Listeria monocytogenes Illness and Deaths Associated With Ongoing Contamination of a Multiregional Brand of Ice Cream Products, United States, 2010-2015.

BACKGROUND: Frozen foods have rarely been linked to Listeria monocytogenes illness. We describe an outbreak investigation prompted by both hospital clustering of illnesses and product testing. METHODS: We identified outbreak-associated listeriosis cases using whole-genome sequencing (WGS), product testing results, and epidemiologic linkage to cases in the same Kansas hospital. We reviewed hospital medical and dietary records, product invoices, and molecular subtyping results. Federal and state officials tested product and environmental samples for L. monocytogenes. RESULTS: Kansas officials were investigating 5 cases of listeriosis at a single hospital when, simultaneously, unrelated sampling for a study in South Carolina identified L. monocytogenes in Company A ice cream products made in Texas. Isolates from 4 patients and Company A products were closely related by WGS, and the 4 patients with known exposures had consumed milkshakes made with Company A ice cream while hospitalized. Further testing identified L. monocytogenes in ice cream produced in a second Company A production facility in Oklahoma; these isolates were closely related by WGS to those from 5 patients in 3 other states. These 10 illnesses, involving 3 deaths, occurred from 2010 through 2015. Company A ultimately recalled all products. CONCLUSIONS: In this US outbreak of listeriosis linked to a widely distributed brand of ice cream, WGS and product sampling helped link cases spanning 5 years to 2 production facilities, indicating longstanding contamination. Comprehensive sanitation controls and environmental and product testing for L. monocytogenes with regulatory oversight should be implemented for ice cream production.

First Record of Aedes japonicus japonicus in Oklahoma, 2017.

In spring 2017, mosquito larvae were collected from 25 sites across eastern Oklahoma as part of a Zika virus vector surveillance effort. Aedes japonicus japonicus larvae were collected from horse troughs at 2 sites in Ottawa County, OK. Identification was made using 1 larva stored in 70% ethanol and 3 adult females reared from the larvae. Another invasive mosquito species, Culex coronator, was detected at 2 different sites, adding 2 additional counties to the 9 where the species had been previously reported. The presence of these invasive species in Oklahoma may have an impact on future regional arbovirus concerns.

Case-crossover analysis of heat-coded deaths and vulnerable subpopulations: Oklahoma, 1990-2011.

The extent of the association between temperature and heat-coded deaths, for which heat is the primary cause of death, remains largely unknown. We explored the association between temperature and heat-coded deaths and potential interactions with various demographic and environmental factors. A total of 335 heat-coded deaths that occurred in Oklahoma from 1990 through 2011 were identified using heat-related International Classification of Diseases codes, cause-of-death nomenclature, and narrative descriptions. Conditional logistic regression models examined the association between temperature and heat index on heat-coded deaths. Interaction by demographic factors (age, sex, marital status, living alone, outdoor/heavy labor occupations) and environmental factors (ozone, PM10, PM2.5) was also explored. Temperatures ≥99 °F (the median value) were associated with approximately five times higher odds of a heat-coded death as compared to temperatures <99 °F (adjusted OR = 4.9, 95% CI 3.3, 7.2). The effect estimates were attenuated when exposure to heat was characterized by heat index. The interaction results suggest that effect of temperature on heat-coded deaths may depend on sex and occupation. For example, the odds of a heat-coded death among outdoor/heavy labor workers exposed to temperatures ≥99 °F was greater than expected based on the sum of the individual effects (observed OR = 14.0, 95% CI 2.7, 72.0; expected OR = 4.1 [2.8 + 2.3-1.0]). Our results highlight the extent of the association between temperature and heat-coded deaths and emphasize the need for a comprehensive, multisource definition of heat-coded deaths. Furthermore, based on the interaction results, we recommend that states implement or expand heat safety programs to protect vulnerable subpopulations, such as outdoor workers.

New Records of Aedes aegypti In Southern Oklahoma, 2016.

Aedes aegypti is an important subtropical vector species and is predicted to have a limited year-round distribution in the southern United States. Collection of the species has not been officially verified in Oklahoma since 1940. Adult mosquitoes were collected in 42 sites across 7 different cities in Oklahoma using 3 different mosquito traps between May and September 2016. Between July and September 2016, 88 Ae. aegypti adults were collected at 18 different sites in 4 different cities across southern Oklahoma. Centers for Disease Control and Prevention mini light traps baited with CO2 attracted the highest numbers of Ae. aegypti individuals compared to Biogents (BG)-Sentinel® traps baited with Biogents (BG)-lure and octenol and Centers for Disease Control and Prevention gravid traps baited with Bermuda grass-infused water. The discovery of Ae. aegypti mosquitoes within urban/exurban areas in Oklahoma is important from an ecological as well as a public health perspective.

Familial Creutzfeldt-Jakob Disease Cluster Among an African American Family.

Familial Creutzfeldt-Jakob disease (fCJD) results from inheritance of mutations in the prion protein gene. Confirming fCJD diagnosis is essential for informing persons of their potential hereditary risk and for genetic counseling to support personal decisions for genetic testing and family planning. We describe a case of fCJD that was linked to a large cluster of African Americans with fCJD identified through a public health investigation, including 8 confirmed cases and 13 suspected cases involving 7 generations in 1 family. Genetic counseling is an important component of fCJD management for families coping with genetic prion diseases.

Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis - United States.

Tickborne rickettsial diseases continue to cause severe illness and death in otherwise healthy adults and children, despite the availability of low-cost, effective antibacterial therapy. Recognition early in the clinical course is critical because this is the period when antibacterial therapy is most effective. Early signs and symptoms of these illnesses are nonspecific or mimic other illnesses, which can make diagnosis challenging. Previously undescribed tickborne rickettsial diseases continue to be recognized, and since 2004, three additional agents have been described as causes of human disease in the United States: Rickettsia parkeri, Ehrlichia muris-like agent, and Rickettsia species 364D. This report updates the 2006 CDC recommendations on the diagnosis and management of tickborne rickettsial diseases in the United States and includes information on the practical aspects of epidemiology, clinical assessment, treatment, laboratory diagnosis, and prevention of tickborne rickettsial diseases. The CDC Rickettsial Zoonoses Branch, in consultation with external clinical and academic specialists and public health professionals, developed this report to assist health care providers and public health professionals to 1) recognize key epidemiologic features and clinical manifestations of tickborne rickettsial diseases, 2) recognize that doxycycline is the treatment of choice for suspected tickborne rickettsial diseases in adults and children, 3) understand that early empiric antibacterial therapy can prevent severe disease and death, 4) request the appropriate confirmatory diagnostic tests and understand their usefulness and limitations, and 5) report probable and confirmed cases of tickborne rickettsial diseases to public health authorities.

Identifying heat-related deaths by using medical examiner and vital statistics data: Surveillance analysis and descriptive epidemiology - Oklahoma, 1990-2011.

OBJECTIVES: Approximately 660 deaths occur annually in the United States associated with excess natural heat. A record heat wave in Oklahoma during 2011 generated increased interest concerning heat-related mortality among public health preparedness partners. We aimed to improve surveillance for heat-related mortality and better characterize heat-related deaths in Oklahoma during 1990-2011, and to enhance public health messaging during future heat emergencies. METHODS: Heat-related deaths were identified by querying vital statistics (VS) and medical examiner (ME) data during 1990-2011. Case inclusion criteria were developed by using heat-related International Classification of Diseases codes, cause-of-death nomenclature, and ME investigation narrative. We calculated sensitivity and predictive value positive (PVP) for heat-related mortality surveillance by using VS and ME data and performed a descriptive analysis. RESULTS: During the study period, 364 confirmed and probable heat-related deaths were identified when utilizing both data sets. ME reports had 87% sensitivity and 74% PVP; VS reports had 80% sensitivity and 52% PVP. Compared to Oklahoma's general population, decedents were disproportionately male (67% vs. 49%), aged ≥65 years (46% vs. 14%), and unmarried (78% vs. 47%). Higher rates of heat-related mortality were observed among Blacks. Of 95 decedents with available information, 91 (96%) did not use air conditioning. CONCLUSIONS: Linking ME and VS data sources together and using narrative description for case classification allows for improved case ascertainment and surveillance data quality. Males, Blacks, persons aged ≥65 years, unmarried persons, and those without air conditioning carry a disproportionate burden of the heat-related deaths in Oklahoma.

An Updated Checklist of the Mosquitoes of Oklahoma Including New State Records and West Nile Virus Vectors, 2003-06.

The mosquito fauna of Oklahoma has not been evaluated since 1965 and no report has been published concerning species associated with urban areas in the state. Mosquito collections were conducted as part of the West Nile virus (WNV) surveillance program between April and November from 2003 to 2006, using standard collection methods. A total of 74,756 adults were collected in 26 urban centers in 16 counties of Oklahoma. Altogether, 40 species were recorded during this study period, bringing the total mosquito species recorded in Oklahoma to 62 species in 9 different genera and 18 subgenera. An updated checklist of Oklahoma mosquito fauna is included with a comparison to historical records. New state records include 3 species: Aedes muelleri, Anopheles perplexens, and Culex coronator. In addition to updating the checklist, 12 species of mosquitoes were tested for WNV. Pools of Culex pipiens complex represented the highest proportion testing positive for WNV (134/766, 17.5%), followed by Cx. tarsalis (13/192, 6.8%) and Aedes albopictus (5/215, 2.3%). West Nile virus-positive mosquitoes were detected earliest in June 2005 and latest in November 2004. Infected Cx. pipiens complex testing positive for WNV were more prevalent in the eastern and central areas of Oklahoma, whereas positive Cx. tarsalis were found mainly in the western areas of the state. This distinct geographical difference needs to be monitored and followed up to ensure optimal mosquito control efforts in Oklahoma communities with mosquito control capabilities.

Impact of Prompt Influenza Antiviral Treatment on Extended Care Needs After Influenza Hospitalization Among Community-Dwelling Older Adults.

BACKGROUND: Patients hospitalized with influenza may require extended care on discharge. We aimed to explore predictors for extended care needs and the potential mitigating effect of antiviral treatment among community-dwelling adults aged ≥ 65 years hospitalized with influenza. METHODS: We used laboratory-confirmed influenza hospitalizations from 3 influenza seasons. Extended care was defined as new placement in a skilled nursing home/long-term/rehabilitation facility on hospital discharge. We focused on those treated with antiviral agents to explore the effect of early treatment on extended care and hospital length of stay using logistic regression and competing risk survival analysis, accounting for time from illness onset to hospitalization. Treatment was categorized as early (≤ 4 days) or late (>4 days) in reference to date of illness onset. RESULTS: Among 6593 community-dwelling adults aged ≥ 65 years hospitalized for influenza, 18% required extended care at discharge. The need for care increased with age and neurologic disorders, intensive care unit admission, and pneumonia were predictors of care needs. Early treatment reduced the odds of extended care after hospital discharge for those hospitalized ≤ 2 or >2 days from illness onset (adjusted odds ratio, 0.38 [95% confidence interval {CI}, .17-.85] and 0.75 [.56-.97], respectively). Early treatment was also independently associated with reduction in length of stay for those hospitalized ≤ 2 days from illness onset (adjusted hazard ratio, 1.81; 95% CI, 1.43-2.30) or >2 days (1.30; 1.20-1.40). CONCLUSIONS: Prompt antiviral treatment decreases the impact of influenza on older adults through shorten hospitalization and reduced extended care needs.

Assessment of Arbovirus Surveillance 13 Years after Introduction of West Nile Virus, United States.

Before 1999, the United States had no appropriated funding for arboviral surveillance, and many states conducted no such surveillance. After emergence of West Nile virus (WNV), federal funding was distributed to state and selected local health departments to build WNV surveillance systems. The Council of State and Territorial Epidemiologists conducted assessments of surveillance capacity of resulting systems in 2004 and in 2012; the assessment in 2012 was conducted after a 61% decrease in federal funding. In 2004, nearly all states and assessed local health departments had well-developed animal, mosquito, and human surveillance systems to monitor WNV activity and anticipate outbreaks. In 2012, many health departments had decreased mosquito surveillance and laboratory testing capacity and had no systematic disease-based surveillance for other arboviruses. Arboviral surveillance in many states might no longer be sufficient to rapidly detect and provide information needed to fully respond to WNV outbreaks and other arboviral threats (e.g., dengue, chikungunya).

Seasonality and survival associated with three outbreak seasons of West Nile virus disease in Oklahoma--2003, 2007, and 2012.

West Nile virus (WNV) activity has fluctuated in the south-central United States since its introduction. Seasonal outbreaks are common, with three in Oklahoma during 2003, 2007, and 2012. Morbidity and mortality rates vary during each outbreak. Long-term neurologic sequelae in association with West Nile virus disease (WNVD) are well-described, but limited information is available about delayed mortality among acute WNV infection survivors. A retrospective cohort analysis of all confirmed and probable WNVD cases reported to the Oklahoma State Department of Health (OSDH) during 2003, 2007, and 2012 was performed. OSDH surveillance data and mortality data from Oklahoma's vital statistics database were used to construct a descriptive epidemiologic analysis of the geography, temporality, severity, and associated mortality for each outbreak season. A Kaplan-Meier survival curve and standardized mortality ratios (SMRs) were calculated to measure survival of the 2003 and 2007 WNVD cohorts. Seventy-nine cases during 2003, 107 cases during 2007, and 180 cases during 2012 met inclusion criteria. Median ages of the 2003, 2007, and 2012 cohorts were 48, 58, and 59 years, respectively; race, sex, and symptom information were not substantially different. Each outbreak season had a different severity, temporality, and geography. Age- and sex-adjusted SMRs for the combined 2003 and 2007 cohorts censored at 5 years was 0.9 (95% confidence interval 0.51-1.75); no substantial difference was observed between the survival curves. Although similar patterns of long-term mortality were evident on the survival curves, SMRs did not demonstrate increased 5-year cumulative risk for death for patients surviving acute WNV infection.

Updated Distribution of Aedes albopictus in Oklahoma, and Implications in Arbovirus Transmission.

A series of statewide surveys were conducted in Oklahoma in the summers between 1991 and 2004 to identify the distribution of Aedes albopictus. Adult mosquitoes were identified in 63 counties, bringing the currently known distribution of Ae. albopictus in the state to 69 of 77 counties. The widespread presence of Ae. albopictus in Oklahoma has important current and future public and veterinary health implications for surveillance and control efforts.

Blood Donor Screening for West NiIe Virus in Oklahoma and Its Contribution to Disease Surveillance, 2003 -2013.

Upon recognition that West Nile virus (WNV) was transmissible by transfusion, universal testing of blood donors by nucleic acid testing (NAT) was initiated in 2003. A retrospective review of 2003-2013 blood donor records and public health surveillance data in Oklahoma was undertaken to determine the percentage of WNV-positive blood donors who developed clinical symptoms post-donation and to examine the incidence and timing of WNV viremic donors in the context of WNV disease reported statewide. Among all WNV NAT-positive blood donors, 19% had self-described symptoms consistent with WNV disease. A viremic blood donor was the seasonal index case of WNV transmission in Oklahoma during one year [2006] of the study period. Blood donors remain an important surveillance component for epidemiologic monitoring of WNV in Oklahoma.

Completeness and timeliness of electronic vs. conventional laboratory reporting for communicable disease surveillance--Oklahoma, 2011.

OBJECTIVES: The Health Information Technology for Economic and Clinical Health (HITECH) Act encourages the meaningful use of certified electronic health record technology. A HITECH-compliant core component is nationwide electronic laboratory reporting (ELR) implementation for communicable disease surveillance. In Oklahoma, laboratories with ≥400 positive tests/year for reportable diseases must use ELR. Of 18 such laboratories, two have adopted ELR. We compared completeness and timeliness of ELR reports from these two laboratories with conventional reports from all other Oklahoma laboratories. METHODS: We retrospectively reviewed confirmed reportable disease cases for January 1-December 31, 2011, excluding tuberculosis, hepatitis, sexually transmitted infections, diseases without laboratory diagnoses, and immediately reportable diseases. Probable reportable tickborne disease cases were included. We compared ELR with conventional reporting (i.e., mail, fax, telephone, and Internet). We assessed data completeness based on eight demographic and two laboratory fields in each disease report and timeliness by percentage of cases reported in ≤1 business day. RESULTS: Overall, 1,867 reports met the inclusion criteria; 24% of these reports had been submitted by ELR. Data completeness was 90% for ELR and 95% for conventional reporting. Patient addresses accounted for 97% of the missing data fields for ELR reports. Timeliness was 91% for ELR and 87% for conventional reports. CONCLUSIONS: Although early in the transition to ELR compliance in Oklahoma, ELR has already yielded improved timeliness for communicable disease surveillance. However, ELR did not yield more complete reports than conventional reporting. Requiring specific demographic data fields for ELR reports can improve the completeness of ELR.

National capacity for surveillance, prevention, and control of West Nile virus and other arbovirus infections--United States, 2004 and 2012.

In the first 5 years after its introduction in the United States in 1999, West Nile virus (WNV) spread to the 48 contiguous states, resulting in 667 reported deaths. To establish detection and response capacity, WNV surveillance and prevention was supported through CDC Epidemiology and Laboratory Capacity (ELC) cooperative agreements with all 50 states and six large cities/counties. In 2005, the Council of State and Territorial Epidemiologists (CSTE) conducted an assessment of ELC recipients and determined that, since 1999, all had developed WNV surveillance and control programs, resulting in a national arboviral surveillance infrastructure. From 2004 to 2012, ELC funding for WNV surveillance decreased by 61%. In 2012, the United States had its most severe WNV season since 2003, prompting a follow-up assessment of the capacity of ELC-supported WNV programs. Since the first assessment, 22% of jurisdictions had stopped conducting active human surveillance, 13% had stopped mosquito surveillance, 70% had reduced mosquito trapping and testing, and 64% had eliminated avian mortality surveillance. Reduction in early detection capacity compromises local and national ability to rapidly detect changes in WNV and other arboviral activity and to initiate prevention measures. Each jurisdiction is encouraged to review its current surveillance systems in light of the local threat of WNV and emerging arboviruses (e.g., dengue and chikungunya) and ensure it is able to rapidly detect and respond to critical changes in arbovirus activity.

Vaccine-preventable disease among homeschooled children: two cases of tetanus in Oklahoma.

Homeschooled children represent an increasing proportion of school-aged children in the United States. Immunization rates among homeschooled children are largely unknown because they are usually not subject to state-based school-entry vaccination requirements. Geographic foci of underimmunized children can increase the risk for outbreaks of vaccine-preventable diseases. In 2012, 2 cases of tetanus were reported in Oklahoma; both cases involved homeschooled children without documentation of diphtheria-tetanus-acellular pertussis vaccination. We describe the characteristics of both patients and outline innovative outreach measures with the potential to increase vaccination access and coverage among homeschooled children.

Recognizing laboratory cross-contamination: two false-positive cultures of Mycobacterium tuberculosis--Oklahoma, 2011.

Mycobacterium tuberculosis (MTB) isolation from clinical specimens is the standard for TB diagnosis. Positive MTB cultures are rarely questioned, but false-positive culture rates range from 2% to 4%. In December 2011, two smear-negative, culture-positive TB cases were reported to the Oklahoma State Department of Health (OSDH) in people without TB signs or symptoms. OSDH TB control officers interviewed physicians and laboratory personnel, reviewed patient charts, traced epidemiologic links, and performed microbiologic studies to determine if these were true TB cases. Both specimens were found to have been processed on the same day, at the same laboratory, under the same hood, and by the same technician sequentially after a strongly smear-positive TB specimen. No epidemiologic links were identified among the three patients. Spoligotyping and 24-locus mycobacterial interspersed repetitive unit typing of the three specimens were identical. Only liquid media grew MTB in the two questionable specimens. A laboratory splash incident was suspected, whereby all three liquid media sample lids were open during inoculation rather than being opened one at a time, causing cross-contamination. Also, the two specimens were incubated for 2-3 weeks longer than standard protocol before MTB growth was observed. Patient 1 was not treated for TB because her physician doubted the culture result. Patient 2, an organ transplant recipient, began four-drug anti-TB therapy, and an investigation was initiated for transplant-associated TB. Adherence to strict laboratory techniques and recognizing the possibility of false-positive MTB cultures, especially when inconsistent with clinical data, are essential in preventing erroneous TB diagnoses.