The first association of a primary amebic meningoencephalitis death with culturable Naegleria fowleri in tap water from a US treated public drinking water system.

BACKGROUND: Naegleria fowleri is a climate-sensitive, thermophilic ameba found in warm, freshwater lakes and rivers. Primary amebic meningoencephalitis (PAM), which is almost universally fatal, occurs when N. fowleri-containing water enters the nose, typically during swimming, and migrates to the brain via the olfactory nerve. In August 2013, a 4-year-old boy died of meningoencephalitis of unknown etiology in a Louisiana hospital. METHODS: Clinical and environmental testing and a case investigation were initiated to determine the cause of death and to identify potential exposures. RESULTS: Based on testing of cerebrospinal fluid and brain specimens, the child was diagnosed with PAM. His only reported water exposure was tap water; in particular, tap water that was used to supply water to a lawn water slide on which the child had played extensively prior to becoming ill. Water samples were collected from both the home and the water distribution system that supplied the home and tested; N. fowleri was identified in water samples from both the home and the water distribution system. CONCLUSIONS: This case is the first reported PAM death associated with culturable N. fowleri in tap water from a US treated drinking water system. This case occurred in the context of an expanding geographic range for PAM beyond southern states, with recent case reports from Minnesota, Kansas, and Indiana. This case also highlights the role of adequate disinfection throughout drinking water distribution systems and the importance of maintaining vigilance when operating drinking water systems using source waters with elevated temperatures.

Severe Acute Respiratory Illness (SARI) Surveillance in Louisiana, 2013-2014.

The objectives of this article are to describe the severe acute respiratory illness (SARI) surveillance implemented in Louisiana during the 2013-2014 influenza season, present the epidemiology of reported SARI cases, and identify ways to improve this system by incorporating formal SARI surveillance into the influenza surveillance program. Of the 212 SARI cases, 181 (85%) had at least one underlying medical condition, 54 (25.7%) had two conditions, 43 (20.3%) had three conditions, and 25 (11.8%) reported four or more. The most common four underlying conditions were: obesity (43.4%), chronic cardiac conditions (39.6%), diabetes (29.7%), and chronic pulmonary conditions (26.9%). While obesity was the most reported underlying condition, it was three times more likely to be reported in less than 65 years old rather than those >65. Continuation of SARI data collection in future seasons will allow comparisons regarding severity, populations affected, and identify risk factors most commonly associated with severe illness. Reporting of SARI cases also increased influenza-associated adult mortality reporting to the Office of Public Health's Office of Infectious Diseases Epidemiology (ID Epi). Though all influenza-associated mortality is reportable in Louisiana, adult mortality was reported rarely prior to the 2013-2014 season.

Intensity of Influenza-Like Illness (ILI) and Congestive Heart Failure (CHF) Deaths: A Correlation Study in Louisiana, 2000-2012.

Influenza infection has been linked to significant morbidity and mortality, especially in vulnerable populations including the elderly and those with chronic disease, such as congestive heart failure (CHF). This correlation analysis used influenza surveillance data and vital statistics mortality data to assess the correlation between influenza-like illness (ILI) and CHF deaths in Louisiana from 2000-2012 on a weekly level and at the seasonal level. The correlation between ILI proportion and mean number of deaths for the entire study period was 0.23. The comparisons made at the seasonal level showed some association between season's intensity and CHF mortality. The clinical implication of this study is that ILI surveillance can be used to issue alert to clinicians who treat CHF patient in order to stress measures aimed at preventing deaths from CHF.

Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water.

BACKGROUND: Naegleria fowleri is a climate-sensitive, thermophilic ameba found in the environment, including warm, freshwater lakes and rivers. Primary amebic meningoencephalitis (PAM), which is almost universally fatal, occurs when N. fowleri-containing water enters the nose, typically during swimming, and N. fowleri migrates to the brain via the olfactory nerve. In 2011, 2 adults died in Louisiana hospitals of infectious meningoencephalitis after brief illnesses. METHODS: Clinical and environmental testing and case investigations were initiated to determine the cause of death and to identify the exposures. RESULTS: Both patients had diagnoses of PAM. Their only reported water exposures were tap water used for household activities, including regular sinus irrigation with neti pots. Water samples, tap swab samples, and neti pots were collected from both households and tested; N. fowleri were identified in water samples from both homes. CONCLUSIONS: These are the first reported PAM cases in the United States associated with the presence of N. fowleri in household plumbing served by treated municipal water supplies and the first reports of PAM potentially associated with the use of a nasal irrigation device. These cases occurred in the context of an expanding geographic range for PAM beyond southern tier states with recent case reports from Minnesota, Kansas, and Virginia. These infections introduce an additional consideration for physicians recommending nasal irrigation and demonstrate the importance of using appropriate water (distilled, boiled, filtered) for nasal irrigation. Furthermore, the changing epidemiology of PAM highlights the importance of raising awareness about this disease among physicians treating persons showing meningitislike symptoms.

Geostatistical model-based estimates of Schistosomiasis prevalence among individuals aged ≤ 20 years in West Africa.

BACKGROUND: Schistosomiasis is a water-based disease that is believed to affect over 200 million people with an estimated 97% of the infections concentrated in Africa. However, these statistics are largely based on population re-adjusted data originally published by Utroska and colleagues more than 20 years ago. Hence, these estimates are outdated due to large-scale preventive chemotherapy programs, improved sanitation, water resources development and management, among other reasons. For planning, coordination, and evaluation of control activities, it is essential to possess reliable schistosomiasis prevalence maps. METHODOLOGY: We analyzed survey data compiled on a newly established open-access global neglected tropical diseases database (i) to create smooth empirical prevalence maps for Schistosoma mansoni and S. haematobium for individuals aged ≤ 20 years in West Africa, including Cameroon, and (ii) to derive country-specific prevalence estimates. We used Bayesian geostatistical models based on environmental predictors to take into account potential clustering due to common spatially structured exposures. Prediction at unobserved locations was facilitated by joint kriging. PRINCIPAL FINDINGS: Our models revealed that 50.8 million individuals aged ≤ 20 years in West Africa are infected with either S. mansoni, or S. haematobium, or both species concurrently. The country prevalence estimates ranged between 0.5% (The Gambia) and 37.1% (Liberia) for S. mansoni, and between 17.6% (The Gambia) and 51.6% (Sierra Leone) for S. haematobium. We observed that the combined prevalence for both schistosome species is two-fold lower in Gambia than previously reported, while we found an almost two-fold higher estimate for Liberia (58.3%) than reported before (30.0%). Our predictions are likely to overestimate overall country prevalence, since modeling was based on children and adolescents up to the age of 20 years who are at highest risk of infection. CONCLUSION/SIGNIFICANCE: We present the first empirical estimates for S. mansoni and S. haematobium prevalence at high spatial resolution throughout West Africa. Our prediction maps allow prioritizing of interventions in a spatially explicit manner, and will be useful for monitoring and evaluation of schistosomiasis control programs.

Epidemiology of animal rabies and its practical application to pre- and postexposure prophylaxis, louisiana, 1988 to 2007.

The incidence of human rabies in the United States has decreased significantly over the past century. This analysis examines the ecological status of rabies in Louisiana with the intent of identifying differences in risk of rabies transmission from exposures to different species of animals. Louisiana presently harbors one terrestrial variant of rabies, a skunk variant, and several bat variants. Surveillance data collected from 1988 through 2007 were examined, comparing areas of the state characterized by circulating terrestrial variants and areas free of terrestrial rabies. Nine state public health regions were also compared. The proportions of rabies-positive laboratory submissions from each species and/or species group were used as indicators of risk. In addition, differences in proportions positive were examined temporally. A significant proportion of positive bats (9.64%) and skunks (44.3%), examined after biting or otherwise exposing a human being, were identified by diagnostic laboratories. Samples from wild terrestrial animals originating in areas known to harbor circulating terrestrial rabies variants were more than 30 times more likely to be positive for rabies than samples originating from areas thought to be free of terrestrial rabies. Bats were also slightly more likely to be positive when submitted from areas known to be endemic for terrestrial rabies. Rabies in pets and agricultural animals were rarely reported. Seasonal variations in prevalence of positive tests were also identified. The results of this examination of rabies epidemiology in Louisiana can be used in determining recommendations for both pre- and postexposure rabies prophylaxis. Similar applications of surveillance data are encouraged in other jurisdictions.

Louisiana autopsy patterns 1999-2006.

This report presents autopsy trends in Louisiana for 1999-2006 data and provides some comparison with national data for 2003. Mortality data for Louisiana was collected from the field 'autopsy' on the Certificate of Death from 1999-2006 and compared with national data for the year 2003. The overall autopsy rate was 9.3% in Louisiana versus 7.7% in the United States (U.S.) in 2003. Autopsy rates were higher than those of the U.S. in almost all categories of personal factors (gender, race and age group). Louisiana's autopsy levels were generally greater for both natural disease (3.7% versus 3.5% for the U.S.) and the high autopsy rate group (61.1% versus 54.3% for the U.S.).

Post-Katrina mortality in the greater New Orleans area, Louisiana.

OBJECTIVES: Death rates in the Greater New Orleans area were examined by month from 2002 to 2006 to assess whether mortality increased after Hurricane Katrina. METHODS: Finalized death data from the Louisiana Office of Vital Statistics and the most recent population estimates were used to calculate annual mortality rates in the Greater New Orleans area by month for 2002-2006. Causes of death were also examined for changes. RESULTS: There was no significant increase in the death rates in the Greater New Orleans area post-Katrina. The only excesses were seen in Orleans Parish from January to June 2006. In the latter months of 2006, rates decreased to those of previous years. Mortality rates for the Greater New Orleans (GNO) area during the same time period showed no increase. In the first months of 2006, deaths due to septicemia and accidents increased significantly in Orleans Parish and returned to normal in the latter half of 2006. Causes of death in the GNO area showed no significant change after Katrina. CONCLUSIONS: There was no significant or lasting increase in morality rates in the Greater New Orleans area following Hurricane Katrina.

Vibrio infections in Louisiana: twenty-five years of surveillance 1980-2005.

A total of 1,007 Vibrio infections were reported to the Infectious Disease Epidemiology Department at the Louisiana Office of Public Heath, between 1980 and 2005. The most common were Vibrio vulnificus (257 infections), Vibrio parahemolyticus (249 infections), and Vibrio cholerae non O1 (200 cases). Other species were much less common. Vibrio vulnificus infections, which are associated with consumption of raw seafood (particularly oysters) or contact with sea water, and severe immuno-suppression or liver disease were increasing. Septicemia and blood stream infections are the main manifestations of this infection. The number of infections due to Vibrio parahemolyticus on the other hand, causing mostly gastroenteritis, has remained stable. Vibrio cholerae infections are less common and almost always associated with consumption of partially cooked or contaminated crabs.

Vibrio vulnificus bacteremia associated with chronic lymphocytic leukemia, hypogammaglobulinemia, and hepatic cirrhosis: relation to host and exposure factors in 252 V. vulnificus infections reported in Louisiana.

BACKGROUND: Vibrio vulnificus infection in persons with B-chronic lymphocytic leukemia (B-CLL) or hypogammaglobulinemia has been reported infrequently. PATIENT AND METHODS: A woman with B-CLL, hypogammaglobulinemia, and hepatic cirrhosis died of V. vulnificus bacteremia after eating cooked shrimp and crabs. We reviewed host and exposure data in 252 cases of V. vulnificus infection reported in Louisiana during the interval of 1980 through 2004. RESULTS: V. vulnificus was isolated from blood in 122 cases (48.8%). Preexisting conditions in 138 cases included liver disease (41.3%), malignancy (13.8%), and immunosuppression (9.4%). The prevalence of preexisting conditions was significantly greater in cases with positive blood cultures than in cases with positive wound or stool cultures. Exposure data in 116 cases revealed crab consumption without raw oyster consumption or seawater exposure in 3.4%. CONCLUSION: The present patient had several conditions associated with increased risk of V. vulnificus infection and bacteremia, especially hepatic cirrhosis, but her route of exposure to V. vulnificus was unusual.

Influenza in Louisiana: an analysis of Louisiana Influenza Sentinel Surveillance Data, 1998-2004.

Analysis of the influenza sentinel surveillance data from the Louisiana Office of Public health showed that the influenza season for Louisiana starts between October and December and ends between December and March. There is no consistent trend as to when the peak of the season occurs. The start of Louisiana's seasons ranged from one week (2002-2003 season) to two months (2001-2002) before the national start date. The finding that Louisiana's flu season starts about the same time as the national flu season is not consistent with the conventional thought that the flu season starts later in the South compared to the rest of the nation.

The current status of malaria in Louisiana.

Between 1992 and 2004, 118 cases of malaria were reported to the Louisiana Office of Public Health. Case surveillance data were collected in response to these case reports. These data are presented and analyzed here. All cases reported in Louisiana were imported from malaria-endemic regions. Despite the fact that malaria is a preventable and treatable disease, deaths due to malaria continue to occur. Counseling for travelers to malaria-endemic areas needs to be improved. In particular, region-specific prophylaxis guidelines published by the CDC are infrequently implemented. A travel history should be elicited from all patients who present with fever in the United States. If a history of travel to malaria-endemic areas is present, blood films should be obtained and examined for malaria parasites.

Hepatitis C infection in Louisiana.

Estimating a prevalence of 1.8% of hepatitis C in the general population, there are in Louisiana about 81,000 individuals who have been infected with the hepatitis C virus. In 2002, the incidence of reported cases of acute hepatitis C was 2.2/100,000 versus 0.64 in the USA. The case register maintained by the Louisiana Office of Public Health has 22,000 cases. Building up a register of hepatitis C past or present infections is an important tool that may be used to resolve some important questions about the epidemiology of hepatitis C or be used for future preventive actions. Physicians and hospitals are encouraged to report hepatitis C infection including sufficient information to distinguish acute hepatitis C from hepatitis C past or present infection.

One-year sequelae in patients with West Nile Virus encephalitis and meningitis in Louisiana.

West Nile Virus (WNV) infection can be severe and complicated by neuroinvasive disease, such as meningitis and encephalitis. Not much is known about the one-year sequelae following a complicated WNV infection. From July to December 2002, the first large outbreak of WNV in the Southern United States occurred in Louisiana. This epidemic resulted in 329 cases of WNV infection including 125 cases of West Nile fever and 204 cases complicated by meningitis and encephalitis. One year later, during the fall of 2003, a telephone survey was conducted to understand the one-year effects of severe WNV infections. WNV case fatality rate was 19.6%. Death certificates of all the deceased were reviewed to verify the mortality rate from WNV infection. The telephone survey revealed that one-year sequelae from severe WNV infections are common and can affect the body and mind. In addition, it can change a person's perception of the state of their health.

Pertussis in Louisiana.

Analysis of the surveillance data from the Louisiana Office of Public Health showed a progressive decline of pertussis in Louisiana. Louisiana rates are lower than those of the United States, and increased rates observed among adults in other states are not observed in Louisiana. This would likely be due a lack of suspicion for pertussis in adults and a resultant lack of diagnosis and reporting. Two recent outbreak investigations in a health facility are summarily described, showing that pertussis is still a major cause of concern for the healthcare community.