Increased HIV diagnoses in West Virginia counties highly vulnerable to rapid HIV dissemination through injection drug use: a cautionary tale.

PURPOSE: To investigate HIV transmission potential from a cluster of HIV infections among men who have sex with men to persons who inject drugs in 15 West Virginia counties. These counties were previously identified as highly vulnerable to rapid HIV dissemination through injection drug use (IDU) associated with high levels of opioid misuse. METHODS: We interviewed persons with 2017 HIV diagnoses about past-year risk behaviors and elicited sexual, IDU, and social contacts. We tested contacts for HIV and assessed risk behaviors. To determine HIV transmission potential from persons with 2017 diagnoses to persons who inject drugs, we assessed viral suppression status, HIV status of contacts, and IDU risk behaviors of persons living with HIV and contacts. RESULTS: We interviewed 78 persons: 39 with 2017 diagnoses and 39 contacts. Overall, 13/78 (17%) injected drugs in the past year. Of 19 persons with 2017 diagnoses and detectable virus, 9 (47%) had more than or equal to 1 sexual or IDU contacts of negative or unknown HIV status. During the past year, 2/9 had injected drugs and shared equipment, and 1/9 had more than or equal to 1 partner who did so. CONCLUSIONS: We identified IDU risk behavior among persons with 2017 diagnoses and their contacts. West Virginia HIV prevention programs should continue to give high priority to IDU harm reduction.

Opioid Overdose Outbreak - West Virginia, August 2016.

On August 15, 2016, the Mayor's Office of Drug Control Policy in Huntington, West Virginia, notified the Cabell-Huntington Health Department (CHHD) of multiple calls regarding opioid overdose received by the emergency medical system (EMS) during 3 p.m.-8 p.m. that day. A public health investigation and response conducted by the West Virginia Bureau for Public Health (BPH) and CHHD identified 20 opioid overdose cases within a 53-hour period in Cabell County; all cases included emergency department (ED) encounters. EMS personnel, other first responders, and ED providers administered the opioid antidote naloxone to 16 (80%) patients, six of whom were administered multiple doses, suggesting exposure to a highly potent opioid. No patients received referral for recovery support services. In addition to the public health investigation, a public safety investigation was conducted; comprehensive opioid toxicology testing of clinical specimens identified the synthetic opioid fentanyl* and novel fentanyl analogs, including carfentanil,† which had been used by patients who overdosed in Huntington. Results of these two investigations highlight the importance of collaboration between public health and public safety agencies to provide in-depth surveillance data from opioid overdose outbreaks that involve high-potency fentanyl analogs. These data facilitated a public health response through increased awareness of powerful opioid substances requiring multiple naloxone doses for reversal, and improved patient linkage to recovery support services and a harm reduction program from the ED after opioid overdose.

Hospital Impact After a Chemical Spill That Compromised the Potable Water Supply: West Virginia, January 2014.

In January 2014, a chemical spill of 4-methylcyclohexanemethanol and propylene glycol phenyl ethers contaminated the potable water supply of approximately 300,000 West Virginia residents. To understand the spill's impact on hospital operations, we surveyed representatives from 10 hospitals in the affected area during January 2014. We found that the spill-related loss of potable water affected many aspects of hospital patient care (eg, surgery, endoscopy, hemodialysis, and infection control of Clostridium difficile). Hospital emergency preparedness planning could be enhanced by specifying alternative sources of potable water sufficient for hemodialysis, C. difficile infection control, and hospital processing and cleaning needs (in addition to drinking water). (Disaster Med Public Health Preparedness. 2017;11:621-624).

Acute Health Effects After the Elk River Chemical Spill, West Virginia, January 2014.

OBJECTIVES: On January 9, 2014, approximately 10 000 gallons of a mixture of 4-methylcyclohexanemethanol and propylene glycol phenyl ether spilled into West Virginia's Elk River, contaminating the potable water supply of about 300 000 West Virginia residents. This study sought to describe acute health effects after the chemical spill. METHODS: We conducted a descriptive analysis using 3 complementary data sources: (1) medical records of patients who visited an emergency department during January 9-23, 2014, with illness potentially related to the spill; (2) West Virginia Poison Center caller records coded as "contaminated water" during January 9-23, 2014; and (3) answers to household surveys about health effects from a Community Assessment for Public Health Emergency Response (CASPER) questionnaire administered 3 months after the spill. RESULTS: In the 2 weeks after the spill, 2000 people called the poison center reporting exposure to contaminated water, and 369 people visited emergency departments in the affected area with reports of exposure and symptoms potentially related to the spill. According to CASPER weighted cluster analyses, an estimated 25 623 households (21.7%; 95% confidence interval [CI], 14.4%-28.9%) had ≥1 person with symptoms who felt that they were related to the spill in the 3 months after it. Reported health effects across all 3 data sources included mild skin, respiratory, and gastrointestinal symptoms that resolved with no or minimal treatment. CONCLUSIONS: Medical records, poison center data, and CASPER household surveys were inexact but useful data sources to describe overall community health effects after a large-scale chemical spill. Analyzing multiple data sources could inform epidemiologic investigations of similar events.

Assessment of Impact and Recovery Needs in Communities Affected by the Elk River Chemical Spill, West Virginia, April 2014.

OBJECTIVES: In January 2014, 4-methylcyclohexanemethanol spilled into the Elk River near Charleston, West Virginia, contaminating the water supply for about 120 000 households. The West Virginia American Water Company (WVAWC) issued a "do not use" water order for 9 counties. After the order was lifted (10 days after the spill), the communities' use of public water systems, information sources, alternative sources of water, and perceived impact of the spill on households were unclear to public health officials. To assist in recovery efforts, the West Virginia Bureau for Public Health and the Centers for Disease Control and Prevention conducted a Community Assessment for Public Health Emergency Response (CASPER). METHODS: We used the CASPER 2-stage cluster sampling design to select a representative sample of households to interview, and we conducted interviews in 171 households in April 2014. We used a weighted cluster analysis to generate population estimates in the sampling frame. RESULTS: Before the spill, 74.4% of households did not have a 3-day alternative water supply for each household member and pet. Although 83.6% of households obtained an alternative water source within 1 day of the "do not use" order, 37.4% of households reportedly used WVAWC water for any purpose. Nearly 3 months after the spill, 36.1% of households believed that their WVAWC water was safe, and 33.5% reported using their household water for drinking. CONCLUSIONS: CASPER results identified the need to focus on basic public health messaging and household preparedness efforts. Recommendations included (1) encouraging households to maintain a 3-day emergency water supply, (2) identifying additional alternative sources of water for future emergencies, and (3) increasing community education to address ongoing concerns about water.

Two-dose varicella vaccine effectiveness and rash severity in outbreaks of varicella among public school students.

BACKGROUND: Universal 2-dose varicella vaccination was recommended in 2006 to further reduce varicella disease burden. This study examined 2-dose varicella vaccine effectiveness (VE) and rash severity in the setting of school-associated varicella outbreaks. METHODS: A case control study was conducted from January 2010 to May 2011 in all West Virginia public schools. Clinically diagnosed cases from varicella outbreaks were matched with classmate controls. Vaccination information was collected from school, health department and healthcare provider immunization information systems. RESULTS: Among the 133 cases and 365 controls enrolled, VE against all varicella was 83.2% [95% confidence interval (CI): 69.2%-90.8%] for 1-dose of varicella vaccine and 93.9% (95% CI: 86.9%-97.1%) for 2-dose; the incremental VE (2-dose vs. 1-dose) was 63.6% (95% CI: 32.6%-80.3%). In preventing moderate/severe varicella, 1-dose varicella vaccine was 88.2% (95% CI: 72.7%- 94.9%) effective, and 2-dose vaccination was 97.5% (95% CI: 91.6%-99.2%) effective, with the incremental VE of 78.6% (95% CI: 40.9%-92.3%). One-dose VE declined along with time since vaccination (VE = 93.0%, 88.0% and 81.8% in <5, 5-9 and ≥ 10 years after vaccination, P = 0.001 for trend). Both 1- and 2-dose breakthrough cases had milder rash than unvaccinated cases (<50 lesion: 24.6%, 49.1% and 70.0% in unvaccinated, 1-dose and 2-dose cases, P < 0.001), and no severe disease was found in 2-dose cases. CONCLUSIONS: Two-dose varicella vaccination is highly effective and confers higher protection than a 1-dose regimen. High 2-dose varicella vaccination coverage should maximize the benefits of the varicella vaccination program and further reduce varicella disease burden in the United States.

Human infections with influenza A(H3N2) variant virus in the United States, 2011-2012.

BACKGROUND. During August 2011-April 2012, 13 human infections with influenza A(H3N2) variant (H3N2v) virus were identified in the United States; 8 occurred in the prior 2 years. This virus differs from previous variant influenza viruses in that it contains the matrix (M) gene from the Influenza A(H1N1)pdm09 pandemic influenza virus. METHODS. A case was defined as a person with laboratory-confirmed H3N2v virus infection. Cases and contacts were interviewed to determine exposure to swine and other animals and to assess potential person-to-person transmission. RESULTS. Median age of cases was 4 years, and 12 of 13 (92%) were children. Pig exposure was identified in 7 (54%) cases. Six of 7 cases with swine exposure (86%) touched pigs, and 1 (14%) was close to pigs without known direct contact. Six cases had no swine exposure, including 2 clusters of suspected person-to-person transmission. All cases had fever; 12 (92%) had respiratory symptoms, and 3 (23%) were hospitalized for influenza. All 13 cases recovered. CONCLUSIONS. H3N2v virus infections were identified at a high rate from August 2011 to April 2012, and cases without swine exposure were identified in influenza-like illness outbreaks, indicating that limited person-to-person transmission likely occurred. Variant influenza viruses rarely result in sustained person-to-person transmission; however, the potential for this H3N2v virus to transmit efficiently is of concern. With minimal preexisting immunity in children and the limited cross-protective effect from seasonal influenza vaccine, the majority of children are susceptible to infection with this novel influenza virus.