collected data on demographics, varicella vaccinations, disease histories and clinical information. We calculated HZ incidence for 2007 to 2010 and assessed trends since 2000. RESULTS: Among children <10 years of age, HZ incidence continued the decreasing trend previously reported. During 2007 to 2010, the average incidence was 12.8 cases/100,000 children compared with 41.6 cases/100,000 children during 2000 to 2006, a 69% decline (P < 0.0001). For the 10- to 19-year olds, during 2007 to 2010 HZ incidence did not continue the increasing trend reported from 2000 to 2006; lower rates than in 2006 were observed in 3 of the 4 additional years evaluated. During 2007 to 2010 the average incidence was 78.2 cases/100,000 children compared with 68.0 cases/100,000 children during 2000 to 2006, a 13% increase (P = 0.123), with substantial fluctuation in annual rates throughout the 11 years of surveillance. CONCLUSIONS: During the mature varicella vaccination program, declines in HZ incidence among children <10 years of age continued through 2010. Among the 10- to 19-year olds, the increase reported through 2006 did not continue further and lower rates than in 2006 were observed through 2010. Widespread use of varicella vaccine could reduce HZ incidence among vaccinated populations. Ongoing monitoring of HZ incidence is needed to detect and understand changes in HZ epidemiology in the varicella vaccine era.