How Is #CDC Funded to Respond to #PublicHealth #Emergencies? Federal Appropriations and Budget Execution Process for Non-Financial Experts (Health Secur., abstract)

[Source: US National Library of Medicine, full page: (LINK). Abstract, edited.]

Health Secur. 2017 May/Jun;15(3):307-311. doi: 10.1089/hs.2017.0009. Epub 2017 Jun 2.

How Is CDC Funded to Respond to Public Health Emergencies? Federal Appropriations and Budget Execution Process for Non-Financial Experts.

Fischer LS, Santibanez S, Jones G, Anderson B, Merlin T.

 

Abstract

The federal budgeting process affects a wide range of people who work in public health, including those who work for government at local, state, and federal levels; those who work with government; those who operate government-funded programs; and those who receive program services. However, many people who are affected by the federal budget are not aware of or do not understand how it is appropriated or executed. This commentary is intended to give non-financial experts an overview of the federal budget process to address public health emergencies. Using CDC as an example, we provide: (1) a brief overview of the annual budget formulation and appropriation process; (2) a description of execution and implementation of the federal budget; and (3) an overview of emergency supplemental appropriations, using as examples the 2009 H1N1 influenza pandemic, the 2014-15 Ebola outbreak, and the 2016 Zika epidemic. Public health emergencies require rapid coordinated responses among Congress, government agencies, partners, and sometimes foreign, state, and local governments. It is important to have an understanding of the appropriation process, including supplemental appropriations that might come into play during public health emergencies, as well as the constraints under which Congress and federal agencies operate throughout the federal budget formulation process and execution.

KEYWORDS: Epidemic management/response; Legal aspects; Legislative issues; Public health preparedness/response

PMID: 28574728 PMCID: PMC5510675 DOI: 10.1089/hs.2017.0009 [Indexed for MEDLINE]  Free PMC Article

Keywords: USA; US CDC; Pandemic Preparedness.

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Use of #Influenza #Risk #Assessment Tool [#IRAT] for #Prepandemic #Preparedness (Emerg Infect Dis., abstract)

[Source: US Centers for Disease Control and Prevention (CDC), Emerging Infectious Diseases Journal, full page: (LINK). Abstract, edited.]

Volume 24, Number 3—March 2018 / Research

Use of Influenza Risk Assessment Tool for Prepandemic Preparedness

Stephen A. Burke   and Susan C. Trock

Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (S.C. Trock, S.A. Burke); Battelle, Atlanta (S.A. Burke)

 

Abstract

In 2010, the Centers for Disease Control and Prevention began to develop an Influenza Risk Assessment Tool (IRAT) to methodically capture and assess information relating to influenza A viruses not currently circulating among humans. The IRAT uses a multiattribute, additive model to generate a summary risk score for each virus. Although the IRAT is not intended to predict the next pandemic influenza A virus, it has provided input into prepandemic preparedness decisions.

Keywords: Pandemic Influenza; US CDC; USA.

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#Diagnosis of #Tuberculosis in Three #Zoo #Elephants and a #Human #Contact — #Oregon, 2013 (@CDCgov, MMWR Morb Mortal Wkly Rep., abstract)

[Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK). Abstract, edited.]

Diagnosis of Tuberculosis in Three Zoo Elephants and a Human Contact — Oregon, 2013 [      ]

Weekly / January 8, 2016 / 64(52);1398-1402

Amy Zlot, MPH1; Jennifer Vines, MD1; Laura Nystrom, MPH1; Lindsey Lane, MPH2; Heidi Behm, MPH2; Justin Denny, MD1; Mitch Finnegan, DVM3; Trevor Hostetler4; Gloria Matthews4; Tim Storms, DVM3; Emilio DeBess, DVM2

1Multnomah County Health Department, Oregon; 2Public Health Division, Oregon Health Authority; 3Oregon Zoo; 4Washington County Department of Health and Human Services, Oregon.

Corresponding author: Amy Zlot, amy.zlot@multco.us, 503-988-3406.

 

Abstract

In 2013, public health officials in Multnomah County, Oregon, started an investigation of a tuberculosis (TB) outbreak among elephants and humans at a local zoo. The investigation ultimately identified three bull elephants with active TB and 118 human contacts of the elephants. Ninety-six (81%) contacts were evaluated, and seven close contacts were found to have latent TB infection. The three bulls were isolated and treated (elephants with TB typically are not euthanized) to prevent infection of other animals and humans, and persons with latent infection were offered treatment. Improved TB screening methods for elephants are needed to prevent exposure of human contacts.

Keywords: Research; Abstracts; USA; Oregon; Elephants; Human; Tuberculosis; US CDC.

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#Rabies in a #Dog Imported from #Egypt with a Falsified Rabies Vaccination Certificate — #Virginia, 2015 (@CDCgov, MMWR Morb Mortal Wkly Rep., abstract)

[Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK). Abstract, edited.]

Rabies in a Dog Imported from Egypt with a Falsified Rabies Vaccination Certificate — Virginia, 2015 [      ]

Weekly / December 18, 2015 / 64(49);1359-62

Julie R. Sinclair, DVM1; Ryan M. Wallace, DVM2; Karen Gruszynski, DVM3; Marilyn Bibbs Freeman, PhD4; Colin Campbell, DVM5; Shereen Semple, MS5; Kristin Innes, MPH5; Sally Slavinski, DVM6; Gabriel Palumbo, MPH1; Heather Bair-Brake, DVM1; Lillian Orciari, MS2; Rene E. Condori, MS2; Adam Langer, DVM1; Darin S. Carroll, PhD2; Julia Murphy, DVM3

_____

Canine rabies virus variant has been eliminated in the United States and multiple other countries. Globally, however, dogs remain the principal source for human rabies infections (1). The World Health Organization recommends that when dogs cross international borders, national importing authorities should require an international veterinary certificate attesting that the animal did not show signs of rabies at the time of shipment, was permanently identified, vaccinated, or revaccinated, and had been subjected to a serologic test for rabies before shipment (1). On June 8, 2015, an adult female dog that had recently been picked up from the streets of Cairo, Egypt, and shipped by a U.S. animal rescue organization to the United States was confirmed to have rabies by the Virginia Department of General Services Division of Consolidated Laboratory Services (DCLS). This dog was part of a large shipment of dogs and cats from Egypt that rescue organizations had distributed to multiple states for adoption. During the investigation, public health officials learned that the rabies vaccination certificate used for entry of the rabid dog into the United States had intentionally been falsified to avoid exclusion of the dog from entry under CDC’s current dog importation regulations. This report underscores the ongoing risk posed by U.S. importation of domestic animals that have not been adequately vaccinated against rabies.

(…)

Keywords: US CDC; USA; Updates; Viriginia; Dogs; Rabies.

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#Update: #Influenza #Activity — #USA, October 4–November 28, 2015 (@CDCgov / MMWR Morb Mortal Wkly Rep., edited)

[Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK). Edited.]

Update: Influenza Activity — United States, October 4–November 28, 2015 [      ]

Weekly / December 11, 2015 / 64(48);1342-8

Sophie Smith, MPH1; Lenee Blanton, MPH1; Krista Kniss, MPH1; Desiree Mustaquim, MPH1; Craig Steffens, MPH1; Carrie Reed, DSc1; Anna Bramley, MPH1; Brendan Flannery, PhD1; Alicia M. Fry, MD1; Lisa A. Grohskopf, MD1; Joseph Bresee, MD1; Teresa Wallis, MS1; Rebecca Garten, PhD1; Xiyan Xu, MD1; Anwar Isa Abd Elal1; Larisa Gubareva, PhD1; John Barnes, PhD1; David E. Wentworth, PhD1; Erin Burns, MA1; Jacqueline Katz, PhD1; Daniel Jernigan, MD1; Lynnette Brammer, MPH1

______

CDC collects, compiles, and analyzes data on influenza activity year-round in the United States. The influenza season generally begins in the fall and continues through the winter and spring months; however, the timing and severity of circulating influenza viruses can vary by geographic location and season. Influenza activity in the United States remained low through October and November in 2015. Influenza A viruses have been most frequently identified, with influenza A (H3) viruses predominating. This report summarizes U.S. influenza activity* for the period October 4–November 28, 2015.†

 

Viral Surveillance

World Health Organization (WHO) collaborating laboratories and National Respiratory and Enteric Virus Surveillance System (NREVSS) laboratories, which include both public health and clinical laboratories located throughout the United States, participate in virologic surveillance for influenza.

Beginning with the 2015–16 influenza season, data for public health and clinical laboratories are presented separately because influenza testing practices differ.

Clinical laboratories test respiratory specimens for diagnostic purposes, and data from these laboratories provide useful information regarding the timing and intensity of influenza activity.

Public health laboratories primarily test specimens for surveillance purposes to understand which influenza viruses are circulating throughout their jurisdictions and which population groups are being affected. The age group distribution of influenza positive tests reported from public health laboratories is summarized.

Clinical laboratories in the United States tested 102,675 respiratory specimens collected during October 4–November 28, 2015, for influenza viruses. Among these, 1,268 (1.2%) tested positive for influenza (Figure 1); 772 (60.9%) were influenza A viruses, and 496 (39.1%) were influenza B viruses.

Public health laboratories in the United States tested 8,488 respiratory specimens collected during October 4–November 28, 2015, for influenza viruses.

Among these, 404 tested positive for influenza (Figure 2); 333 (82.4%) were influenza A viruses, and 71 (17.6%) were influenza B viruses.

Of the 333 influenza A viruses, 317 (95.2%) were subtyped; 55 (17.4%) were influenza A(H1N1)pdm09 (pH1N1), and 262 (82.6%) were influenza A (H3) viruses.

Of the 71 influenza B viruses, 21 (29.6%) had lineage determined; 13 (61.9%) belonged to the B/Yamagata lineage, and eight (38.1%) belonged to the B/Victoria lineage.

Since October 4, influenza-positive test results have been reported from all 50 states, the District of Columbia, Guam, and Puerto Rico, representing all 10 U.S. Department of Health and Human Services (HHS) regions.§ Influenza A viruses have predominated nationally and in all 10 HHS regions.

During October 4–November 28, 2015, age data were available for 370 positive influenza test results, including 31 (8.4%) in children aged 0–4 years, 96 (26.0%) in persons aged 5–24 years, 130 (35.1%) in persons aged 25–64 years, and 113 (30.5%) in persons aged ≥65 years.

Influenza A (H3) viruses were predominant in all age groups, accounting for a proportion of influenza positives ranging from 41.9% (ages 0–4 years) to 84.1% (ages ≥65 years).

The largest number of influenza A pH1N1 viruses were reported in persons aged 25–64 years. The largest number of influenza B viruses were reported in persons aged 5–24 years and 25–64 years.

 

Influenza Virus Characterization

WHO collaborating laboratories in the United States are requested to submit a subset of influenza-positive respiratory specimens to CDC for further virus characterization.

CDC characterizes influenza viruses through one or more laboratory tests including genome sequencing, or hemagglutination inhibition (HI), or neutralization assays. These data are used to compare how similar currently circulating influenza viruses are to the influenza vaccine reference viruses, and to monitor for changes in circulating influenza viruses.

Most viruses tested are propagated in mammalian cell cultures because isolation rates of human influenza viruses are higher in mammalian cell cultures than in eggs. However, egg-propagated vaccine viruses are used widely for production of influenza vaccines because most influenza vaccines are egg-based. Propagation of influenza viruses in eggs can lead to isolation of viruses that differ genetically and antigenically from corresponding clinical specimens isolated in mammalian cell cultures. In addition, mammalian cell-propagated viruses are genetically more representative of viruses present in original clinical specimens (1,2). Antigenic and genetic characterization of circulating viruses is performed using both mammalian cell- and egg-propagated reference viruses.

Historically HI data have been used most commonly to assess the similarity between reference viruses and circulating viruses. Although vaccine effectiveness field studies must be conducted to actually determine how well the vaccine is working, these laboratory data are used to determine whether changes in the virus have occurred that could affect vaccine effectiveness.

Beginning with the 2014–15 season and to date, however, a proportion of influenza A (H3N2) viruses have not yielded sufficient hemagglutination titers for antigenic characterization by HI.

For all viruses characterized at CDC laboratories, whole genome sequencing is performed to determine the genetic group identity of these circulating viruses. For the subset of viruses that do not yield sufficient hemagglutination titers, antigenic properties of those viruses are inferred using results from viruses within the same genetic group that have been characterized antigenically.

Since October 1, 2015, CDC has antigenically or genetically characterized 62 specimens (18 influenza A (H1N1)pdm09, 43 influenza A (H3N2), and one influenza B/Yamagata lineage).

A total of 43 H3N2 viruses have been genetically sequenced and all 43 viruses belonged to genetic groups for which a majority of antigenically characterized viruses were similar to the cell-propagated reference virus A/Switzerland/9715293/2013 representing the influenza A (H3N2) component of the 2015–16 Northern Hemisphere vaccine.

A total of 35 viruses (18 influenza A (H1N1)pdm09, 16 influenza A (H3N2), and one B/Yamagata lineage) collected since October 1, 2015, have been antigenically characterized.

All A(H1N1)pdm09, all B viruses, and 15 of the 16 A(H3N2) viruses were similar to the reference viruses representing the 2015–16 Northern Hemisphere influenza vaccine components.

 

Antiviral Resistance of Influenza Viruses

The WHO Collaborating Center for Surveillance, Epidemiology, and Control of Influenza at CDC tested 56 influenza virus specimens (11 influenza A (H1N1)pdm09, 33 influenza A (H3N2) and 12 influenza B) collected since October 1, 2015, in the United States for resistance to the influenza neuraminidase inhibitor antiviral medications oseltamivir, zanamivir, and peramivir, which are the drugs currently approved for use against seasonal influenza.

All 56 influenza viruses tested were sensitive to all three antiviral medications. High levels of resistance to the adamantanes (amantadine and rimantadine) persist among influenza A (H1N1)pdm09 and (H3N2) viruses. Adamantane drugs are not recommended for use against influenza at this time.

 

Outpatient Illness Surveillance

Since October 4, the weekly percentage of outpatient visits for influenza-like illness (ILI)¶ reported by approximately 1,800 U.S. Outpatient ILI Surveillance Network (ILINet) providers in 50 states, New York City, Chicago, the U.S. Virgin Islands, Puerto Rico, and the District of Columbia, has ranged from 1.3% to 1.9% and has remained below the national baseline** of 2.1% (Figure 3).

Peak weekly percentages of outpatient visits for ILI ranged from 2.4% to 7.6% from the 1997–98 through 2014–15 influenza seasons, excluding the 2009 pandemic.

Data collected in ILINet are used to produce a measure of ILI activity†† by jurisdiction.

During surveillance week 47, Puerto Rico and two states (Oklahoma and South Carolina) experienced moderate ILI activity, and four states (Arizona, Mississippi, New Jersey, and Virginia) experienced low ILI activity.

Minimal ILI activity was experienced in New York City and 44 states (Alabama, Alaska, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, South Dakota, Tennessee, Texas, Utah, Vermont, Washington, West Virginia, Wisconsin, and Wyoming).

Data were insufficient to calculate an ILI activity level for the District of Columbia.

 

Geographic Spread of Influenza Activity

For the week ending November 28 (week 47), Guam reported widespread geographic spread of influenza,§§ Puerto Rico reported regional spread, and seven states (Iowa, Maryland, Massachusetts, New Hampshire, North Carolina, Oregon, and Utah) reported local spread.

The District of Columbia, the U.S. Virgin Islands, and 38 states (Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Jersey, New Mexico, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Texas, Vermont, Washington, West Virginia, Wisconsin, and Wyoming) reported sporadic spread.

Five states (Alabama, Mississippi, Rhode Island, Tennessee, and Virginia) reported no influenza activity.

 

Pneumonia- and Influenza-Associated Mortality

CDC tracks pneumonia and influenza (P&I)–associated deaths through two systems, the National Center for Health Statistics (NCHS) Mortality Surveillance System and the 122 Cities Mortality Reporting System.

Beginning during the 2015–16 season, data from the newer NCHS system will be the principal component of the U.S. mortality surveillance system.

NCHS mortality data are presented by the week that the death occurred, whereas the 122 Cities Mortality Reporting System data are reported the week that the death certificate was registered. The length of time from the occurrence of a death until registration of the death certificate in the vital statistics office can vary considerably; therefore, these two data sources produce different percentages.

Presenting data by the week of the death, rather than the date of filing of the death certificate more accurately reflects the timing of P&I mortality. The percentage of P&I deaths from each system should be compared with the corresponding system-specific baselines and thresholds.

Through the NCHS Mortality Surveillance System, the percentages of deaths associated with P&I are released 2 weeks after the week of death to allow for collection of sufficient data to produce a stable P&I mortality percentage.

Based on NCHS data available December 3, 5.9% (1,370 of 23,191) of all U.S. deaths occurring during the week ending November 14, 2015 (week 45) were classified as resulting from P&I. This percentage is below the epidemic threshold¶¶ of 6.8% for week 45.

Since October 4, the weekly percentage of deaths attributed to P&I ranged from 5.9% to 6.2% and has not exceeded the epidemic threshold this season. Peak weekly percentages of deaths attributable to P&I during the previous five influenza seasons ranged from 8.7% during the 2011–12 season to 11.1% during the 2012–13 season.

During the week ending November 28 (week 47), P&I was reported as an underlying or contributing cause of 6.1% (524 of 8,634) of all deaths reported to the 122 Cities Mortality Reporting System. This percentage is below the epidemic threshold of 6.5% for the week. Since October 4, the weekly percentage of deaths attributed to P&I ranged from 5.2% to 6.1% and has not exceeded the epidemic threshold so far this season. Peak weekly percentages of deaths attributable to P&I in the previous five seasons ranged from 7.8% during the 2011–12 season to 9.9% during the 2012–13 season.

 

Influenza-Associated Pediatric Mortality

As of November 28 (week 47), two influenza-associated pediatric deaths have been reported to CDC during the 2015–16 influenza season, both of which occurred during week 44 (the week ending November 7, 2015). One death was associated with an influenza A virus for which no subtyping was performed, and one death was associated with an influenza B virus. The number of influenza-associated pediatric deaths reported to CDC in the previous three seasons ranged from 111 during the 2013–14 season to 171 during the 2012–13 season. During the 2009 pandemic, 358 pediatric deaths were reported from April 15, 2009, through October 2, 2010 (historically, influenza seasons include data from October [week 40] through September [week 39] of the following year).

 

Discussion

Influenza activity in the United States for the 2015–16 season remained low during October 4–November 28, 2015. Although the timing of influenza activity can vary, peak activity in the United States most commonly occurs during December–March; however, substantial influenza activity can be observed in November and activity can last as late as May. During the 2014–15 influenza season, activity increased in November and peaked in December; however during the current 2015–16 season, activity remains low. During October 4–November 28, 2015, influenza A (H3N2) viruses were identified most frequently in the United States, but pH1N1 and influenza B viruses also were reported.

Antigenic and genetic characterization of influenza-positive respiratory specimens submitted to CDC indicate that the majority of influenza virus isolates recently examined in the United States are similar to the 2015–16 influenza vaccine reference viruses. Although antigenic and genetic characterization of circulating influenza viruses can indicate whether antigenically different (i.e., “drifted”) viruses have emerged, vaccine effectiveness studies are needed to determine how much protection has been provided to the community by vaccination. Last season, laboratory data indicated that most influenza A (H3N2) viruses had drifted from the 2014–15 influenza A (H3N2) vaccine reference virus. During that season, reduced vaccine effectiveness against the predominant influenza A (H3N2) viruses was noted (3). During other seasons, however, antigenic differences between circulating and reference vaccine viruses that suggested reduced vaccine effectiveness were not shown to have resulted in reduced protection in community studies undertaken during the season (35). Predicting which influenza viruses will predominate during a season is challenging. Although no significant drift has been identified in influenza viruses circulating recently, it is possible that drift may still occur.

Vaccination remains the most effective method of preventing influenza and its complications. Even during seasons when vaccine effectiveness is reduced, substantial public health impact can still be observed (6). CDC previously developed a model to estimate the illnesses and hospitalizations averted by influenza vaccination in the United States. During 2010–2014, annual vaccination prevented an estimated 1.7–7.8 million cases and 34,000–114,000 hospitalizations per season, or 9.4%–22.3% of hospitalizations associated with influenza (6). For the 2014–15 influenza season, updated estimates of vaccination coverage, vaccine effectiveness, and rates of influenza were used in the same model to estimate that influenza vaccination resulted in an estimated 1.9 million (95% confidence interval [CI] = 707,000–4.4 million) fewer illnesses, 966,000 (CI = 344,000–2.2 million) fewer medically attended illnesses, and 67,000 (CI = 15,000–208,000) fewer hospitalizations associated with influenza (6).

As of December 4, 2015, vaccine manufacturers have reported that approximately 140 million doses of influenza vaccine have been distributed. Health care providers should offer vaccine to all unvaccinated persons aged ≥6 months now and throughout the influenza season as long as influenza viruses are circulating. Vaccination coverage typically declines markedly after November, prompting CDC to annually observe a National Influenza Vaccination Week (December 6–12 this year) to promote influenza vaccination beyond November. Although the timing of influenza activity can vary, little influenza activity has occurred to date this season; thus, vaccination at this time should still offer substantial public health benefit. Past and current vaccine coverage estimates highlight low influenza vaccination coverage in the United States, despite a universal vaccination recommendation that has been in place since 2010. For the 2015–16 season, the Advisory Committee on Immunization Practices (ACIP) recommends that healthy children aged 2 years through 8 years who have no vaccine contraindications or precautions receive either live attenuated influenza vaccine (LAIV) or inactivated influenza vaccine (IIV), with no preference expressed for either vaccine when one is otherwise appropriate and available (5). For the 2015–16 season, ACIP recommends that children aged 6 months through 8 years who have previously received ≥2 total doses of trivalent or quadrivalent influenza vaccine at any time before July 1, 2015, require only 1 dose of 2015–16 influenza vaccine (5). The 2 previous doses do not need to have been given during the same or consecutive seasons (5). Children in this age group who are being vaccinated for the first time or who have not previously received a total of ≥2 doses before July 1, 2015, require 2 doses of 2015–16 influenza vaccine, administered ≥4 weeks apart (7).

Although influenza vaccination is the first and best way to prevent influenza, antiviral medications continue to be an important adjunct to vaccination for reducing the health impact of influenza. Treatment is most effective when given early during illness, and providers should not delay treatment until test results become available or rely on insensitive assays such as rapid antigen detection influenza diagnostic tests to determine treatment decisions (8). Treatment with influenza antiviral medications as early as possible is recommended for patients with confirmed or suspected influenza (either seasonal influenza or novel influenza virus infection) who have severe, complicated, or progressive illness; who require hospitalization; or who are at high risk for serious influenza-related complications*** (8). Antiviral treatment should not be withheld from severely ill patients or those at high risk with suspected influenza infection pending confirmatory influenza test results or based on illness onset††† (8).

Influenza surveillance reports for the United States are posted online weekly and are available at http://www.cdc.gov/flu/weekly. Additional information regarding influenza viruses, influenza surveillance, influenza vaccine, influenza antiviral medications, and novel influenza A virus infections in humans is available at http://www.cdc.gov/flu.

 

Acknowledgments

State, county, city, and territorial health departments and public health laboratories; U.S. World Health Organization collaborating laboratories; National Respiratory and Enteric Virus Surveillance System laboratories; U.S. Outpatient Influenza-Like Illness Surveillance Network sites; National Center for Health Statistics, CDC; 122 Cities Mortality Reporting System; World Health Organization FluNet; Angie Foust, Wendy Sessions, Elisabeth Blanchard, Priya Budhathoki, Thomas Rowe, Lizheng Guo, Ewelina Lyszkowicz, Shoshona Le, Malania Wilson, Juliana DaSilva, Alma Trujillo, Michael Hillman, Thomas Stark, Samuel Shepard, Sujatha Seenu, Ha Nguyen, Vasiliy Mishin, Margaret Okomo-Adhiambo, Michelle Adamczyk, Juan De la Cruz, Influenza Division, National Center for Immunization and Respiratory Diseases, CDC.

______

1Influenza Division, National Center for Immunization and Respiratory Diseases, CDC.

Corresponding author: Sophie Smith, ssmith11@cdc.gov, 404-639-3747.

 

References

  1. Schild GC, Oxford JS, de Jong JC, Webster RG. Evidence for host-cell selection of influenza virus antigenic variants. Nature 1983;303:706–9.
  2. Katz JM, Wang M, Webster RG. Direct sequencing of the HA gene of influenza (H3N2) virus in original clinical samples reveals sequence identity with mammalian cell-grown virus. J Virol 1990;64:1808–11.
  3. Flannery B, Clippard J, Zimmerman RK, et al. Early estimates of seasonal influenza vaccine effectiveness—United States, January 2015. MMWR Morb Mortal Wkly Rep 2015;64:10–5.
  4. Ohmit SE, Victor JC, Rotthoff JR, et al. Prevention of antigenically drifted influenza by inactivated and live attenuated vaccines. N Engl J Med 2006;355:2513–22.
  5. Grohskopf LA, Sokolow LZ, Olsen SJ, Bresee JS, Broder KR, Karron RA. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2015–16 influenza season. MMWR Morb Mortal Wkly Rep 2015;64:818–25.
  6. CDC. Estimated influenza illnesses and hospitalizations averted by vaccination—United States, 2015–16 influenza season. Atlanta, GA: US Department of Health and Human Services, CDC. Available at http://www.cdc.gov/flu/about/disease/2014-15.htm.
  7. Neuzil KM, Jackson LA, Nelson J, et al. Immunogenicity and reactogenicity of 1 versus 2 doses of trivalent inactivated influenza vaccine in vaccine-naive 5–8-year-old children. J Infect Dis 2006;194:1032–9.
  8. Fiore AE, Fry A, Shay D, Gubareva L, Bresee JS, Uyeki TM. Antiviral agents for the treatment and chemoprophylaxis of influenza—recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011;60(No. RR-1).

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* CDC collects five categories of surveillance data from nine data sources: 1) viral surveillance (World Health Organization collaborating laboratories, the National Respiratory and Enteric Virus Surveillance System, and novel influenza A virus case reporting); 2) outpatient illness surveillance (U.S. Outpatient Influenza-Like Illness Surveillance Network); 3) mortality (the National Center for Health Statistics Mortality Surveillance System, 122 Cities Mortality Reporting System, and influenza-associated pediatric mortality reports); 4) hospitalizations (Influenza Hospitalization Surveillance Network [FluSurv-NET], which includes the Emerging Infections Program and surveillance in three additional states); and 5) summary of the geographic spread of influenza (state and territorial epidemiologist reports). Additional information available at http://www.cdc.gov/flu/weekly/fluactivitysurv.htm.

† Data reported as of December 4, 2015.

§ Region 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. Region 2: New Jersey, New York, Puerto Rico, and the U.S. Virgin Islands. Region 3: Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia. Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee. Region 5: Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. Region 6: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas. Region 7: Iowa, Kansas, Missouri, and Nebraska. Region 8: Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming. Region 9: Arizona, California, Hawaii, Nevada, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Marshall Islands, and Republic of Palau. Region 10: Alaska, Idaho, Oregon, and Washington.

¶ Defined as a temperature of ≥100°F (≥37.8°C), oral or equivalent, and cough or sore throat, without a known cause other than influenza.

** The national and regional baselines are the mean percentage of visits for ILI during noninfluenza weeks for the previous three seasons plus two standard deviations. A noninfluenza week is defined as periods of ≥2 consecutive weeks in which each week accounted for <2% of the season’s total number of specimens that tested positive for influenza. National and regional percentages of patient visits for ILI are weighted on the basis of state population. Use of the national baseline for regional data is not appropriate.

†† Activity levels are based on the percentage of outpatient visits in a jurisdiction attributed to ILI and are compared with the average percentage of ILI visits that occur during weeks with little or no influenza virus circulation. Activity levels range from minimal, corresponding to ILI activity from outpatient clinics at or below the average, to high, corresponding to ILI activity from outpatient clinics much higher than the average. Because the clinical definition of ILI is very nonspecific, not all ILI is caused by influenza; however, when combined with laboratory data, the information on ILI activity provides a clearer picture of influenza activity in the United States.

§§ Levels of activity are 1) no activity; 2) sporadic: isolated laboratory-confirmed influenza case(s) or a laboratory-confirmed outbreak in one institution, with no increase in activity; 3) local: increased ILI, or at least two institutional outbreaks (ILI or laboratory-confirmed influenza) in one region of the state, with recent laboratory evidence of influenza in that region and virus activity no greater than sporadic in other regions; 4) regional: increased ILI activity or institutional outbreaks (ILI or laboratory-confirmed influenza) in at least two but less than half of the regions in the state with recent laboratory evidence of influenza in those regions; and 5) widespread: increased ILI activity or institutional outbreaks (ILI or laboratory-confirmed influenza) in at least half the regions in the state, with recent laboratory evidence of influenza in the state.

¶¶ The seasonal baseline proportion of P&I deaths is projected using a robust regression procedure, in which a periodic regression model is applied to the observed percentage of deaths from P&I that were reported by the National Center for Health Statistics Mortality Surveillance System and the 122 Cities Mortality Reporting System during the preceding 5 years. The epidemic threshold is set at 1.645 standard deviations above the seasonal baseline. Users of the data should not expect the NCHS mortality surveillance data and the 122 Cities Mortality Reporting System to produce the same percentages and the percent P&I deaths from each system should be compared to the corresponding system specific baselines and thresholds.

*** Persons at higher risk include 1) children aged <2 years; 2) adults aged ≥65 years; 3) persons with chronic pulmonary conditions (including asthma); cardiovascular disease (except hypertension alone); renal, hepatic, hematologic (including sickle cell) disease; metabolic disorders (including diabetes mellitus); or neurologic and neurodevelopmental conditions (including disorders of the brain, spinal cord, peripheral nerves, and muscles, such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability [mental retardation], moderate to severe developmental delay, muscular dystrophy, or spinal cord injury); 4) persons with immunosuppression, including that caused by medications or by human immunodeficiency virus infection; 5) women who are pregnant or postpartum (within 2 weeks after delivery); 6) persons aged ≤18 years who are receiving long-term aspirin therapy; 7) American Indians/Alaska Natives; 8) persons who are morbidly obese (i.e., body mass index ≥40); and 9) residents of nursing homes and other chronic care facilities.

††† Additional information on antiviral use and treatment of influenza is available at: http://www.cdc.gov/flu/antivirals.

Keywords: USA; US CDC; Updates; Seasonal Influenza; H1N1pdm09; H3N2; Flu B; Vaccines; Antivirals.

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Concurrent #Outbreaks of St. Louis #Encephalitis Virus and #WestNile #Virus #Disease — #Arizona, 2015 (MMWR Morb Mortal Wkly Rep., abstract)

[Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK). Abstract, edited.]

Notes from the Field: Concurrent Outbreaks of St. Louis Encephalitis Virus and West Nile Virus Disease — Arizona, 2015 [      ]

Weekly / December 11, 2015 / 64(48);1349-50

Heather Venkat, DVM1,2,3,*; Elisabeth Krow-Lucal, PhD1,4,*; Morgan Hennessey, DVM1,4; Jefferson Jones, MD1,2,3; Laura Adams, DVM3,6; Marc Fischer, MD4; Tammy Sylvester, MSN2; Craig Levy, MS2; Kirk Smith, PhD5; Lydia Plante, MSPH3; Kenneth Komatsu, MPH3; J. Erin Staples, MD4; Susan Hills, MBBS4

 

Abstract

St. Louis encephalitis virus (SLEV) and West Nile virus (WNV) are closely related mosquito-borne flaviviruses that can cause outbreaks of acute febrile illness and neurologic disease. Both viruses are endemic throughout much of the United States and have the same Culex species mosquito vectors and avian hosts (1); however, since WNV was first identified in the United States in 1999, SLEV disease incidence has been substantially lower than WNV disease incidence, and no outbreaks involving the two viruses circulating in the same location at the same time have been identified. Currently, there is a commercially available laboratory test for diagnosis of acute WNV infection, but there is no commercially available SLEV test, and all SLEV testing must be performed at public health laboratories. In addition, because antibodies against SLEV and WNV can cross-react on standard diagnostic tests, confirmatory neutralizing antibody testing at public health laboratories is usually required to determine the flavivirus species (2). This report describes the first known concurrent outbreaks of SLEV and WNV disease in the United States.

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1Epidemic Intelligence Service, CDC; 2Maricopa County Department of Public Health, Phoenix, Arizona; 3Arizona Department of Health Services; 4Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 5Maricopa County Environmental Services Vector Control Division; 6Career Epidemiology Field Officer Program, CDC.

Corresponding authors: Heather Venkat, HeatherVenkat@mail.maricopa.gov, 602-531-4422; Elisabeth Krow-Lucal, ekrowlucal@cdc.gov, 970-266-3565.

Keywords: USA; US CDC; Updates; West Nile Fever; St Louis Encephalitis; Arizona.

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#Outbreaks of Acute #Gastroenteritis Transmitted by Person-to-Person #Contact, #Environmental #Contamination, and Unknown Modes of #Transmission — #USA, 2009–2013 (MMWR Morb Mortal Wkly Rep., abstract)

[Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK). Abstract.]

Outbreaks of Acute Gastroenteritis Transmitted by Person-to-Person Contact, Environmental Contamination, and Unknown Modes of Transmission — United States, 2009–2013 [      ]

Surveillance Summaries / December 11, 2015 / 64(SS12);1-16

Mary E. Wikswo, MPH1, Anita Kambhampati, MPH1, Kayoko Shioda, DVM1, Kelly A. Walsh, MPH2, Anna Bowen, MD2, Aron J. Hall, DVM1

1Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC; 2Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC

Corresponding author: Mary Wikswo, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC. Telephone: 404-639-0881; E-mail: ezq1@cdc.gov.

 

Abstract

Problem/Condition:

Acute gastroenteritis (AGE) is a major cause of illness in the United States, with an estimated 179 million episodes annually. AGE outbreaks propagated through direct person-to-person contact, contaminated environmental surfaces, and unknown modes of transmission were not systematically captured at the national level before 2009 and thus were not well characterized.

Reporting Period:

2009–2013.

Description of System:

The National Outbreak Reporting System (NORS) is a voluntary national reporting system that supports reporting of all waterborne and foodborne disease outbreaks and all AGE outbreaks resulting from transmission by contact with contaminated environmental sources, infected persons or animals, or unknown modes. Local, state, and territorial public health agencies within the 50 U.S. states, the District of Columbia (DC), five U.S. territories, and three Freely Associated States report outbreaks to CDC via NORS using a standard online data entry system.

Results:

A total of 10,756 AGE outbreaks occurred during 2009–2013, for which the primary mode of transmission occurred through person-to-person contact, environmental contamination, and unknown modes of transmission. NORS received reports from public health agencies in 50 U.S. states, DC, and Puerto Rico. These outbreaks resulted in 356,532 reported illnesses, 5,394 hospitalizations, and 459 deaths. The median outbreak reporting rate for all sites in a given year increased from 2.7 outbreaks per million population in 2009 to 11.8 outbreaks in 2013. The etiology was unknown in 31% (N = 3,326) of outbreaks. Of the 7,430 outbreaks with a suspected or confirmed etiology reported, norovirus was the most common, reported in 6,223 (84%) of these outbreaks. Other reported suspected or confirmed etiologies included Shigella (n = 332) and Salmonella (n = 320). Outbreaks were more frequent during the winter, with 5,716 (53%) outbreaks occurring during December–February, and 70% of the 7,001 outbreaks with a reported setting of exposure occurred in long-term–care facilities (n = 4,894). In contrast, 59% (n = 143) of shigellosis outbreaks, 36% (n = 30) of salmonellosis outbreaks, and 32% (n = 84) of other or multiple etiology outbreaks were identified in child care facilities.

Interpretation:

NORS is the first U.S. surveillance system that provides national data on AGE outbreaks spread through person-to-person contact, environmental contamination, and unknown modes of transmission. The increase in reporting rates during 2009–2013 indicates that reporting to NORS improved notably in the 5 years since its inception. Norovirus is the most commonly reported cause of these outbreaks and, on the basis of epidemiologic data, might account for a substantial proportion of outbreaks without a reported etiology. During 2009–2013, norovirus accounted for most deaths and health care visits in AGE outbreaks spread through person-to-person contact, environmental contamination, and unknown modes of transmission.

Public Health Action:

Recommendations for prevention and control of AGE outbreaks transmitted through person-to-person contact, environmental contamination, and unknown modes of transmission depend primarily on appropriate hand hygiene, environmental disinfection, and isolation of ill persons. NORS surveillance data can help identify priority targets for the development of future control strategies, including hygiene interventions and vaccines, and help monitor the frequency and severity of AGE outbreaks in the United States. Ongoing study of these AGE outbreaks can provide a better understanding of certain pathogens and their modes of transmission. For example, certain reported outbreak etiologies (e.g., Salmonella) are considered primarily foodborne pathogens but can be transmitted through multiple routes. Similarly, further examination of outbreaks of unknown etiology could help identify barriers to making an etiologic determination, to analyze clinical and epidemiologic clues suggestive of a probable etiology, and to discover new and emerging etiologic agents. Outbreak reporting to NORS has improved substantially since its inception, and further outreach efforts and system improvements might facilitate additional increases in the number and completeness of reports to NORS.

Keywords: USA; US CDC; Updates; Research; Abstracts; Gastroenteritis; Food Safety.

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#Carbapenem-resistant #Enterobacteriaceae Producing OXA-48-like Carbapenemases — #USA, 2010–2015 (@CDCgov / MMWR, extract)

[Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK). Abstract, edited.]

Carbapenem-resistant Enterobacteriaceae Producing OXA-48-like Carbapenemases — United States, 2010–2015 [      ]

Weekly / December 4, 2015 / 64(47);1315-6

Meghan Lyman, MD1,2; Maroya Walters, PhD2; David Lonsway, MMSc2; Kamile Rasheed, PhD2; Brandi Limbago, PhD2; Alexander Kallen, MD2

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Carbapenem-resistant Enterobacteriaceae (CRE) are bacteria that are often resistant to most classes of antibiotics and cause health care–associated infections with high mortality rates (1). Among CRE, strains that carry plasmid-encoded carbapenemase enzymes that inactivate carbapenem antibiotics are of greatest public health concern because of their potential for rapid global dissemination, as evidenced by the increasing distribution of CRE that produce the Klebsiella pneumoniae carbapenemase and the New Delhi metallo-β-lactamase. Newly described resistance in Enterobacteriaceae, such as plasmid-mediated resistance to the last-line antimicrobial colistin, recently detected in China, and resistance to the newly approved antimicrobial, ceftazidime-avibactam, identified from a U.S. K. pneumoniae carbapenemase-producing isolate, highlight the continued urgency to delay spread of CRE (2,3). Monitoring the emergence of carbapenemases is crucial to limiting their spread; identification of patients carrying carbapenemase-producing CRE should result in the institution of transmission-based precautions and enhanced environmental cleaning to prevent transmission.* The OXA-48 carbapenemase was first identified in Enterobacteriaceae in Turkey in 2001 (2), and OXA-48-like variants have subsequently been reported around the world. The first U.S. reports of OXA-48-like carbapenemases were published in 2013 and included retrospectively identified isolates from 2009 (3) and two isolates collected in 2012 from patients in Virginia who had recently been hospitalized outside the United States (4). Although there are limited additional published reports from the United States (5), CDC continues to receive reprots of these organisms. This report describes patients identified as carrying CRE producing OXA-48-like carbapenemases in the United States during June 2010–August 2015.

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Keywords: USA; US CDC; Updates; Antibiotics; Drugs Resistance; Carbapenem; Enterobacteriaceae.

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#Clinical #Framework and #Medical #Countermeasure Use During an #Anthrax Mass-Casualty #Incident (@CDCgov / MMWR, summary)

[Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK). Summary, edited.]

Clinical Framework and Medical Countermeasure Use During an Anthrax Mass-Casualty Incident [      ]

Recommendations and Reports /  December 4, 2015 / 64(RR04);1-28 / CDC Recommendations

Prepared by William A. Bower, MD1, Katherine Hendricks, MD1, Satish Pillai, MD2, Julie Guarnizo2, Dana Meaney-Delman, MD3

1Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases; 2Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases; 3Office of the Director, National Center for Emerging and Zoonotic Infectious Diseases

Corresponding author: William A. Bower, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC. Telephone: 404-639-0376; E-mail: wab4@cdc.gov.

 

Summary

In 2014, CDC published updated guidelines for the prevention and treatment of anthrax (Hendricks KA, Wright ME, Shadomy SV, et al. Centers for Disease Control and Prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014;20[2]. Available at http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article.htm). These guidelines provided recommended best practices for the diagnosis and treatment of persons with naturally occurring or bioterrorism-related anthrax in conventional medical settings. An aerosolized release of Bacillus anthracis spores over densely populated areas could become a mass-casualty incident. To prepare for this possibility, the U.S. government has stockpiled equipment and therapeutics (known as medical countermeasures [MCMs]) for anthrax prevention and treatment. However, previously developed, publicly available clinical recommendations have not addressed the use of MCMs or clinical management during an anthrax mass-casualty incident, when the number of patients is likely to exceed the ability of the health care infrastructure to provide conventional standards of care and supplies of MCMs might be inadequate to meet the demand required. To address this gap, in 2013, CDC conducted a series of systematic reviews of the scientific literature on anthrax to identify evidence that could help clinicians and public health authorities set guidelines for intravenous antimicrobial and antitoxin use, diagnosis of anthrax meningitis, and management of common anthrax-specific complications in the setting of a mass-casualty incident. Evidence from these reviews was presented to professionals with expertise in anthrax, critical care, and disaster medicine during a series of workgroup meetings that were held from August 2013 through March 2014. In March 2014, a meeting was held at which 102 subject matter experts discussed the evidence and adapted the existing best practices guidance to a clinical use framework for the judicious, efficient, and rational use of stockpiled MCMs for the treatment of anthrax during a mass-casualty incident, which is described in this report. This report addresses elements of hospital-based acute care, specifically antitoxins and intravenous antimicrobial use, and the diagnosis and management of common anthrax-specific complications during a mass-casualty incident. The recommendations in this report should be implemented only after predefined triggers have been met for shifting from conventional to contingency or crisis standards of care, such as when the magnitude of cases might lead to impending shortages of intravenous antimicrobials, antitoxins, critical care resources (e.g., chest tubes and chest drainage systems), or diagnostic capability. This guidance does not address primary triage decisions, anthrax postexposure prophylaxis, hospital bed or workforce surge capacity, or the logistics of dispensing MCMs. Clinicians, hospital administrators, state and local health officials, and planners can use these recommendations to assist in the development of crisis protocols that will ensure national preparedness for an anthrax mass-casualty incident.

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Keywords: US CDC; USA; Updates; Mass Casualty Events; Anthrax.

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Increase in #Human #Cases of #Tularemia — #Colorado, #Nebraska, South #Dakota, and #Wyoming, January–September 2015 (@CDCgov / MMWR, abstract)

[Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK). Abstract, edited.]

Increase in Human Cases of Tularemia — Colorado, Nebraska, South Dakota, and Wyoming, January–September 2015 [      ]

Weekly /  December 4, 2015 / 64(47);1317-8

Caitlin Pedati, MD1,2; Jennifer House, DVM3; Jessica Hancock-Allen, MPH1,3; Leah Colton, PhD3; Katie Bryan, MPH4; Dustin Ortbahn5; Lon Kightlinger, PhD5; Kiersten Kugeler, PhD6; Jeannine Petersen, PhD6; Paul Mead, MD6; Tom Safranek MD2; Bryan Buss DVM2,7

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Tularemia is a rare, often serious disease caused by a gram-negative coccobacillus, Francisella tularensis, which infects humans and animals in the Northern Hemisphere (1). Approximately 125 cases have been reported annually in the United States during the last two decades (2). As of September 30, a total of 100 tularemia cases were reported in 2015 among residents of Colorado (n = 43), Nebraska (n = 21), South Dakota (n = 20), and Wyoming (n = 16) (Figure). This represents a substantial increase in the annual mean number of four (975% increase), seven (200%), seven (186%) and two (70%) cases, respectively, reported in each state during 2004–2014 (2).

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Keywords: US CDC; USA; Updates; Tularemia; Nebraska; Colorado; South Dakota; Wyoming; Human.

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