Atlanta, GA, United States
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Lessa F.C.,Centers for Disease Control and Prevention | Mu Y.,Centers for Disease Control and Prevention | Beldavs Z.G.,Oregon Health Authority | Dumyati G.K.,University of Rochester | And 12 more authors.
New England Journal of Medicine | Year: 2015

Background: The magnitude and scope of Clostridium difficile infection in the United States continue to evolve. Methods: In 2011, we performed active population- and laboratory-based surveillance across 10 geographic areas in the United States to identify cases of C. difficile infection (stool specimens positive for C. difficile on either toxin or molecular assay in residents -1 year of age). Cases were classified as community-associated or health care-associated. In a sample of cases of C. difficile infection, specimens were cultured and isolates underwent molecular typing. We used regression models to calculate estimates of national incidence and total number of infections, first recurrences, and deaths within 30 days after the diagnosis of C. difficile infection. Results: A total of 15,461 cases of C. difficile infection were identified in the 10 geographic areas; 65.8% were health care-associated, but only 24.2% had onset during hospitalization. After adjustment for predictors of disease incidence, the estimated number of incident C. difficile infections in the United States was 453,000 (95% confidence interval [CI], 397,100 to 508,500). The incidence was estimated to be higher among females (rate ratio, 1.26; 95% CI, 1.25 to 1.27), whites (rate ratio, 1.72; 95% CI, 1.56 to 2.0), and persons 65 years of age or older (rate ratio, 8.65; 95% CI, 8.16 to 9.31). The estimated number of first recurrences of C. difficile infection was 83,000 (95% CI, 57,000 to 108,900), and the estimated number of deaths was 29,300 (95% CI, 16,500 to 42,100). The North American pulsed-field gel electrophoresis type 1 (NAP1) strain was more prevalent among health care-associated infections than among community-associated infections (30.7% vs. 18.8%, P<0.001) Conclusions: C. difficile was responsible for almost half a million infections and was associated with approximately 29,000 deaths in 2011. Copyright © 2015 Massachusetts Medical Society. All rights reserved.


Gould L.H.,Centers for Disease Control and Prevention | Mungai E.,Centers for Disease Control and Prevention | Mungai E.,Atlanta Research and Education Foundation | Barton Behravesh C.,Centers for Disease Control and Prevention
Foodborne Pathogens and Disease | Year: 2014

Introduction: The interstate commerce of unpasteurized fluid milk, also known as raw milk, is illegal in the United States, and intrastate sales are regulated independently by each state. However, U.S. Food and Drug Administration regulations allow the interstate sale of certain types of cheeses made from unpasteurized milk if specific aging requirements are met. We describe characteristics of these outbreaks, including differences between outbreaks linked to cheese made from pasteurized or unpasteurized milk. Methods: We reviewed reports of outbreaks submitted to the Foodborne Disease Outbreak Surveillance System during 1998-2011 in which cheese was implicated as the vehicle. We describe characteristics of these outbreaks, including differences between outbreaks linked to cheese made from pasteurized versus unpasteurized milk. Results: During 1998-2011, 90 outbreaks attributed to cheese were reported; 38 (42%) were due to cheese made with unpasteurized milk, 44 (49%) to cheese made with pasteurized milk, and the pasteurization status was not reported for the other eight (9%). The most common cheese-pathogen pairs were unpasteurized queso fresco or other Mexican-style cheese and Salmonella (10 outbreaks), and pasteurized queso fresco or other Mexican-style cheese and Listeria (6 outbreaks). The cheese was imported from Mexico in 38% of outbreaks caused by cheese made with unpasteurized milk. In at least five outbreaks, all due to cheese made from unpasteurized milk, the outbreak report noted that the cheese was produced or sold illegally. Outbreaks caused by cheese made from pasteurized milk occurred most commonly (64%) in restaurant, delis, or banquet settings where cross-contamination was the most common contributing factor. Conclusions: In addition to using pasteurized milk to make cheese, interventions to improve the safety of cheese include limiting illegal importation of cheese, strict sanitation and microbiologic monitoring in cheese-making facilities, and controls to limit food worker contamination. © 2014 Mary Ann Liebert, Inc.


Mungai E.A.,Atlanta Research and Education Foundation | Mungai E.A.,Centers for Disease Control and Prevention | Behravesh C.B.,Centers for Disease Control and Prevention | Gould L.H.,Centers for Disease Control and Prevention
Emerging Infectious Diseases | Year: 2015

The number of US outbreaks caused by nonpasteurized milk increased from 30 during 2007–2009 to 51 during 2010–2012. Most outbreaks were caused by Campylobacter spp. (77%) and by nonpasteurized milk purchased from states in which nonpasteurized milk sale was legal (81%). Regulations to prevent distribution of nonpasteurized milk should be enforced. © 2015, Centers for Disease Control and Prevention (CDC). All rights reserved.


Payne D.C.,Centers for Disease Control and Prevention | Vinje J.,Centers for Disease Control and Prevention | Szilagyi P.G.,University of Rochester | Edwards K.M.,Vanderbilt University | And 12 more authors.
New England Journal of Medicine | Year: 2013

BACKGROUND: Cases of rotavirus-associated acute gastroenteritis have declined since the introduction of rotavirus vaccines, but the burden of norovirus-associated acute gastroenteritis in children remains to be assessed. METHODS: We conducted active surveillance for laboratory-confirmed cases of norovirus among children younger than 5 years of age with acute gastroenteritis in hospitals, emergency departments, and outpatient clinical settings. The children resided in one of three U.S. counties during the years 2009 and 2010. Fecal specimens were tested for norovirus and rotavirus. We calculated population-based rates of norovirus-associated acute gastroenteritis and reviewed billing records to determine medical costs; these data were extrapolated to the U.S. population of children younger than 5 years of age. RESULTS: Norovirus was detected in 21% of young children (278 of 1295) seeking medical attention for acute gastroenteritis in 2009 and 2010, with norovirus detected in 22% (165 of 742) in 2009 and 20% (113 of 553) in 2010 (P=0.43). The virus was also detected in 4% of healthy controls (19 of 493) in 2009. Rotavirus was identified in 12% of children with acute gastroenteritis (152 of 1295) in 2009 and 2010. The respective rates of hospitalization, emergency department visits, and outpatient visits for the norovirus were 8.6, 146.7, and 367.7 per 10,000 children younger than 5 years of age in 2009 and 5.8, 134.3, and 260.1 per 10,000 in 2010, with an estimated cost per episode of $3,918, $435, and $151, respectively, in 2009. Nationally, we estimate that the average numbers of annual hospitalizations, emergency department visits, and outpatient visits due to norovirus infection in 2009 and 2010 among U.S. children in this age group exceeded 14,000, 281,000, and 627,000, respectively, with more than $273 million in treatment costs each year. CONCLUSIONS: Since the introduction of rotavirus vaccines, norovirus has become the leading cause of medically attended acute gastroenteritis in U.S. children and is associated with nearly 1 million health care visits annually. Copyright © 2013 Massachusetts Medical Society.


Vega E.,Centers for Disease Control and Prevention | Barclay L.,Centers for Disease Control and Prevention | Gregoricus N.,Centers for Disease Control and Prevention | Shirley S.H.,Centers for Disease Control and Prevention | And 4 more authors.
Journal of Clinical Microbiology | Year: 2014

Noroviruses are the leading cause of epidemic acute gastroenteritis in the United States. From September 2009 through August 2013, 3,960 norovirus outbreaks were reported to CaliciNet. Of the 2,895 outbreaks with a known transmission route, person-toperson and food-borne transmissions were reported for 2,425 (83.7%) and 465 (16.1%) of the outbreaks, respectively. A total of 2,475 outbreaks (62.5%) occurred in long-term care facilities (LTCF), 389 (9.8%) in restaurants, and 227 (5.7%) in schools. A total of 435 outbreaks (11%) were typed as genogroup I (GI) and 3,525 (89%) as GII noroviruses. GII.4 viruses caused 2,853 (72%) of all outbreaks, of which 94% typed as either GII.4 New Orleans or GII.4 Sydney. In addition, three non-GII.4 viruses, i.e., GII.12, GII.1, and GI.6, caused 528 (13%) of all outbreaks. Several non-GII.4 genotypes (GI.3, GI.6, GI.7, GII.3, GII.6, and GII.12) were significantly more associated with food-borne transmission (odds ratio, 1.9 to 7.1; P<0.05). Patients in LTCF and people>65 years of age were at higher risk for GII.4 infections than those in other settings and with other genotypes (P<0.05). Phylogeographic analysis identified three major dispersions from two geographic locations that were responsible for the GI.6 outbreaks from 2011 to 2013. In conclusion, our data demonstrate the cyclic emergence of new (non-GII.4) norovirus strains, and several genotypes are more often associated with food-borne outbreaks. These surveillance data can be used to improve viral food-borne surveillance and to help guide studies to develop and evaluate targeted prevention methods such as norovirus vaccines, antivirals, and environmental decontamination methods. Copyright © 2014, American Society for Microbiology.


Vega E.,Centers for Disease Control and Prevention | Barclay L.,Centers for Disease Control and Prevention | Gregoricus N.,Centers for Disease Control and Prevention | Williams K.,Atlanta Research and Education Foundation | And 2 more authors.
Emerging Infectious Diseases | Year: 2011

CaliciNet, the outbreak surveillance network for noroviruses in the United States, was launched in March 2009. As of January 2011, twenty state and local health laboratories had been certified to submit norovirus sequences and epidemiologic outbreak data to CaliciNet. During the network's first year, 552 outbreaks were submitted to CaliciNet, of which 78 (14%) were associated with foodborne transmission. A total of 395 (72%) outbreaks were typed as GII.4, of which 298 (75%) belonged to a new variant, GII.4 New Orleans, which first emerged in October 2009. Analysis of the complete capsid and P2 region sequences confirmed that GII.4 New Orleans is distinct from previous GII.4 variants, including GII.4 Minerva (2006b).


Griffing S.M.,Centers for Disease Control and Prevention | Griffing S.M.,Atlanta Research and Education Foundation | Gamboa D.,Cayetano Heredia Peruvian University | Udhayakumar V.,Centers for Disease Control and Prevention
Malaria Journal | Year: 2013

Malaria has been part of Peruvian life since at least the 1500s. While Peru gave the world quinine, one of the first treatments for malaria, its history is pockmarked with endemic malaria and occasional epidemics. In this review, major increases in Peruvian malaria incidence over the past hundred years are described, as well as the human factors that have facilitated these events, and concerted private and governmental efforts to control malaria. Political support for malaria control has varied and unexpected events like vector and parasite resistance have adversely impacted morbidity and mortality. Though the ready availability of novel insecticides like DDT and efficacious medications reduced malaria to very low levels for a decade after the post eradication era, malaria reemerged as an important modern day challenge to Peruvian public health. Its reemergence sparked collaboration between domestic and international partners towards the elimination of malaria in Peru. © 2013 Griffing et al.; licensee BioMed Central Ltd.


Grass J.E.,Atlanta Research and Education Foundation | Grass J.E.,Centers for Disease Control and Prevention | Gould L.H.,Centers for Disease Control and Prevention | Mahon B.E.,Centers for Disease Control and Prevention
Foodborne Pathogens and Disease | Year: 2013

Clostridium perfringens is estimated to be the second most common bacterial cause of foodborne illness in the United States, causing one million illnesses each year. Local, state, and territorial health departments voluntarily report C. perfringens outbreaks to the U.S. Centers for Disease Control and Prevention through the Foodborne Disease Outbreak Surveillance System. Our analysis included outbreaks confirmed by laboratory evidence during 1998-2010. A food item was implicated if C. perfringens was isolated from food or based on epidemiologic evidence. Implicated foods were classified into one of 17 standard food commodities when possible. From 1998 to 2010, 289 confirmed outbreaks of C. perfringens illness were reported with 15,208 illnesses, 83 hospitalizations, and eight deaths. The number of outbreaks reported each year ranged from 16 to 31 with no apparent trend over time. The annual number of outbreak-associated illnesses ranged from 359 to 2,173, and the median outbreak size was 24 illnesses. Outbreaks occurred year round, with the largest number in November and December. Restaurants (43%) were the most common setting of food preparation. Other settings included catering facility (19%), private home (16%), prison or jail (11%), and other (10%). Among the 144 (50%) outbreaks attributed to a single food commodity, beef was the most common commodity (66 outbreaks, 46%), followed by poultry (43 outbreaks, 30%), and pork (23 outbreaks, 16%). Meat and poultry outbreaks accounted for 92% of outbreaks with an identified single food commodity. Outbreaks caused by C. perfringens occur regularly, are often large, and can cause substantial morbidity yet are preventable if contamination of raw meat and poultry products is prevented at the farm or slaughterhouse or, after contamination, if these products are properly handled and prepared, particularly in restaurants and catering facilities. © Mary Ann Liebert, Inc.


Nguyen H.T.,Centers for Disease Control and Prevention | Nguyen H.T.,Atlanta Research and Education Foundation | Nguyen H.T.,Batelle Memorial Institute | Fry A.M.,Centers for Disease Control and Prevention | Gubareva L.V.,Centers for Disease Control and Prevention
Antiviral Therapy | Year: 2012

Infection with influenza viruses, including seasonal, avian and pandemic viruses, remains a worldwide public health problem. Although influenza virus infection is both vaccine preventable and drug treatable, high rates of mutation and reassortment of viruses can result in reduced effectiveness of vaccines or drugs. Currently, two classes of drugs, adamantanes (M2 blockers) and neuraminidase (NA) inhibitors (NAIs), are available for treatment and chemoprophylaxis of influenza infections. Given these limited antiviral therapy options, resistance to anti-influenza drugs is a constant concern. The emergence and global spread of adamantane-resistant H3N2 viruses in 2003-2004 and oseltamivir-resistant seasonal H1N1 viruses in 2007-2009 demonstrated the ability of drug-resistant variants to rapidly become predominant worldwide. Since the 2009 H1N1 pandemic, all influenza viruses circulating in humans are M2-blocker-resistant and, in general, NAI-susceptible. However, pandemic H1N1 viruses with resistance to the NAI oseltamivir have been reported. 'Permissive' drift mutations and reassortment of viral gene segments have been proposed as mechanisms underlying the retained replicative fitness of resistant viruses. Nevertheless, the precise role of these genetic changes in the efficient transmission and maintenance of resistant viruses in the absence of drug pressure remains poorly understood. In this review, we summarize NAI resistance in influenza viruses and discuss recent challenges in laboratory testing methods. Close monitoring of antiviral resistance among all influenza viruses, both locally and globally, are essential to inform public health strategies for the control of influenza infections. © 2012 International Medical Press.


Hall R.L.,Atlanta Research and Education Foundation | Hall R.L.,Center for Global Health | Jones J.L.,Center for Global Health | Herwaldt B.L.,Center for Global Health
Morbidity and Mortality Weekly Report | Year: 2011

Problem/Condition: Cyclosporiasis is an enteric disease caused by the parasite Cyclospora cayetanensis. Cyclosporiasis is reported most commonly in tropical and subtropical regions. In the United States, outbreaks of cyclosporiasis associated with various types of imported fresh produce have been documented and described since the mid-1990s. No molecular tools are available for linking C. cayetanensis cases. National data regarding laboratory-confirmed sporadic cases (i.e., cases not linked to documented outbreaks) have not been summarized previously. Reporting Period: This summary includes laboratory-confirmed sporadic cases that occurred during 1997-2008 and were reported to CDC by 2009. Description of System: In January 1999, cyclosporiasis became a nationally notifiable disease, and, as of 2008, it was a reportable condition in 37 states, New York City (NYC), and the District of Columbia. For 1997-2008, CDC was notified of laboratory-confirmed cases via two active surveillance systems (the Cyclospora Sentinel Surveillance Network and the Foodborne Diseases Active Surveillance Network), two passive systems (the National Notifiable Diseases Surveillance System and the Public Health Laboratory Information System), and informal mechanisms (e.g., electronic mail). Results: CDC was notified of 1,110 laboratory-confirmed sporadic cases of cyclosporiasis that occurred during 1997-2008. The overall population-adjusted incidence rates ranged from a low of 0.01 cases per 100,000 persons in 1997 to a high of 0.07 in 2002. Of the 1,110 cases, 849 (76.5%) were reported by seven states: 498 (44.9%) occurred in residents of Florida (228 cases), NYC (200 cases), and elsewhere in New York state (70 cases); and >50 cases were reported by each of five other states (Connecticut, Georgia, Massachusetts, New Jersey, and Pennsylvania). Overall, the case-patients' median age was 44 years (range: 3 months-96 years); 50.5% were female, 47.2% were male, and the sex was unknown for 2.3%. A total of 372 case-patients (33.5%) had a documented history of international travel during the 2-week period before symptom onset or diagnosis, 398 (35.9%) reported no international travel, and 340 (30.6%) had an unknown travel history. Some details about the travel were available for 317 (85.2%) of the case-patients with a known history of international travel; 142 (44.8%) had traveled to Mexico (60 persons), Guatemala (44 persons), or Peru (38 persons). Among the 398 case-patients classified as having domestically acquired cases, 124 persons (31.2%) lived in Florida, and 64 persons (16.1%) lived either in NYC (49 persons) or elsewhere in New York state (15 persons). The majority (278 [69.8%]) of onset or diagnosis dates for domestically acquired cases occurred during April-August. Interpretation: Approximately one third of cases occurred in persons with a known history of international travel who might have become infected while traveling outside the continental United States. Domestically acquired cases were concentrated in time (spring and summer) and place (eastern and southeastern states): some of these cases probably were outbreak associated but were not linked to other cases, in part because of a lack of molecular tools. Public Health Action: Surveillance for cases of cyclosporiasis and research to develop molecular methods for linking seemingly sporadic cases should remain U.S. public health priorities, in part to facilitate identification and investigation of outbreaks and to increase understanding of the biology of Cyclospora and the epidemiology of cyclosporiasis. Unidentified, uninvestigated cases and outbreaks represent missed opportunities to identify vehicles of infection, modes of contamination, and preventive measures. Travelers to known areas of endemicity should be advised that food and water precautions for Cyclospora are similar to those for other enteric pathogens, except that this parasite is unlikely to be killed by routine chemical disinfection or sanitizing methods. The diagnosis of cyclosporiasis should be considered for persons with persistent or remitting-relapsing diarrheal illness, and testing for Cyclospora should be requested explicitly.

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