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BackgroundLaw enforcement-related deaths of unarmed black Americans may lead black communities to distrust public institutions. Our study quantifies the impact of law enforcement-related deaths of black New York residents on the use of hospital emergency departments (ED) during 2013–2016.MethodsWe used regression discontinuity models stratified by race and time period (2013–2015 and 2015–2016) to estimate the impact of law enforcement-related deaths on ED rates. Dates of deaths and media reports were from the Mapping Police Violence database. We calculated the daily overall and condition-specific ED visit rates from the New York’s Statewide Planning and Research Cooperative System.ResultsThere were 14 law enforcement-related deaths of unarmed black New York residents from 2013 to 2016. In 2013–2014, the ED rate among black New Yorkers decreased by 7.7 visits per 100 000 black New Yorkers (5% less than the average ED rate) using the date of media report as the cut-off with a 2-week exposure window. No changes in ED rates were noted for black New Yorkers in 2015–2016 or for white New Yorkers in either time period. Models using the date of death followed a similar pattern.ConclusionThe decrease in ED rates among black New Yorkers immediately following media reports of law enforcement-related deaths involving unarmed black New Yorkers during 2013–2014 may represent potentially harmful delays in healthcare. Reforms implemented during 2015–2016 might have modified the impact of these deaths. Further investigation into the population health impacts of law enforcement-related deaths is needed.

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AbstractNewport is the third most common Salmonella entericaserotype identified among the estimated 1.2 million human salmonellosis infections occurring annually in the United States. Risk factors for infection and food items implicated in outbreaks vary by antimicrobial resistance pattern. We conducted a descriptive analysis of data from four enteric disease surveillance systems capturing information on incidence, demographics, seasonality, geographic distribution, outbreaks, and antimicrobial resistance of Newport infections over a 10-year period from 2004 through 2013. Incidence increased through 2010, then declined to rates similar to those in the early years of the study. Incidence was highest in the South and among children <5 years old. Among isolates submitted for antimicrobial susceptibility testing, 88% were susceptible to all antimicrobials tested (pansusceptible) and 8% were resistant to at least seven agents, including ceftriaxone. Rates of pansusceptible isolates were also highest in the South and among young children, particularly in 2010. Pansusceptible strains of Newport have been associated with produce items and environmental sources, such as creek water and sediment. However, the role of environmental transmission of Newport in human illness is unclear. Efforts to reduce produce contamination through targeted legislation, as well as collaborative efforts to identify sources of contamination in agricultural regions, are underway.

AbstractIntroduction:Molecular subtyping of pathogens is critical for foodborne disease outbreak detection and investigation. Many clusters initially identified by pulsed-field gel electrophoresis (PFGE) are not confirmed as point-source outbreaks. We evaluated characteristics of clusters that can help prioritize investigations to maximize effective use of limited resources.Materials and Methods:A multiagency collaboration (FoodNet) collected data on Salmonellaand Escherichia coliO157 clusters for 3 years. Cluster size, timing, extent, and nature of epidemiologic investigations were analyzed to determine associations with whether the cluster was identified as a confirmed outbreak.Results:During the 3-year study period, 948 PFGE clusters were identified; 849 (90%) were Salmonellaand 99 (10%) were E. coliO157. Of those, 192 (20%) were ultimately identified as outbreaks (154 [18%] of Salmonellaand 38 [38%] of E. coliO157 clusters). Successful investigation was significantly associated with larger cluster size, more rapid submission of isolates (e.g., for Salmonella, 6 days for outbreaks vs. 8 days for nonoutbreaks) and PFGE result reporting to investigators (16 days vs. 29 days, respectively), and performance of analytic studies (completed in 33% of Salmonellaoutbreaks vs. 1% of nonoutbreaks) and environmental investigations (40% and 1%, respectively). Intervals between first and second cases in a cluster did not differ significantly between outbreaks and nonoutbreaks.Conclusions:Molecular subtyping of pathogens is a rapidly advancing technology, and successfully identifying outbreaks will vary by pathogen and methods used. Understanding criteria for successfully investigating outbreaks is critical for efficiently using limited resources.

AbstractIntroduction:Changes in food production and distribution have increased opportunities for foods contaminated early in the supply chain to be distributed widely, increasing the possibility of multistate outbreaks. In recent decades, surveillance systems for foodborne disease have been improved, allowing officials to more effectively identify related cases and to trace and identify an outbreak's source.Materials and Methods:We reviewed multistate foodborne disease outbreaks reported to the Centers for Disease Control and Prevention's Foodborne Disease Outbreak Surveillance System during 1973–2010. We calculated the percentage of multistate foodborne disease outbreaks relative to all foodborne disease outbreaks and described characteristics of multistate outbreaks, including the etiologic agents and implicated foods.Results:Multistate outbreaks accounted for 234 (0.8%) of 27,755 foodborne disease outbreaks, 24,003 (3%) of 700,600 outbreak-associated illnesses, 2839 (10%) of 29,756 outbreak-associated hospitalizations, and 99 (16%) of 628 outbreak-associated deaths. The median annual number of multistate outbreaks increased from 2.5 during 1973–1980 to 13.5 during 2001–2010; the number of multistate outbreak-associated illnesses, hospitalizations, and deaths also increased. Most multistate outbreaks were caused by Salmonella(47%) and Shiga toxin–producing Escherichia coli(26%). Foods most commonly implicated were beef (22%), fruits (13%), and leafy vegetables (13%).Conclusions:The number of identified and reported multistate foodborne disease outbreaks has increased. Improvements in detection, investigation, and reporting of foodborne disease outbreaks help explain the increasing number of reported multistate outbreaks and the increasing percentage of outbreaks that were multistate. Knowing the etiologic agents and foods responsible for multistate outbreaks can help to identify sources of food contamination so that the safety of the food supply can be improved.

AbstractFresh fruits and vegetables are an important part of a healthy diet. Melons have been associated with enteric infections. We reviewed outbreaks reported to the Centers for Disease Control and Prevention's Foodborne Disease Outbreak Surveillance System during 1973–2011 in which the implicated food was a single melon type. We also reviewed published literature and records obtained from investigating agencies. During 1973–2011, 34 outbreaks caused by a single melon type were reported, resulting in 3602 illnesses, 322 hospitalizations, 46 deaths, and 3 fetal losses. Cantaloupes accounted for 19 outbreaks (56%), followed by watermelons (13, 38%) and honeydew (2, 6%). Melon-associated outbreaks increased from 0.5 outbreaks per year during 1973–1991 to 1.3 during 1992–2011. Salmonellawas the most common etiology reported (19, 56%), followed by norovirus (5, 15%). Among 13 outbreaks with information available, melons imported from Mexico and Central America were implicated in 9 outbreaks (69%) and domestically grown melons were implicated in 4 outbreaks (31%). The point of contamination was known for 20 outbreaks; contamination occurred most commonly during growth, harvesting, processing, or packaging (13, 65%). Preventive measures focused on reducing bacterial contamination of melons both domestically and internationally could decrease the number and severity of melon-associated outbreaks.

AbstractIntroduction: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 frescoor other Mexican-style cheese and Salmonella(10 outbreaks), and pasteurized queso frescoor 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.

An estimated 48 million cases of foodborne illness occur each year in the United States, resulting in approximately 128,000 hospitalizations and 3,000 deaths. Over half of all foodborne disease outbreaks reported to the Centers for Disease Control and Prevention are associated with eating in restaurants or delicatessens. We reviewed data from restaurant-associated foodborne disease outbreaks to better understand the factors that contribute to these outbreaks. Data on restaurant-associated foodborne disease outbreaks reported by sites participating in the Foodborne Diseases Active Surveillance Network (FoodNet) were analyzed to characterize contributing factors reported in foodborne disease outbreaks and the levels of evidence used to identify these factors. Of 457 foodborne disease outbreaks reported in 2006 and 2007 by FoodNet sites, 300 (66%) were restaurant associated, and of these 295 (98%) had at least one reported contributing factor. One to nine (with a median of two) contributing factors were reported per outbreak. Of the 257 outbreaks with a single etiology reported, contributing factors associated with food worker health and hygiene were reported for 165 outbreaks (64%), factors associated with food preparation practices within the establishment were reported for 88 outbreaks (34%), and factors associated with contamination introduced before reaching the restaurant were reported for 56 outbreaks (22%). The pronounced role of food workers in propagating outbreaks makes it clear that more work is needed to address prevention at the local level. Food workers should be instructed not to prepare food while ill to prevent the risk of transmitting pathogens.

IMPORTANCE Clostridium difficile infection (CDI) has been increasingly reported among healthy individuals in the community. Recent data suggest that community-associated CDI represents one-third of all C difficile cases. The epidemiology and potential sources of C difficile in the community are not fully understood. OBJECTIVES To determine epidemiological and clinical characteristics of community-associated CDI and to explore potential sources of C difficile acquisition in the community. DESIGN AND SETTING Active population-based and laboratory-based CDI surveillance in 8 US states. PARTICIPANTS Medical records were reviewed and interviews performed to assess outpatient, household, and food exposures among patients with community-associated CDI (ie, toxin or molecular assay positive for C difficile and no overnight stay in a health care facility within 12 weeks). Molecular characterization of C difficile isolates was performed. Outpatient health care exposure in the prior 12 weeks among patients with community-associated CDI was a priori categorized into the following 3 levels: no exposure, low-level exposure (ie, outpatient visit with physician or dentist), or high-level exposure (ie, surgery, dialysis, emergency or urgent care visit, inpatient care with no overnight stay, or health care personnel with direct patient care). MAIN OUTCOMES AND MEASURES Prevalence of outpatient health care exposure among patients with community-associated CDI and identification of potential sources of C difficile by level of outpatient health care exposure. RESULTS Of 984 patients with community-associated CDI, 353 (35.9%) did not receive antibiotics, 177 (18.0%) had no outpatient health care exposure, and 400 (40.7%) had low-level outpatient health care exposure. Thirty-one percent of patients without antibiotic exposure received proton pump inhibitors. Patients having CDI with no or low-level outpatient health care exposure were more likely to be exposed to infants younger than 1 year (P = .04) and to household members with active CDI (P = .05) compared with those having high-level outpatient health care exposure. No association between food exposure or animal exposure and level of outpatient health care exposure was observed. North American pulsed-field gel electrophoresis (NAP) 1 was the most common (21.7%) strain isolated; NAP7 and NAP8 were uncommon (6.7%). CONCLUSIONS AND RELEVANCE Most patients with community-associated CDI had recent outpatient health care exposure, and up to 36% would not be prevented by reduction of antibiotic use only. Our data support evaluation of additional strategies, including further examination of C difficile transmission in outpatient and household settings and reduction of proton pump inhibitor use.

AbstractBackground:Shiga toxin–producing Escherichia coli(STEC) are an important cause of diarrhea and the major cause of postdiarrheal hemolytic uremic syndrome. Non-O157 STEC infections are being recognized with greater frequency because of changing laboratory practices.Methods:Foodborne Diseases Active Surveillance Network (FoodNet) site staff conducted active, population-based surveillance for laboratory-confirmed STEC infections. We assessed frequency and incidence of STEC infections by serogroup and examined and compared demographic factors, clinical characteristics, and frequency of international travel among patients.Results:During 2000–2010, FoodNet sites reported 2006 cases of non-O157 STEC infection and 5688 cases of O157 STEC infections. The number of reported non-O157 STEC infections increased from an incidence of 0.12 per 100,000 population in 2000 to 0.95 per 100,000 in 2010; while the rate of O157 STEC infections decreased from 2.17 to 0.95 per 100,000. Among non-O157 STEC, six serogroups were most commonly reported: O26 (26%), O103 (22%), O111 (19%), O121 (6%), O45 (5%), and O145 (4%). Non-O157 STEC infections were more common among Hispanics, and infections were less severe than those caused by O157 STEC, but this varied by serogroup. Fewer non-O157 STEC infections were associated with outbreaks (7% versus 20% for O157), while more were associated with international travel (14% versus 3% for O157).Conclusions:Improved understanding of the epidemiologic features of non-O157 STEC infections can inform food safety and other prevention efforts. To detect both O157 and non-O157 STEC infections, clinical laboratories should routinely and simultaneously test all stool specimens submitted for diagnosis of acute community-acquired diarrhea for O157 STEC and for Shiga toxin and ensure that isolates are sent to a public health laboratory for serotyping and subtyping.

AbstractClostridium perfringensis 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. perfringensoutbreaks 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. perfringenswas 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. perfringensillness 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. perfringensoccur 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.

Infection resulting from foodborne pathogens, including Escherichia coliO157:H7, is often associated with consumption of raw or undercooked ground beef. However, little is known about the frequency of ground beef consumption in the general population. The objective of this study was to describe patterns of self-reported ground beef and pink ground beef consumption using data from the 2006 through 2007 FoodNet Population Survey. From 1 July 2006 until 30 June 2007, residents of 10 FoodNet sites were contacted by telephone and asked about foods consumed within the previous week. The survey included questions regarding consumption of ground beef patties both inside and outside the home, the consumption of pink ground beef patties and other types of ground beef inside the home, and consumption of ground beef outside the home. Of 8,543 survey respondents, 75.3% reported consuming some type of ground beef in the home. Of respondents who ate ground beef patties in the home, 18.0% reported consuming pink ground beef. Consumption of ground beef was reported most frequently among men, persons with incomes from $40,000 to $75,000 per year, and persons with a high school or college education. Ground beef consumption was least often reported in adults ≥65 years of age. Men and persons with a graduate level education most commonly reported eating pink ground beef in the home. Reported consumption of ground beef and pink ground beef did not differ by season. Ground beef is a frequently consumed food item in the United States, and rates of consumption of pink ground beef have changed little since previous studies. The high rate of consumption of beef that has not been cooked sufficiently to kill pathogens makes pasteurization of ground beef an important consideration, especially for those individuals at high risk of complications from foodborne illnesses such as hemolytic uremic syndrome.

AbstractSalmonellaspecies cause an estimated 1.2 million infections per year in the United States, making it one of the most commonly reported enteric pathogens. In addition, Salmonellais an important cause of travel-associated diarrhea and enteric fever, a systemic illness commonly associated with Salmonellaserotypes Typhi and Paratyphi A. We reviewed cases of Salmonellainfection reported to the Centers for Disease Control and Prevention's (CDC) Foodborne Diseases Active Surveillance Network (FoodNet), a sentinel surveillance network, from 2004 to 2008. We compared travelers with Salmonellainfection to nontravelers with Salmonellainfection with respect to demographics, clinical characteristics, and serotypes. Among 23,712 case-patients with known travel status, 11% had traveled internationally in the 7 days before illness. Travelers with Salmonellainfection tended to be older (median age, 30 years) than nontravelers (median age, 24 years; p<0.0001), but were similar with respect to gender. The most common destinations reported were Mexico (38% of travel-associated infections), India (9%), Jamaica (7%), the Dominican Republic (4%), China (3%), and the Bahamas (2%). The proportions of travelers with Salmonellainfection hospitalized and with invasive disease were inversely related to the income level of the destination (p<0.0001). The most commonly reported serotypes, regardless of travel status, were Enteritidis (19% of cases), Typhimurium (14%), Newport (9%), and Javiana (5%). Among infections caused by these four serotypes, 22%, 6%, 5%, and 4%, respectively, were associated with travel. A high index of clinical suspicion for Salmonellainfection is appropriate when evaluating recent travelers, especially those who visited Africa, Asia, or Latin America.

AbstractClinical laboratory practices affect patient care and disease surveillance. It is recommended that laboratories routinely use both culture for Escherichia coliO157 and a method that detects Shiga toxins (Stx) to identify all Stx-producing E. coli(STEC) and that labs send broths or isolates to a public health laboratory. In 2007, we surveyed laboratories serving Foodborne Diseases Active Surveillance Network sites that performed on-site enteric disease diagnostic testing to determine their culture and nonculture-based testing practices for STEC identification. Our goals were to measure changes over time in laboratory practices and to compare reported practices with published recommendations. Overall, 89% of laboratories used only culture-based methods, 7% used only Stx enzyme immunoassay (EIA), and 4% used both Stx EIA and culture-based methods. Only 2% of laboratories reported simultaneous culture for O157 STEC and use of Stx EIA. The proportion that ever used Stx EIA increased from 6% in 2003 to 11% in 2007. The proportion that routinely tested all specimens with at least one method was 66% in 2003 versus 71% in 2007. Reference laboratories were less likely than others to test all specimens routinely by one or more of these methods (48% vs. 73%, p= 0.03). As of 2007, most laboratories complied with recommendations for O157 STEC testing by culture but not with recommendations for detection of non-O157 STEC. The proportion of laboratories that culture stools for O157 STEC has changed little since 2003, whereas testing for Stx has increased.

ABSTRACTClostridium difficileisolates from presumed community-associated infections (n= 92) were characterized by toxinotyping, pulsed-field gel electrophoresis, tcdCand cdtBPCR, and antimicrobial susceptibility. Nine toxinotypes (TOX) and 31 PFGE patterns were identified. TOX 0 (48, 52%), TOX III (18, 20%), and TOX V (9, 10%) were the most common; three isolates were nontoxigenic.

Clostridium difficile isolates from presumed community-associated infections (n = 92) were characterized by toxinotyping, pulsed-field gel electrophoresis, tcdC and cdtB PCR, and antimicrobial susceptibility. Nine toxinotypes (TOX) and 31 PFGE patterns were identified. TOX 0 (48, 52%), TOX III (18, 20%), and TOX V (9, 10%) were the most common; three isolates were nontoxigenic.

OBJECTIVES To determine the extent and scope of the outbreak of skin eruptions, to identify the causes of the acute skin diseases, to identify risk factors for the conditions, and to reduce the dermatologic morbidity among workers repairing buildings damaged by Hurricane Katrina and Hurricane Rita. DESIGN Retrospective cohort study. SETTING Military base in New Orleans, Louisiana. PARTICIPANTS Civilian construction workers living and working at a New Orleans military base between August 30, 2005, and October 3, 2005. Living conditions were mainly wooden huts and tents with limited sanitation facilities. MAIN OUTCOME MEASURES Survey of risk factors, physical examination, skin biopsy specimens, and environmental investigation of the occupational and domiciliary exposures. RESULTS Of 136 workers, 58 reported rash, yielding an attack rate of 42.6%. The following 4 clinical entities were diagnosed among 41 workers who had a physical examination (some had >1 diagnosis): 27 (65.9%) having papular urticaria, 8 (19.5%) having bacterial folliculitis, 6 (14.6%) having fiberglass dermatitis, and 2 (4.9%) having brachioradial photodermatitis. All diagnoses except brachioradial photodermatitis were confirmed by histopathologic examination. After adjusting for race/ethnicity and occupation, sleeping in previously flooded huts was statistically significantly (adjusted odds ratio, 20.4; 95% confidence interval, 5.9-70.2) associated with developing papular urticaria, the most common cause of rash in this cluster. CONCLUSIONS We identified 4 distinct clinical entities, although most workers were diagnosed as having papular urticaria. Huts previously flooded as a result of the hurricanes and used for sleeping may have harbored mites, a likely source of papular urticaria. To reduce the morbidity of hurricane-related skin diseases, we suggest avoiding flooded areas, fumigating with an acaricide, and wearing protective clothing.Arch Dermatol. 2007;143(11)1393-1398--

Recombinant West Nile virus envelope (E) protein was examined in enzyme-linked immunosorbent assay (ELISA) to detect antibodies elicited during West Nile virus infection. Horses (nine of 10) and humans (six of six) with confirmed West Nile virus infection had IgG and/or IgM antibodies to the E protein. Antibodies to the recombinant West Nile virus membrane and nonstructural 1 proteins were not detected in any of these sera. An E protein-based ELISA may aid in the serological diagnosis of West Nile virus infection.

Bike share has been hypothesized to be a phenomenon of social contagion. The current study describes the features of the social network of annual subscribers of the Citi Bike share system in NYC and the characteristics of those who ever took a trip with another member.

Ground beef has been implicated as a transmission vehicle in foodborne outbreaks of infection with pathogens such as Escherichia coliO157:H7 and Salmonella.During outbreak investigations, traceback of contaminated beef to the producing facility is often unsuccessful because of inadequate recordkeeping at retail establishments that grind beef products. We conducted a survey in three states participating in the Environmental Health Specialists Network to describe beef grinding and recordkeeping practices at retail establishments. In each establishment that maintained grinding logs, three randomly selected records were reviewed to determine whether important data elements for traceback investigations were recorded. One hundred twenty- five stores were surveyed, of which 60 (49%) kept grinding logs, including 54 (74%) of 73 chain stores and 6 (12%) of 51 independent stores. One hundred seventy-six grinding records from 61 stores were reviewed. Seventy-three percent of the records included the establishment code of the source beef, 72% included the grind date and time, and 59% included the lot number of the source beef. Seventy-five percent of records noted whether trimmings were included in grinds, and 57% documented cleanup activities. Only 39 (22%) records had all of these variables completed. Of stores that did not keep grinding logs, 40% were unaware of their purpose. To facilitate effective and efficient traceback investigations by regulatory agencies, retail establishments should maintain records more detailed and complete of all grinding activities.