Association of Mycobacterium tuberculosis infection test results with risk factors for tuberculosis transmission.

Background: Close contacts infected with Mycobacterium tuberculosis are at high risk of tuberculosis (TB) disease and a priority for preventive treatment. Three tests measure infection: two interferon-gamma release assays (IGRAs) and the tuberculin skin test (TST). The objective of our study was to assess the association of positive test results in contacts with infectiousness of the presumed TB source case. Methods: Contacts in a cohort study at 10 United States sites received both IGRAs (QuantiFERON-TB Gold In-Tube (QFT-GIT) and T-SPOT.TB (T-SPOT)) and TST. We defined test conversion as negative for all tests at baseline and positive for at least one on retest. Risk ratios (RR) and 95% confidence intervals (CI) assessed association of positive test results with increased infectiousness of the TB case-defined as acid-fast bacilli (AFB) on sputum microscopy or cavities on chest radiographs- and contact demographics. Results: Adjusted for contacts' age, nativity, sex, and race, IGRAs (QFT-GIT RR = 6.1, 95% CI 1.7-22.2; T-SPOT RR = 9.4, 95% CI 1.1-79.1), but not TST (RR = 1.7, 95% CI 0.8-3.7), were more likely to convert among contacts exposed to persons with cavitary TB disease. Conclusions: Because IGRA conversions in contacts are associated with infectiousness of the TB case, their use may improve efficiency of health department contact investigations by focusing efforts on those likely to benefit from preventive treatment in the United States.

COVID-19 Among American Indian and Alaska Native Persons - 23 States, January 31-July 3, 2020.

Although non-Hispanic American Indian and Alaska Native (AI/AN) persons account for 0.7% of the U.S. population,* a recent analysis reported that 1.3% of coronavirus disease 2019 (COVID-19) cases reported to CDC with known race and ethnicity were among AI/AN persons (1). To assess the impact of COVID-19 among the AI/AN population, reports of laboratory-confirmed COVID-19 cases during January 22†-July 3, 2020 were analyzed. The analysis was limited to 23 states§ with >70% complete race/ethnicity information and five or more laboratory-confirmed COVID-19 cases among both AI/AN persons (alone or in combination with other races and ethnicities) and non-Hispanic white (white) persons. Among 424,899 COVID-19 cases reported by these states, 340,059 (80%) had complete race/ethnicity information; among these 340,059 cases, 9,072 (2.7%) occurred among AI/AN persons, and 138,960 (40.9%) among white persons. Among 340,059 cases with complete patient race/ethnicity data, the cumulative incidence among AI/AN persons in these 23 states was 594 per 100,000 AI/AN population (95% confidence interval [CI] = 203-1,740), compared with 169 per 100,000 white population (95% CI = 137-209) (rate ratio [RR] = 3.5; 95% CI = 1.2-10.1). AI/AN persons with COVID-19 were younger (median age = 40 years; interquartile range [IQR] = 26-56 years) than were white persons (median age = 51 years; IQR = 32-67 years). More complete case report data and timely, culturally responsive, and evidence-based public health efforts that leverage the strengths of AI/AN communities are needed to decrease COVID-19 transmission and improve patient outcomes.

Cost Analysis of 3 Concurrent Public Health Response Events: Financial Impact of Measles Outbreak, Super Bowl Surveillance, and Ebola Surveillance in Maricopa County.

OBJECTIVE: To generate estimates of the direct costs of mounting simultaneous emergency preparedness and response activities to respond to 3 major public health events. DESIGN: A cost analysis was performed from the perspective of the public health department using real-time activity diaries and retrospective time and activity self-reporting, wage and fringe benefit data, and financial records to track costs. SETTING: Maricopa County Department of Public Health (MCDPH) in Arizona. The nation's third largest local public health jurisdiction, MCDPH is the only local health agency serving Maricopa's more than 4 000 000 residents. Responses analyzed included activities related to a measles outbreak with 2 confirmed cases, enhanced surveillance activities surrounding Super Bowl XLIX, and ongoing Ebola monitoring, all between January 22, 2015, and March 4, 2015. PARTICIPANTS: Time data were sought from all MCDPH staff who participated in activities related to any of the 3 relevant responses. In addition, time data were sought from partners at the state health department and a community hospital involved in response activities. Time estimates were received from 128 individuals (response rate 88%). MAIN OUTCOME MEASURE: Time and cost to MCDPH for each response and overall. RESULTS: Total MCDPH costs for measles-, Super Bowl-, and Ebola-related activities from January 22, 2015, through March 4, 2015, were $224 484 (>5800 hours). The majority was for personnel ($203 743) and the costliest response was measles ($122 626 in personnel costs). In addition, partners reported working more than 700 hours for these 3 responses during this period. CONCLUSIONS: Funding for public health departments remains limited, yet public health responses can be cost- and time-intensive. To effectively plan for future public health responses, it may be necessary to share experiences and financial lessons learned from similar public health responses. External partnerships represent a key contribution for responses such as those examined. It can be expensive for local public health departments to mount effective responses, especially when multiple responses occur simultaneously.

Public Health Surveillance Strategies for Mass Gatherings: Super Bowl XLIX and Related Events, Maricopa County, Arizona, 2015.

Super Bowl XLIX took place on February 1, 2015, in Glendale, Arizona. In preparation for this event and associated activities, the Maricopa County Department of Public Health (MCDPH) developed methods for enhanced surveillance, situational awareness, and early detection of public health emergencies. Surveillance strategies implemented from January 22 to February 6, 2015, included enhanced surveillance alerts; animal disease surveillance; review of NFL clinic visits; syndromic surveillance for emergency room visits, urgent care facilities, and hotels; real-time onsite syndromic surveillance; all-hazards mortality surveillance; emergency medical services surveillance, review of poison control center reports; media surveillance; and aberration detection algorithms for notifiable diseases. Surveillance results included increased influenzalike illness activity reported from urgent care centers and a few influenza cases reported in the NFL clinic. A cyanide single event exposure was investigated and determined not to be a public health threat. Real-time field syndromic surveillance documented minor injuries at all events and sporadic cases of gastrointestinal and neurological (mostly headaches) disease. Animal surveillance reports included a cat suspected of carrying plague and tularemia and an investigation of highly pathogenic avian influenza in a backyard chicken flock. Laboratory results in both instances were negative. Aberration detection and syndromic surveillance detected an increase in measles reports associated with a Disneyland exposure, and syndromic surveillance was used successfully during this investigation. Coordinated enhanced epidemiologic surveillance during Super Bowl XLIX increased the response capacity and preparedness of MCDPH to make informed decisions and take public health actions in a timely manner during these mass gathering events.

Factors associated with receipt of 2009 pandemic influenza A (H1N1) monovalent and seasonal influenza vaccination among school-aged children: Maricopa County, Arizona, 2009-2010 influenza season.

CONTEXT: To target school-aged children (SAC), who were identified as a priority for pandemic 2009 Influenza A (pH1N1) vaccination, Maricopa County (MC) initiated school-based influenza vaccination in 69% of its 706 schools during the 2009-2010 influenza season. OBJECTIVE: To determine factors associated with receipt of pH1N1 monovalent and 2009-2010 seasonal influenza vaccination among SAC and evaluate the association of school-based vaccination with vaccination status of SAC. DESIGN: Random-digit dialing was used to survey 600 MC households with willing adult participants and children grades K-12. Logistic regression was used to identify factors associated with pH1N1 and seasonal vaccine receipt. SETTING: Arizona. PARTICIPANTS: Household adults with children grades K-12. MAIN OUTCOME MEASURE: Characteristics of children, parents, and households were obtained. RESULTS: Among 909 SAC, 402 (44%) received pH1N1 and 436 (48%) received seasonal vaccination. Factors associated with pH1N1 vaccination included vaccine availability at school (adjusted odds ratio [AOR]: 1.6; 95% confidence interval [CI]: 1.0-2.7), high-risk medical condition in child (AOR: 2.4; 95% CI: 1.4-4.0), elementary versus high school attendance (AOR: 1.6; 95% CI: 1.0-2.7), and seasonal influenza vaccination (AOR: 10.0; 95% CI: 6.4-15.6). Factors associated with seasonal vaccination included Hispanic ethnicity (AOR: 2.2; 95% CI: 1.1-4.2), health insurance coverage (AOR: 4.8; 95% CI: 1.7-13.7), elementary versus high school attendance (AOR: 1.5; 95% CI: 1.0-2.5), and pH1N1 vaccination (AOR: 10.5; 95% CI: 6.7-16.6). CONCLUSIONS: Availability of pH1N1 vaccine at school was independently associated with pH1N1 vaccination of MC school-aged children. School-based influenza vaccination campaigns should be considered to increase vaccination among this population.

An outbreak of dengue fever in St. Croix (US Virgin Islands), 2005.

BACKGROUND: Periodic outbreaks of dengue fever occur in the United States Virgin Islands. In June 2005, an outbreak of dengue virus (DENV) serotype-2 with cases of dengue hemorrhagic fever (DHF) was detected in St. Croix, US Virgin Islands. The objective of this report is to describe this outbreak of DENV-2 and the findings of a case-control study examining risk factors for DHF. METHODOLOGY/PRINCIPAL FINDINGS: This is the largest dengue outbreak ever recorded in St. Croix, with 331 suspected dengue cases reported island-wide during 2005 (62.2 cases/10,000 population); 54% were hospitalized, 21% had at least one hemorrhagic manifestation, 28% had thrombocytopenia, 5% had DHF and 1 patient died. Eighty-nine laboratory-positive hospitalized patients were identified. Of these, there were 15 (17%) who met the WHO criteria for DHF (cases) and 74 (83%) who did not (controls). The only variable significantly associated with DHF on bivariate or multivariable analysis was age, with an adjusted odds ratio (95% confidence interval) of 1.033 (1.003,1.064). CONCLUSIONS/SIGNIFICANCE: During this outbreak of DENV-2, a high proportion of cases developed DHF and increasing age was significantly associated with DHF.