Microbial Characterization, Factors Contributing to Contamination, and Household Use of Cistern Water, U.S. Virgin Islands.

Households in the United States Virgin Islands (USVI) heavily rely on roof-harvested rainwater stored in cisterns for their daily activities. However, there are insufficient data on cistern water microbiological and physicochemical characteristics to inform appropriate cistern water management. Cistern and kitchen tap water samples were collected from 399 geographically representative households across St. Croix, St. Thomas, and St. John and an administered survey captured household site and cistern characteristics and water use behaviors. Water samples were analyzed for Escherichia coli by culture, and a subset of cistern water samples (N = 47) were analyzed for Salmonella, Naegleria fowleri, pathogenic Leptospira, Cryptosporidium, Giardia, and human-specific fecal contamination using real-time polymerase chain reaction (PCR). Associations between E. coli cistern contamination and cistern and site characteristics were evaluated to better understand possible mechanisms of contamination. E. coli was detected in 80% of cistern water samples and in 58% of kitchen tap samples. For the subset of samples tested by PCR, at least one of the pathogens was detected in 66% of cisterns. Our results suggest that covering overflow pipes with screens, decreasing animal presence at the household, and preventing animals or insects from entering the cisterns can decrease the likelihood of E. coli contamination in USVI cistern water.

Survey of healthcare providers' testing practices for vulvovaginal candidiasis and treatment outcomes-United States, 2021.

Vulvovaginal candidiasis (VVC) is a common infection, and high-quality studies report that misdiagnosis is frequent, with diagnostic testing needed to distinguish it from other causes of vaginitis and avoid inappropriate empiric treatment. However, few recent studies have evaluated U.S. healthcare providers' testing practices for VVC in detail. We evaluated healthcare providers' self-reported testing practices for VVC and treatment outcomes as part of a nationwide online survey in order to identify potential opportunities for improving VVC testing and treatment in the United States. Among 1,503 providers surveyed, 21.3% reported "always" (7.4%) or "usually" (13.9%) ordering diagnostic testing for patients with suspected VVC; this proportion was higher among gynecologists (36.0%) compared with family practitioners (17.8%) and internists (15.8%). Most providers (91.2%) reported that patients' VVC "always" (6.4%) or "usually" (84.9%) responds to initial treatment. Whether the symptom resolution reported in this survey was truly related to VVC is unclear given high rates of misdiagnosis and known widespread empiric prescribing. With only about one-in-five providers reporting usually or always performing diagnostic testing for VVC despite guidelines recommending universal use, research is needed to address barriers to proper testing.

Mortality Risk Among Patients Hospitalized Primarily for COVID-19 During the Omicron and Delta Variant Pandemic Periods - United States, April 2020-June 2022.

The risk for COVID-19-associated mortality increases with age, disability, and underlying medical conditions (1). Early in the emergence of the Omicron variant of SARS-CoV-2, the virus that causes COVID-19, mortality among hospitalized COVID-19 patients was lower than that during previous pandemic peaks (2-5), and some health authorities reported that a substantial proportion of COVID-19 hospitalizations were not primarily for COVID-19-related illness,* which might account for the lower mortality among hospitalized patients. Using a large hospital administrative database, CDC assessed in-hospital mortality risk overall and by demographic and clinical characteristics during the Delta (July-October 2021), early Omicron (January-March 2022), and later Omicron (April-June 2022) variant periods† among patients hospitalized primarily for COVID-19. Model-estimated adjusted mortality risk differences (aMRDs) (measures of absolute risk) and adjusted mortality risk ratios (aMRRs) (measures of relative risk) for in-hospital death were calculated comparing the early and later Omicron periods with the Delta period. Crude mortality risk (cMR) (deaths per 100 patients hospitalized primarily for COVID-19) was lower during the early Omicron (13.1) and later Omicron (4.9) periods than during the Delta (15.1) period (p<0.001). Adjusted mortality risk was lower during the Omicron periods than during the Delta period for patients aged ≥18 years, males and females, all racial and ethnic groups, persons with and without disabilities, and those with one or more underlying medical conditions, as indicated by significant aMRDs and aMRRs (p<0.05). During the later Omicron period, 81.9% of in-hospital deaths occurred among adults aged ≥65 years and 73.4% occurred among persons with three or more underlying medical conditions. Vaccination, early treatment, and appropriate nonpharmaceutical interventions remain important public health priorities for preventing COVID-19 deaths, especially among persons most at risk.

Outbreaks of Acute Gastrointestinal Illness Associated with a Splash Pad in a Wildlife Park - Kansas, June 2021.

In June 2021, Kansas state and county public health officials identified and investigated three cases of shigellosis (a bacterial diarrheal illness caused by Shigella spp.) associated with visiting a wildlife park. The park has animal exhibits and a splash pad. Two affected persons visited animal exhibits, and all three entered the splash pad. Nonhuman primates are the only known animal reservoir of Shigella. The splash pad, which sprays water on users and is designed so that water does not collect in the user area, was closed on June 19. The state and county public health codes do not include regulations for splash pads. Thus, these venues are not typically inspected, and environmental health expertise is limited. A case-control study identified two distinct outbreaks associated with the park (a shigellosis outbreak involving 21 cases and a subsequent norovirus infection outbreak involving six cases). Shigella and norovirus can be transmitted by contaminated water; in both outbreaks, illness was associated with getting splash pad water in the mouth (multiply imputed adjusted odds ratio [aORMI] = 6.4, p = 0.036; and 28.6, p = 0.006, respectively). Maintaining adequate water disinfection and environmental health expertise and targeting prevention efforts to caregivers of splash pad users help prevent splash pad-associated outbreaks. Outbreak incidence might be further reduced when U.S. jurisdicitons voluntarily adopt CDC's Model Aquatic Health Code (MAHC) recommendations and through the prevention messages: "Don't get in the water if sick with diarrhea," "Don't stand or sit above the jets," and "Don't swallow the water."†.

Survey of incidence, lifetime prevalence, and treatment of self-reported vulvovaginal candidiasis, United States, 2020.

BACKGROUND: Vulvovaginal candidiasis (VVC) is a common gynecologic problem in the United States but estimates of its true incidence and prevalence are lacking. We estimated self-reported incidence and lifetime prevalence of healthcare provider-diagnosed VVC and recurrent VVC (RVVC), assessed treatment types, and evaluated demographic and health-related risk factors associated with VVC. METHODS: An online survey sent to 4548 U.S. adults; data were weighted to be representative of the population. We conducted descriptive and bivariate analyses to examine demographic characteristics and health related factors associated with having VVC in the past year, lifetime prevalence of VVC, and over-the-counter (OTC) and prescription antifungal treatment use. We conducted multivariate analyses to assess features associated with 1) having VVC in the past year, 2) number of VVC episodes in the past year, and 3) lifetime prevalence of VVC. RESULTS: Among the subset of 1869 women respondents, 98 (5.2%) had VVC in the past year; of those, 5 (4.7%) had RVVC. Total, 991 (53%) women reported healthcare provider-diagnosed VVC in their lifetime. Overall, 72% of women with VVC in the past year reported prescription antifungal treatment use, 40% reported OTC antifungal treatment use, and 16% reported both. In multivariate analyses, odds of having VVC in the past year were highest for women with less than a high school education (aOR = 6.30, CI: 1.84-21.65), with a child/children under 18 years old (aOR = 3.14, CI: 1.58-6.25), with diabetes (aOR = 2.93, CI: 1.32-6.47), who were part of a couple (aOR = 2.86, CI: 1.42-5.78), and with more visits to a healthcare provider for any reason (aOR = 2.72, CI: 1.84-4.01). Similar factors were associated with increasing number of VVC episodes in the past year and with lifetime prevalence of VVC. CONCLUSION: VVC remains a common infection in the United States. Our analysis supports known clinical risk factors for VVC and suggests that antifungal treatment use is high, underscoring the need to ensure appropriate diagnosis and treatment.

Trends in Disease Severity and Health Care Utilization During the Early Omicron Variant Period Compared with Previous SARS-CoV-2 High Transmission Periods - United States, December 2020-January 2022.

The B.1.1.529 (Omicron) variant of SARS-CoV-2, the virus that causes COVID-19, was first clinically identified in the United States on December 1, 2021, and spread rapidly. By late December, it became the predominant strain, and by January 15, 2022, it represented 99.5% of sequenced specimens in the United States* (1). The Omicron variant has been shown to be more transmissible and less virulent than previously circulating variants (2,3). To better understand the severity of disease and health care utilization associated with the emergence of the Omicron variant in the United States, CDC examined data from three surveillance systems and a large health care database to assess multiple indicators across three high-COVID-19 transmission periods: December 1, 2020-February 28, 2021 (winter 2020-21); July 15-October 31, 2021 (SARS-CoV-2 B.1.617.2 [Delta] predominance); and December 19, 2021-January 15, 2022 (Omicron predominance). The highest daily 7-day moving average to date of cases (798,976 daily cases during January 9-15, 2022), emergency department (ED) visits (48,238), and admissions (21,586) were reported during the Omicron period, however, the highest daily 7-day moving average of deaths (1,854) was lower than during previous periods. During the Omicron period, a maximum of 20.6% of staffed inpatient beds were in use for COVID-19 patients, 3.4 and 7.2 percentage points higher than during the winter 2020-21 and Delta periods, respectively. However, intensive care unit (ICU) bed use did not increase to the same degree: 30.4% of staffed ICU beds were in use for COVID-19 patients during the Omicron period, 0.5 percentage points lower than during the winter 2020-21 period and 1.2 percentage points higher than during the Delta period. The ratio of peak ED visits to cases (event-to-case ratios) (87 per 1,000 cases), hospital admissions (27 per 1,000 cases), and deaths (nine per 1,000 cases [lagged by 3 weeks]) during the Omicron period were lower than those observed during the winter 2020-21 (92, 68, and 16 respectively) and Delta (167, 78, and 13, respectively) periods. Further, among hospitalized COVID-19 patients from 199 U.S. hospitals, the mean length of stay and percentages who were admitted to an ICU, received invasive mechanical ventilation (IMV), and died while in the hospital were lower during the Omicron period than during previous periods. COVID-19 disease severity appears to be lower during the Omicron period than during previous periods of high transmission, likely related to higher vaccination coverage,† which reduces disease severity (4), lower virulence of the Omicron variant (3,5,6), and infection-acquired immunity (3,7). Although disease severity appears lower with the Omicron variant, the high volume of ED visits and hospitalizations can strain local health care systems in the United States, and the average daily number of deaths remains substantial.§ This underscores the importance of national emergency preparedness, specifically, hospital surge capacity and the ability to adequately staff local health care systems. In addition, being up to date on vaccination and following other recommended prevention strategies are critical to preventing infections, severe illness, or death from COVID-19.

Health Care Providers' Testing Practices for Coccidioidomycosis and Histoplasmosis in Patients With Community-Acquired Pneumonia-United States, 2020.

Laboratory testing is required to distinguish coccidioidomycosis and histoplasmosis from other types of community-acquired pneumonia (CAP). In this nationwide survey of 1258 health care providers, only 3.7% reported frequently testing CAP patients for coccidioidomycosis and 2.8% for histoplasmosis. These diseases are likely underdiagnosed, and increased awareness is needed.

Demographic Characteristics, Experiences, and Beliefs Associated with Hand Hygiene Among Adults During the COVID-19 Pandemic - United States, June 24-30, 2020.

Frequent hand hygiene, including handwashing with soap and water or using a hand sanitizer containing ≥60% alcohol when soap and water are not readily available, is one of several critical prevention measures recommended to reduce the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19).* Previous studies identified demographic factors associated with handwashing among U.S. adults during the COVID-19 pandemic (1,2); however, demographic factors associated with hand sanitizing and experiences and beliefs associated with hand hygiene have not been well characterized. To evaluate these factors, an Internet-based survey was conducted among U.S. adults aged ≥18 years during June 24-30, 2020. Overall, 85.2% of respondents reported always or often engaging in hand hygiene following contact with high-touch public surfaces such as shopping carts, gas pumps, and automatic teller machines (ATMs).† Respondents who were male (versus female) and of younger age reported lower handwashing and hand sanitizing rates, as did respondents who reported lower concern about their own infection with SARS-CoV-2§ and respondents without personal experience with COVID-19. Focused health promotion efforts to increase hand hygiene adherence should include increasing visibility and accessibility of handwashing and hand sanitizing materials in public settings, along with targeted communication to males and younger adults with focused messages that address COVID-19 risk perception.

Public Awareness of Invasive Fungal Diseases - United States, 2019.

Fungal diseases range from minor skin and mucous membrane infections to life-threatening disseminated disease. The estimated yearly direct health care costs of fungal diseases exceed $7.2 billion (1). These diseases are likely widely underdiagnosed (1,2), and improved recognition among health care providers and members of the public is essential to reduce delays in diagnoses and treatment. However, information about public awareness of fungal diseases is limited. To guide public health educational efforts, a nationally representative online survey was conducted to assess whether participants had ever heard of six invasive fungal diseases. Awareness was low and varied by disease, from 4.1% for blastomycosis to 24.6% for candidiasis. More than two thirds (68.9%) of respondents had never heard of any of the diseases. Female sex, higher education, and increased number of prescription medications were associated with awareness. These findings can serve as a baseline to compare with future surveys; they also indicate that continued strategies to increase public awareness about fungal diseases are needed.

Participation in Community Preparedness Programs in Human Services Organizations and Faith-Based Organizations - New York City, 2018.

Community-based organizations have a long history of engagement with public health issues; these relationships can contribute to disaster preparedness (1,2). Preparedness training improves response capacity and strengthens overall resilience (1). Recognizing the importance of community-based organizations in community preparedness, the Office of Emergency Preparedness and Response in New York City's (NYC's) Department of Health and Mental Hygiene (DOHMH) launched a community preparedness program in 2016 (3), which engaged two community sectors (human services and faith-based). To strengthen community preparedness for public health emergencies in human services organizations and faith-based organizations, the community preparedness program conducted eight in-person preparedness trainings. Each training focused on preparedness topics, including developing plans for 1) continuity of operations, 2) emergency management, 3) volunteer management, 4) emergency communications, 5) emergency notification systems, 6) communication with persons at risk, 7) assessing emergency resources, and 8) establishing dedicated emergency funds (2,3). To evaluate training effectiveness, data obtained through online surveys administered during June-September 2018 were analyzed using multivariate logistic regression. Previously described preparedness indicators among trained human services organizations and faith-based organizations were compared with those of organizations that were not trained (3). Participation in the community preparedness program training was associated with increased odds of meeting preparedness indicators. NYC's community preparedness program can serve as a model for other health departments seeking to build community preparedness through partnership with community-based organizations.

Preassessment of Community-Based Organization Preparedness in Two Sectors, Human Services and Faith Based: New York City, 2016.

Objectives. To determine the level of preparedness among New York City community-based organizations by using a needs assessment.Methods. We distributed online surveys to 582 human services and 6017 faith-based organizations in New York City from March 17, 2016 through May 11, 2016. We calculated minimal indicators of preparedness to determine the proportion of organizations with preparedness indicators. We used bivariate analyses to examine associations between agency characteristics and minimal preparedness indicators.Results. Among the 210 human service sector respondents, 61.9% reported emergency management plans and 51.9% emergency communications systems in place. Among the 223 faith-based respondents, 23.9% reported emergency management plans and 92.4% emergency communications systems in place. Only 10.0% of human services and 18.8% of faith-based organizations reported having funds allocated for emergency response. Only 2.9% of human services sector and 39.5% of faith-based sector respondents reported practicing emergency communication alerts.Conclusions. New York City human service and faith-based sector organizations are striving to address emergency preparedness concerns, although notable gaps are evident.Public Health Implications. Our results can inform the development of metrics for community-based organizational readiness.

The Impact of Hurricane Sandy on HIV Testing Rates: An Interrupted Time Series Analysis, January 1, 2011‒December 31, 2013.

BACKGROUND: Hurricane Sandy made landfall on the eastern coast of the United States on October 29, 2012 resulting in 117 deaths and 71.4 billion dollars in damage. Persons with undiagnosed HIV infection might experience delays in diagnosis testing, status confirmation, or access to care due to service disruption in storm-affected areas. The objective of this study is to describe the impact of Hurricane Sandy on HIV testing rates in affected areas and estimate the magnitude and duration of disruption in HIV testing associated with storm damage intensity. METHODS: Using MarketScan data from January 2011‒December 2013, this study examined weekly time series of HIV testing rates among privately insured enrollees not previously diagnosed with HIV; 95 weeks pre- and 58 weeks post-storm. Interrupted time series (ITS) analyses were estimated by storm impact rank (using FEMA's Final Impact Rank mapped to Core Based Statistical Areas) to determine the extent that Hurricane Sandy affected weekly rates of HIV testing immediately and the duration of that effect after the storm. RESULTS: HIV testing rates declined significantly across storm impact rank areas. The mean decline in rates detected ranged between -5% (95% CI: -9.3, -1.5) in low impact areas and -24% (95% CI: -28.5, -18.9) in very high impact areas. We estimated at least 9,736 (95% CI: 7,540, 11,925) testing opportunities were missed among privately insured persons following Hurricane Sandy. Testing rates returned to baseline in low impact areas by 6 weeks post event (December 9, 2012); by 15 weeks post event (February 10, 2013) in moderate impact areas; and by 17 weeks after the event (February 24, 2013) in high and very high impact areas. CONCLUSIONS: Hurricane Sandy resulted in a detectable and immediate decline in HIV testing rates across storm-affected areas. Greater storm damage was associated with greater magnitude and duration of testing disruption. Disruption of basic health services, like HIV testing and treatment, following large natural and man-made disasters is a public health concern.  Disruption in testing services availability for any length of time is detrimental to the efforts of the current HIV prevention model, where status confirmation is essential to control disease spread.

Vulnerabilities Associated with Post-disaster Declines in HIV-testing: Decomposing the Impact of Hurricane Sandy.

INTRODUCTION: Using Interrupted Time Series Analysis and generalized estimating equations, this study identifies factors that influence the size and significance of Hurricane Sandy's estimated impact on HIV testing in 90 core-based statistical areas from January 1, 2011 to December 31, 2013. METHODS: Generalized estimating equations were used to examine the effects of sociodemographic and storm-related variables on relative change in HIV testing resulting from Interrupted Time Series analyses. RESULTS: There is a significant negative relationship between HIV prevalence and the relative change in testing at all time periods. A one unit increase in HIV prevalence corresponds to a 35% decrease in relative testing the week of the storm and a 14% decrease in relative testing at week twelve. Building loss was also negatively associated with relative change for all time points. For example, a one unit increase in building loss at week 0 corresponds with an 8% decrease in the relative change in testing (p=0.0001) and a 2% at week twelve (p=0.001). DISCUSSION: Our results demonstrate that HIV testing can be negatively affected during public health emergencies. Communities with high percentages of building loss and significant HIV disease burden should prioritize resumption of testing to support HIV prevention.

The Impact of a Case of Ebola Virus Disease on Emergency Department Visits in Metropolitan Dallas-Fort Worth, TX, July, 2013-July, 2015: An Interrupted Time Series Analysis.

BACKGROUND: The first Ebola virus disease (EVD) case in the United States (US) was confirmed September 30, 2014 in a man 45 years old. This event created considerable media attention and there was fear of an EVD outbreak in the US. METHODS: This study examined whether emergency department (ED) visits changed in metropolitan Dallas-Fort Worth--, Texas (DFW) after this EVD case was confirmed. Using Texas Health Services Region 2/3 syndromic surveillance data and focusing on DFW, interrupted time series analyses were conducted using segmented regression models with autoregressive errors for overall ED visits and rates of several chief complaints, including fever with gastrointestinal distress (FGI). Date of fatal case confirmation was the "event." RESULTS: Results indicated the event was highly significant for ED visits overall (P<0.05) and for the rate of FGI visits (P<0.0001). An immediate increase in total ED visits of 1,023 visits per day (95% CI: 797.0, 1,252.8) was observed, equivalent to 11.8% (95% CI: 9.2%, 14.4%) increase ED visits overall. Visits and the rate of FGI visits in DFW increased significantly immediately after confirmation of the EVD case and remained elevated for several months even adjusting for seasonality both within symptom specific chief complaints as well as overall. CONCLUSIONS: These results have implications for ED surge capacity as well as for public health messaging in the wake of a public health emergency.

Progress in Public Health Emergency Preparedness-United States, 2001-2016.

OBJECTIVES: To evaluate the Public Health Emergency Preparedness (PHEP) program's progress toward meeting public health preparedness capability standards in state, local, and territorial health departments. METHODS: All 62 PHEP awardees completed the Centers for Disease Control and Prevention's self-administered PHEP Impact Assessment as part of program review measuring public health preparedness capability before September 11, 2001 (9/11), and in 2014. We collected additional self-reported capability self-assessments from 2016. We analyzed trends in congressional funding for public health preparedness from 2001 to 2016. RESULTS: Before 9/11, most PHEP awardees reported limited preparedness capabilities, but considerable progress was reported by 2016. The number of jurisdictions reporting established capability functions within the countermeasures and mitigation domain had the largest increase, almost 200%, by 2014. However, more than 20% of jurisdictions still reported underdeveloped coordination between the health system and public health agencies in 2016. Challenges and barriers to building PHEP capabilities included lack of trained personnel, plans, and sustained resources. CONCLUSIONS: Considerable progress in public health preparedness capability was observed from before 9/11 to 2016. Support, sustainment, and advancement of public health preparedness capability is critical to ensure a strong public health infrastructure.

Primary Care Emergency Preparedness Network, New York City, 2015: Comparison of Member and Nonmember Sites.

OBJECTIVES: To assess whether Primary Care Emergency Preparedness Network member sites reported indicators of preparedness for public health emergencies compared with nonmember sites. The network-a collaboration between government and New York City primary care associations-offers technical assistance to primary care sites to improve disaster preparedness and response. METHODS: In 2015, we administered an online questionnaire to sites regarding facility characteristics and preparedness indicators. We estimated differences between members and nonmembers with natural logarithm-linked binomial models. Open-ended assessments identified preparedness gaps. RESULTS: One hundred seven sites completed the survey (23.3% response rate); 47 (43.9%) were nonmembers and 60 (56.1%) were members. Members were more likely to have completed hazard vulnerability analysis (risk ratio [RR] = 1.94; 95% confidence interval [CI] = 1.28, 2.93), to have identified essential services for continuity of operations (RR = 1.39; 95% CI = 1.03, 1.86), to have memoranda of understanding with external partners (RR = 2.49; 95% CI = 1.42, 4.36), and to have completed point-of-dispensing training (RR = 4.23; 95% CI = 1.76, 10.14). Identified preparedness gaps were improved communication, resource availability, and train-the-trainer programs. Public Health Implications. Primary Care Emergency Preparedness Network membership is associated with improved public health emergency preparedness among primary care sites.

Who's at Risk When the Power Goes Out? The At-home Electricity-Dependent Population in the United States, 2012.

OBJECTIVES: Natural and man-made disasters can result in power outages that can affect certain vulnerable populations dependent on electrically powered durable medical equipment. This study estimated the size and prevalence of that electricity-dependent population residing at home in the United States. METHODS: We used the Truven Health MarketScan 2012 database to estimate the number of employer-sponsored privately insured enrollees by geography, age group, and sex who resided at home and were dependent upon electrically powered durable medical equipment to sustain life. We estimated nationally representative prevalence and used US Census population estimates to extrapolate the national population and produce maps visualizing prevalence and distribution of electricity-dependent populations residing at home. RESULTS: As of 2012, among the 175 million persons covered by employer-sponsored private insurance, the estimated number of electricity-dependent persons residing at home was 366 619 (95% confidence interval: 365 700-367 537), with a national prevalence of 218.2 per 100 000 covered lives (95% confidence interval: 217.7-218.8). Prevalence varied significantly by age group (χ = 264 289 95, P < .0001) and region (χ = 12 286 30, P < .0001), with highest prevalence in those 65 years of age or older and in the South and the West. Across all insurance types in the United States, approximately 685 000 electricity-dependent persons resided at home. CONCLUSIONS: These results may assist public health jurisdictions addressing unique needs and necessary resources for this particularly vulnerable population. Results can verify and enhance the development of functional needs registries, which are needed to help first responders target efforts to those most vulnerable during disasters affecting the power supply.

Indirect, out-of-pocket and medical costs from influenza-related illness in young children.

BACKGROUND: Studies have documented direct medical costs of influenza-related illness in young children, however little is known about the out-of-pocket and indirect costs (e.g., missed work time) incurred by caregivers of children with medically attended influenza. OBJECTIVE: To determine the indirect, out-of-pocket (OOP), and direct medical costs of laboratory-confirmed medically attended influenza illness among young children. METHODS: Using a population-based surveillance network, we evaluated a representative group of children aged <5 years with laboratory-confirmed, medically attended influenza during the 2003-2004 season. Children hospitalized or seen in emergency department (ED) or outpatient settings in surveillance counties with laboratory-confirmed influenza were identified and data were collected from medical records, accounting databases, and follow-up interviews with caregivers. Outcome measures included work time missed, OOP expenses (e.g., over-the-counter medicines, travel expenses), and direct medical costs. Costs were estimated (in 2009 US Dollars) and comparisons were made among children with and without high risk conditions for influenza-related complications. RESULTS: Data were obtained from 67 inpatients, 121 ED patients and 92 outpatients with laboratory-confirmed influenza. Caregivers of hospitalized children missed an average of 73 work hours (estimated cost $1456); caregivers of children seen in the ED and outpatient clinics missed 19 ($383) and 11 work hours ($222), respectively. Average OOP expenses were $178, $125 and $52 for inpatients, ED-patients and outpatients, respectively. OOP and indirect costs were similar between those with and without high risk conditions (p>0.10). Medical costs totaled $3990 for inpatients and $730 for ED-patients. CONCLUSIONS: Out-of-pocket and indirect costs of laboratory-confirmed and medically attended influenza in young children are substantial and support the benefits of vaccination.

Deaths in international travelers arriving in the United States, July 1, 2005 to June 30, 2008.

BACKGROUND: The Centers for Disease Control and Prevention's (CDC) Quarantine Activity Reporting System (QARS), which documents reports of morbidity and mortality among travelers, was analyzed to describe the epidemiology of deaths during international travel. METHODS: We analyzed travel-related deaths reported to CDC from July 1, 2005 to June 30, 2008, in which international travelers died (1) on a U.S.-bound conveyance, or (2) within 72 hours after arriving in the United States, or (3) at any time after arriving in the United States from an illness possibly acquired during international travel. We analyzed age, sex, mode of travel (eg, by air, sea, land), date, and cause of death, and estimated rates using generalized linear models. RESULTS: We identified 213 deaths. The median age of deceased travelers was 66 years (range 1-95); 65% were male. Most deaths (62%) were associated with sea travel; of these, 111 (85%) occurred in cruise ship passengers and 20 (15%) among cargo and cruise ship crew members. Of 81 air travel-associated deaths, 77 occurred in passengers, 3 among air ambulance patients, and 1 in a stowaway. One death was associated with land travel. Deaths were categorized as cardiovascular (70%), infectious disease (12%), cancer (6%), unintentional injury (4%), intentional injury (1%), and other (7%). Of 145 cardiovascular deaths with reported ages, 62% were in persons 65 years of age and older. Nineteen (73%) of 26 persons who died from infectious diseases had chronic medical conditions. There was significant seasonal variation (lowest in July-September) in cardiovascular mortality in cruise ship passengers. CONCLUSIONS: Cardiovascular conditions were the major cause of death for both sexes. Travelers should seek pre-travel medical consultation, including guidance on preventing cardiovascular events, infections, and injuries. Persons with chronic medical conditions and the elderly should promptly seek medical care if they become ill during travel.

Herpes zoster incidence among insured persons in the United States, 1993-2006: evaluation of impact of varicella vaccination.

BACKGROUND: herpes zoster (HZ) is caused by reactivation of latent varicella zoster virus and is often associated with substantial pain and disability. Baseline incidence of HZ prior to introduction of HZ vaccine is not well described, and it is unclear whether introduction of the varicella vaccination program in 1995 has altered the epidemiology of HZ. We examined trends in the incidence of HZ and impact of varicella vaccination on HZ trends using a large medical claims database. METHODS: medical claims data from the MarketScan databases were obtained for 1993-2006. We calculated HZ incidence using all persons with a first outpatient service associated with a 053.xx code (HZ ICD-9 code) as the numerator, and total MarketScan enrollment as the denominator; HZ incidence was stratified by age and sex. We used statewide varicella vaccination coverage in children aged 19-35 months to explore the impact of varicella vaccination on HZ incidence. RESULTS: HZ incidence increased for the entire study period and for all age groups, with greater rates of increase 1993-1996 (P < .001). HZ rates were higher for females than males throughout the study period (P < .001) and for all age groups (P < .001). HZ incidence did not vary by state varicella vaccination coverage. CONCLUSIONS: HZ incidence has been increasing from 1993-2006. We found no evidence to attribute the increase to the varicella vaccine program.