Competencies for Public Health Professionals and Epidemiologists Who Detect and Investigate Enteric Disease Outbreaks.

OBJECTIVE: Food safety progress depends on the ability of public health agencies to detect and investigate foodborne disease outbreaks. The Integrated Food Safety Centers of Excellence identify and implement best practices and serve as resources for public health professionals who investigate enteric disease outbreaks. To target the needs of this diverse workforce, the Integrated Food Safety Centers of Excellence developed and assessed a professional tier framework and competencies. METHODS: We described the characteristics of public health professionals who investigate enteric disease outbreaks in the epidemiology role in a conceptual tiered framework. We mapped core competencies to each tier and disseminated a survey to practitioners at local (June 2019) and state (August 2018) US public health agencies to evaluate the importance and frequency of each competency. RESULTS: We developed 15 competencies on surveillance, outbreak detection, interview skills, investigation team, specimen testing, data analysis, hypothesis generation, study design, communication, enteric disease biology, control measures, legal authority, quality improvement, environmental health, and reporting to surveillance. The 286 survey respondents selected interview skills, surveillance, control measures, and hypothesis generation as the competencies most important to their work and most frequently performed. CONCLUSION: The Integrated Food Safety Centers of Excellence created the first published workforce framework and competencies for public health professionals who detect and investigate enteric disease outbreaks in the epidemiology role, in collaboration with local, state, and federal public health agencies and national organizations. These tools have been integrated into existing programs and can be used to develop training curricula, assess workforce competency over time, and identify priorities for continuing education and training.

Fatal Human Rabies Infection With Suspected Host-Mediated Failure of Post-Exposure Prophylaxis Following a Recognized Zoonotic Exposure-Minnesota, 2021.

BACKGROUND: No human rabies post-exposure prophylaxis (PEP) failure has been documented in the United States using modern cell culture-based vaccines. In January 2021, an 84-year-old male died from rabies 6 months after being bitten by a rabid bat despite receiving timely rabies PEP. We investigated the cause of breakthrough infection. METHODS: We reviewed medical records, laboratory results, and autopsy findings and performed whole-genome sequencing (WGS) to compare patient and bat virus sequences. Storage, administration, and integrity of PEP biologics administered to the patient were assessed; samples from leftover rabies immunoglobulin were evaluated for potency. We conducted risk assessments for persons potentially exposed to the bat and for close patient contacts. RESULTS: Rabies virus antibodies present in serum and cerebrospinal fluid were nonneutralizing. Antemortem blood testing revealed that the patient had unrecognized monoclonal gammopathy of unknown significance. Autopsy findings showed rabies meningoencephalitis and metastatic prostatic adenocarcinoma. Rabies virus sequences from the patient and the offending bat were identical by WGS. No deviations were identified in potency, quality control, administration, or storage of administered PEP. Of 332 persons assessed for potential rabies exposure to the case patient, 3 (0.9%) warranted PEP. CONCLUSIONS: This is the first reported failure of rabies PEP in the Western Hemisphere using a cell culture-based vaccine. Host-mediated primary vaccine failure attributed to previously unrecognized impaired immunity is the most likely explanation for this breakthrough infection. Clinicians should consider measuring rabies neutralizing antibody titers after completion of PEP if there is any suspicion for immunocompromise.

Improving Foodborne Disease Surveillance and Outbreak Detection and Response Using Peer Networks-The Integrated Food Safety Centers of Excellence.

CONTEXT: Foodborne disease surveillance and outbreak investigations are foundational to the prevention and control of foodborne disease in the United States, where contaminated foods cause an estimated 48 million illnesses, 128 000 hospitalizations, and 3000 deaths each year. Surveillance activities and rapid detection and investigation of foodborne disease outbreaks require a trained and coordinated workforce across epidemiology, environmental health, and laboratory programs. PROGRAM: Under the 2011 Food Safety Modernization Act, the Centers for Disease Control and Prevention (CDC) was called on to establish Integrated Food Safety (IFS) Centers of Excellence (CoEs) at state health departments, which would collaborate with academic partners, to identify, implement, and evaluate model practices in foodborne disease surveillance and outbreak response and to serve as a resource for public health professionals. IMPLEMENTATION: CDC designated 5 IFS CoEs in August 2012 in Colorado, Florida, Minnesota, Oregon, and Tennessee; a sixth IFS CoE in New York was added in August 2014. For the August 2019-July 2024 funding period, 5 IFS CoEs were designated in Colorado, Minnesota, New York, Tennessee, and Washington. Each IFS CoE is based at the state health department that partners with at least one academic institution. EVALUATION: IFS CoEs have built capacity across public health agencies by increasing the number of workforce development opportunities (developing >70 trainings, tools, and resources), supporting outbreak response activities (responding to >50 requests for outbreak technical assistance annually), mentoring students, and responding to emerging issues, such as changing laboratory methods and the COVID-19 pandemic.

Transmission Dynamics of Severe Acute Respiratory Syndrome Coronavirus 2 in High-Density Settings, Minnesota, USA, March-June 2020.

Coronavirus disease has disproportionately affected persons in congregate settings and high-density workplaces. To determine more about the transmission patterns of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in these settings, we performed whole-genome sequencing and phylogenetic analysis on 319 (14.4%) samples from 2,222 SARS-CoV-2-positive persons associated with 8 outbreaks in Minnesota, USA, during March-June 2020. Sequencing indicated that virus spread in 3 long-term care facilities and 2 correctional facilities was associated with a single genetic sequence and that in a fourth long-term care facility, outbreak cases were associated with 2 distinct sequences. In contrast, cases associated with outbreaks in 2 meat-processing plants were associated with multiple SARS-CoV-2 sequences. These results suggest that a single introduction of SARS-CoV-2 into a facility can result in a widespread outbreak. Early identification and cohorting (segregating) of virus-positive persons in these settings, along with continued vigilance with infection prevention and control measures, is imperative.

Hypothesis Generation During Foodborne-Illness Outbreak Investigations.

Hypothesis generation is a critical, but challenging, step in a foodborne outbreak investigation. The pathogens that contaminate food have many diverse reservoirs, resulting in seemingly limitless potential vehicles. Identifying a vehicle is particularly challenging for clusters detected through national pathogen-specific surveillance, because cases can be geographically dispersed and lack an obvious epidemiologic link. Moreover, state and local health departments could have limited resources to dedicate to cluster and outbreak investigations. These challenges underscore the importance of hypothesis generation during an outbreak investigation. In this review, we present a framework for hypothesis generation focusing on 3 primary sources of information, typically used in combination: 1) known sources of the pathogen causing illness; 2) person, place, and time characteristics of cases associated with the outbreak (descriptive data); and 3) case exposure assessment. Hypothesis generation can narrow the list of potential food vehicles and focus subsequent epidemiologic, laboratory, environmental, and traceback efforts, ensuring that time and resources are used more efficiently and increasing the likelihood of rapidly and conclusively implicating the contaminated food vehicle.

Design and Implementation of the Pre-Clinical DICOM Standard in Multi-Cohort Murine Studies.

The small animal imaging Digital Imaging and Communications in Medicine (DICOM) acquisition context structured report (SR) was developed to incorporate pre-clinical data in an established DICOM format for rapid queries and comparison of clinical and non-clinical datasets. Established terminologies (i.e., anesthesia, mouse model nomenclature, veterinary definitions, NCI Metathesaurus) were utilized to assist in defining terms implemented in pre-clinical imaging and new codes were added to integrate the specific small animal procedures and handling processes, such as housing, biosafety level, and pre-imaging rodent preparation. In addition to the standard DICOM fields, the small animal SR includes fields specific to small animal imaging such as tumor graft (i.e., melanoma), tissue of origin, mouse strain, and exogenous material, including the date and site of injection. Additionally, the mapping and harmonization developed by the Mouse-Human Anatomy Project were implemented to assist co-clinical research by providing cross-reference human-to-mouse anatomies. Furthermore, since small animal imaging performs multi-mouse imaging for high throughput, and queries for co-clinical research requires a one-to-one relation, an imaging splitting routine was developed, new Unique Identifiers (UID's) were created, and the original patient name and ID were saved for reference to the original dataset. We report the implementation of the small animal SR using MRI datasets (as an example) of patient-derived xenograft mouse models and uploaded to The Cancer Imaging Archive (TCIA) for public dissemination, and also implemented this on PET/CT datasets. The small animal SR enhancement provides researchers the ability to query any DICOM modality pre-clinical and clinical datasets using standard vocabularies and enhances co-clinical studies.

COVID-19 Outbreak Associated with a 10-Day Motorcycle Rally in a Neighboring State - Minnesota, August-September 2020.

During August 7-16, 2020, a motorcycle rally was held in western South Dakota that attracted approximately 460,000 persons from across the United States to numerous indoor and outdoor events over a 10-day period. During August-September 2020, the Minnesota Department of Health (MDH) investigated a coronavirus disease 2019 (COVID-19) outbreak associated with the rally in Minnesota residents. Fifty-one primary event-associated cases were identified, and 35 secondary or tertiary cases occurred among household, social, and workplace contacts, for a total of 86 cases; four patients were hospitalized, and one died. Approximately one third (34%) of 87 counties in Minnesota had at least one primary, secondary, or tertiary case associated with this rally. Genomic sequencing supported the associations with the motorcycle rally. These findings support current recommendations for mask use, physical distancing, reducing the number of attendees at gatherings, isolation for patients with COVID-19, and quarantine for close contacts to slow the spread of SARS-CoV-2 (1). Furthermore, although these findings did not capture the impact of the motorcycle rally on residents of other states, they demonstrate the rationale for consistent mitigation measures across states.

Accelerated Cortical Osteolysis of Metatarsals in Charcot Neuroarthropathy: A Cross-Sectional Observational Study.

Metatarsals are frequent sites of stress and fragility fractures in younger athletic populations and aging older adults. Metatarsal fractures are particularly common in Charcot neuroarthropathy (CN), a complication of diabetes mellitus (DM) and peripheral neuropathy (PN). Neuropathic metatarsal fractures may be caused by an accelerated cortical bone osteolysis and may be reflected as geometric-derived strength estimates from standard foot radiographs. The purpose of this cross-sectional study was to determine geometry and strength-derived estimates of the metatarsals in individuals with DM, PN, and CN compared with younger and older adult controls who were nondiabetic and nonneuropathic. We studied 62 participants: 20 young adult controls (YACs), 22 older adult controls (OACs), and 20 diagnosed with DMPN&CN. From weight-bearing radiographs, we measured the outer diaphysis diameter and inner marrow diameter at the distal, middle, and proximal diaphysis sites of the second and fifth metatarsal. From these diameters, we derived strength estimates of combined cortical width (CCt.Wi), percent cortical area (%Ct.rA), buckling ratio (BR), moment of inertia (MOI), and section modulus (SM) at each site in both metatarsals. DMPN&CN participants had an accelerated cortical thinning, decreased %Ct.Ar, increased BR, and lower MOI and SM compared with OACs and YACs. The OACs showed age-related decreases in CCt.Wi and % Ct.Ar, and increased BR. The BR demonstrated significant group × bone × site interaction with the distal fifth metatarsal in the DMPN&CN group having the lowest bone strength. The BR in the distal fifth metatarsal of DMPN&CN participants was 36% and 49% greater than in the OAC and YAC groups, respectively. DMPN&CN participants have lower metatarsal bone strength estimates compared with younger and older adult controls. Standard foot radiographs demonstrate an accelerated cortical osteolysis in DMPN&CN individuals, particularly in the distal fifth metatarsal diaphysis. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Author Correction: Imaging and clinical data archive for head and neck squamous cell carcinoma patients treated with radiotherapy.

In the original version of the Data Descriptor the surname of author Hesham Elhalawani was misspelled. This has now been corrected in the HTML and PDF versions.

Imaging and clinical data archive for head and neck squamous cell carcinoma patients treated with radiotherapy.

Cross sectional imaging is essential for the patient-specific planning and delivery of radiotherapy, a primary determinant of head and neck cancer outcomes. Due to challenges ensuring data quality and patient de-identification, publicly available datasets including diagnostic and radiation treatment planning imaging are scarce. In this data descriptor, we detail the collection and processing of computed tomography based imaging in 215 patients with head and neck squamous cell carcinoma that were treated with radiotherapy. Using cross sectional imaging, we calculated total body skeletal muscle and adipose content before and after treatment. We detail techniques for validating the high quality of these data and describe the processes of data de-identification and transfer. All imaging data are subject- and date-matched to clinical data from each patient, including demographics, risk factors, grade, stage, recurrence, and survival. These data are a valuable resource for studying the association between patient-specific anatomic and metabolic features, treatment planning, and oncologic outcomes, and the first that allows for the integration of body composition as a risk factor or study outcome.

A Candidate Imaging Marker for Early Detection of Charcot Neuroarthropathy.

Inflammation-mediated foot osteopenia may play a pivotal role in the etiogenesis, pathogenesis, and therapeutic outcomes in individuals with diabetes mellitus (DM), peripheral neuropathy (PN), and Charcot neuroarthropathy (CN). Our objective was to establish a volumetric quantitative computed tomography-derived foot bone measurement as a candidate prognostic imaging marker to identify individuals with DMPN who were at risk of developing CN. We studied 3 groups: 16 young controls (27 ± 5 years), 20 with DMPN (57 ± 11 years), and 20 with DMPN and CN (55 ± 9 years). Computed tomography image analysis was used to measure metatarsal and tarsal bone mineral density in both feet. The mean of 12 right (7 tarsals and 5 metatarsals) and 12 left foot bone mineral densities, maximum percent difference in bone mineral density between paired bones of the right and the left feet, and the mean difference of the 12 right and the 12 left bone mineral density measurements were used as input variables in different classification analysis methods to determine the best classifier. Classification tree analysis produced no misclassification of the young controls and individuals with DMPN and CN. The tree classifier found 7 of 20 (35%) individuals with DMPN to be classified as CN (1 participant developed CN during follow-up) and 13 (65%) to be classified as healthy. These results indicate that a decision tree employing 3 measurements derived from volumetric quantitative computed tomography foot bone mineral density defines a candidate prognostic imaging marker to identify individuals with diabetes and PN who are at risk of developing CN.

Persistent inflammation with pedal osteolysis 1year after Charcot neuropathic osteoarthropathy.

AIMS: To determine local and systemic markers of inflammation and bone mineral density (BMD) in the foot and central sites in participants with diabetes mellitus and peripheral neuropathy (DMPN) with and without acute Charcot neuropathic osteoarthropathy (CN). METHODS: Eighteen participants with DMPN and CN and 19 participants without CN had foot temperature assessments, serum markers of inflammation [C-reactive protein, (CRP) and erythrocyte sedimentation rate, (ESR)] and BMD of the foot, hip and lumbar spine at baseline and 1year follow-up. RESULTS: CN foot temperature difference was higher compared to DMPN controls at baseline (4.2±1.9°F vs. 1.2±0.9°F, P<0.01) and after 1year (2.9±3.2°F vs. 0.9±1.1°F, P<0.01). Serum inflammatory markers in the CN group were greater at baseline and remained elevated 1year later compared to DMPN controls (CRP, P=0.02, ESR, P=0.03). All pedal bones' BMD decreased an average of 3% in the CN foot with no changes in hip or lumbar spine. DMPN controls' foot, hip and lumbar spine BMD remained unchanged. CONCLUSIONS: Local and systemic inflammation persists 1 year after CN with an accompanying pedal osteolysis that may contribute to mid foot deformity which is the hallmark of the chronic Charcot foot.

Quantitative Computed Tomography Classification of Lung Nodules: Initial Comparison of 2- and 3-Dimensional Analysis.

OBJECTIVE: The aim of this study was to compare the performance of 2- (2D) and 3-dimensional (3D) quantitative computed tomography (CT) methods for classifying lung nodules as lung cancer, metastases, or benign. METHODS: Using semiautomated software and computerized analysis, we analyzed more than 50 quantitative CT features of 96 solid nodules in 94 patients, in 2D from a single slice and in 3D from the entire nodule volume. Multivariable logistic regression was used to classify nodule types. Model performance was assessed by the area under the receiver operating characteristic curve (AUC) using leave-one-out cross-validation. RESULTS: The AUC for distinguishing 53 primary lung cancers from 18 benign nodules and 25 metastases ranged from 0.79 to 0.83 and was not significantly different for 2D and 3D analyses (P = 0.29-0.78). Models distinguishing metastases from benign nodules were statistically significant only by 3D analysis (AUC = 0.84). CONCLUSIONS: Three-dimensional CT methods did not improve discrimination of lung cancer, but may help distinguish benign nodules from metastases.

Long-Term Sentinel Surveillance for Enterotoxigenic Escherichia coli and Non-O157 Shiga Toxin-Producing E. coli in Minnesota.

Background. Enterotoxigenic Escherichia coli (ETEC) and non-O157 Shiga toxin-producing E. coli (STEC) are not detected by conventional culture methods. The prevalence of ETEC infections in the United States is unknown, and recognized cases are primarily associated with foreign travel. Gaps remain in our understanding of STEC epidemiology. Methods. Two sentinel surveillance sites were enrolled: an urban health maintenance organization laboratory (Laboratory A) and a rural hospital laboratory (Laboratory B). Residual sorbitol MacConkey (SMAC) plates from stool cultures performed at Laboratory A (1996-2006) and Laboratory B (2000-2008) were collected. Colony sweeps from SMAC plates were tested for genes encoding STEC toxins stx1 and stx2 (1996-2008) and ETEC heat-labile and heat-stable toxins eltB, estA 1, 2 and 3 (2000-2008) by polymerase chain reaction (PCR)-based assays. Results. In Laboratory A, a bacterial pathogen was identified in 7.0% of 21 970 specimens. During 1996-2006, Campylobacter was the most common bacterial pathogen (2.7% of cultures), followed by Salmonella (1.2%), Shigella (1.0%), and STEC (0.9%). Among STEC (n = 196), O157 was the most common serogroup (31%). During 2000-2006, ETEC (1.9%) was the second most common bacterial pathogen after Campylobacter (2.6%). In Laboratory B, of 19 293 specimens tested, a bacterial pathogen was identified for 5.5%, including Campylobacter (2.1%), STEC (1.3%), Salmonella (1.0%), and ETEC (0.8%). Among STEC (n = 253), O157 was the leading serogroup (35%). Among ETEC cases, 61% traveled internationally. Conclusions. Enterotoxigenic E. coli and STEC infections were as common as most other enteric bacterial pathogens, and ETEC may be detected more frequently by culture-independent multiplex PCR diagnostic methods. A high proportion of ETEC cases were domestically acquired.

Survey of occupational hazards in Minnesota veterinary practices in 2012.

OBJECTIVE: To identify the scope of occupational hazards encountered by veterinary personnel and compare hazard exposures between veterinarians and technicians working in small and large animal practices. DESIGN: Cross-sectional survey. POPULATION: Licensed veterinarians and veterinary staff in Minnesota. PROCEDURES: A survey of Minnesota veterinary personnel was conducted between February 1 and December 1, 2012. Adult veterinary personnel working in clinical practice for > 12 months were eligible to participate. Information was collected on various workplace hazards as well as on workplace safety culture. RESULTS: 831 eligible people responded, representing approximately 10% of Minnesota veterinary personnel. A greater proportion of veterinarians (93%; 368/394) reported having received preexposure rabies vaccinations than did veterinary technicians (54%; 198/365). During their career, 226 (27%) respondents had acquired at least 1 zoonotic infection and 636 (77%) had been injured by a needle or other sharps. Recapping of needles was reported by 87% of respondents; the most common reason reported by veterinarians (41%; 142/345) and veterinary technicians (71%; 238/333) was being trained to do so at school or work. Recent feelings of depression were reported by 204 (25%) respondents. A greater proportion of technicians (42%; 155/365) than veterinarians (21%; 81/394) indicated working in an environment in which employees experienced some form of workplace abuse. CONCLUSIONS AND CLINICAL RELEVANCE: Veterinary personnel in Minnesota were exposed to several work-related hazards. Practice staff should assess workplace hazards, implement controls, and incorporate instruction on occupational health into employee training.

Emerging Infections Program--State Health Department Perspective.

The Emerging Infections Program (EIP) is a collaboration between the Centers for Disease Control and Prevention and 10 state health departments working with academic partners to conduct active population-based surveillance and special studies for several emerging infectious disease issues determined to need special attention. The Centers for Disease Control and Prevention funds the 10 EIP sites through cooperative agreements. Our objective was to highlight 1) what being an EIP site has meant for participating health departments and associated academic centers, including accomplishments and challenges, and 2) the synergy between the state and federal levels that has resulted from the collaborative relationship. Sharing these experiences should provide constructive insight to other public health programs and other countries contemplating a collaborative federal-local approach to collective public health challenges.

De-identification of Medical Images with Retention of Scientific Research Value.

Online public repositories for sharing research data allow investigators to validate existing research or perform secondary research without the expense of collecting new data. Patient data made publicly available through such repositories may constitute a breach of personally identifiable information if not properly de-identified. Imaging data are especially at risk because some intricacies of the Digital Imaging and Communications in Medicine (DICOM) format are not widely understood by researchers. If imaging data still containing protected health information (PHI) were released through a public repository, a number of different parties could be held liable, including the original researcher who collected and submitted the data, the original researcher's institution, and the organization managing the repository. To minimize these risks through proper de-identification of image data, one must understand what PHI exists and where that PHI resides, and one must have the tools to remove PHI without compromising the scientific integrity of the data. DICOM public elements are defined by the DICOM Standard. Modality vendors use private elements to encode acquisition parameters that are not yet defined by the DICOM Standard, or the vendor may not have updated an existing software product after DICOM defined new public elements. Because private elements are not standardized, a common de-identification practice is to delete all private elements, removing scientifically useful data as well as PHI. Researchers and publishers of imaging data can use the tools and process described in this article to de-identify DICOM images according to current best practices.

Disease risk in a dynamic environment: the spread of tick-borne pathogens in Minnesota, USA.

As humans and climate change alter the landscape, novel disease risk scenarios emerge. Understanding the complexities of pathogen emergence and subsequent spread as shaped by landscape heterogeneity is crucial to understanding disease emergence, pinpointing high-risk areas, and mitigating emerging disease threats in a dynamic environment. Tick-borne diseases present an important public health concern and incidence of many of these diseases are increasing in the United States. The complex epidemiology of tick-borne diseases includes strong ties with environmental factors that influence host availability, vector abundance, and pathogen transmission. Here, we used 16 years of case data from the Minnesota Department of Health to report spatial and temporal trends in Lyme disease (LD), human anaplasmosis, and babesiosis. We then used a spatial regression framework to evaluate the impact of landscape and climate factors on the spread of LD. Finally, we use the fitted model, and landscape and climate datasets projected under varying climate change scenarios, to predict future changes in tick-borne pathogen risk. Both forested habitat and temperature were important drivers of LD spread in Minnesota. Dramatic changes in future temperature regimes and forest communities predict rising risk of tick-borne disease.

Outbreak of Trichinella spiralis infections associated with a wild boar hunted at a game farm in Iowa.

BACKGROUND: Rates of trichinellosis have declined significantly in the United States due to improved pork production practices and public awareness of the danger of eating raw or undercooked pork. In April 2011, the Minnesota Department of Health received a report of presumptive trichinellosis in a 50-year-old man with a history of wild boar consumption. A public health investigation was initiated. METHODS: Medical record reviews and patient and family interviews were conducted. Trichinella species serology was performed on patient and family serum samples, and larval identification was attempted on clinical specimens and meat samples. RESULTS: The index patient harvested a wild boar from an Iowa game farm; he processed the meat after returning home and developed gastrointestinal symptoms 2 days later. Four days after his illness onset, all 5 family members consumed a roast from the boar. The index patient sought healthcare 4 times after illness onset before being definitively diagnosed with trichinellosis. Following initiation of albendazole therapy, the index patient developed atrial fibrillation. One additional family member who processed the raw meat was diagnosed with trichinellosis. Trichinella spiralis larvae were identified in wild boar meat samples. CONCLUSIONS: Trichinellosis has long been recognized as a potential hazard of consuming undercooked wild carnivore meat, and historically has been associated with consumption of pork from domestic swine, but may be unfamiliar to practicing clinicians in the United States. Education of hunters and the broader population on the potential for trichinellosis and the importance of proper handling and cooking meat from wild or free-range animals needs to be reinforced.