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Problem/condition Salmonella, Shiga toxin-producing Escherichia coli (STEC), and Listeria monocytogenes are the leading causes of multistate foodborne disease outbreaks in the United States. Responding to multistate outbreaks quickly and effectively and applying lessons learned about outbreak sources, modes of transmission, and risk factors for infection can prevent additional outbreak-associated illnesses and save lives. This report summarizes the investigations of multistate outbreaks and possible outbreaks of Salmonella, STEC, and L. monocytogenes infections coordinated by CDC during the 2016 reporting period. Period covered 2016. An investigation was considered to have occurred in 2016 if it began during 2016 and ended on or before March 31, 2017, or if it began before January 1, 2016, and ended during March 31, 2016-March 31, 2017. Description of system CDC maintains a database of investigations of possible multistate foodborne and animal-contact outbreaks caused by Salmonella, STEC, and L. monocytogenes. Data were collected by local, state, and federal investigators during the detection, investigation and response, and control phases of the outbreak investigations. Additional data sources used for this report included PulseNet, the national molecular subtyping network based on isolates uploaded by local, state, and federal laboratories, and the Foodborne Disease Outbreak Surveillance System (FDOSS), which collects information from state, local, and territorial health departments and federal agencies about single-state and multistate foodborne disease outbreaks in the United States. Multistate outbreaks reported to FDOSS were linked using a unique outbreak identifier to obtain food category information when a confirmed or suspected food source was identified. Food categories were determined and assigned in FDOSS according to a classification scheme developed by CDC, the Food and Drug Administration (FDA), and the U.S. Department of Agriculture Food Safety and Inspection Service (FSIS) in the Interagency Food Safety Analytics Collaboration. A possible multistate outbreak was determined by expert judgment to be an outbreak if supporting data (e.g., temporal, geographic, demographic, dietary, travel, or food history) suggested a common source. A solved outbreak was an outbreak for which a specific kind of food or animal was implicated (i.e., confirmed or suspected) as the source. Outbreak-level variables included number of illnesses, hospitalizations, cases of hemolytic uremic syndrome (HUS), and deaths; the number of states with illnesses; date of isolation for the earliest and last cases; demographic data describing patients associated with a possible outbreak (e.g., age, sex, and state of residence); the types of data collected (i.e., epidemiologic, traceback, or laboratory); the outbreak source, mode of transmission, and exposure location; the name or brand of the source; whether the source was suspected or confirmed; whether a food was imported into the United States; the types of regulatory agencies involved; whether regulatory action was taken (and what type of action); whether an outbreak was publicly announced by CDC via website posting; beginning and end date of the investigation; and general comments about the investigation. The number of illnesses, hospitalizations, cases of HUS, and deaths were characterized by transmission mode, pathogen, outcome (i.e., unsolved, solved with suspected source, or solved with confirmed source), source, and food or animal category. Results During the 2016 reporting period, 230 possible multistate outbreaks were detected and 174 were investigated. A median of 24 possible outbreaks was under investigation per week, and investigations were open for a median of 37 days. Of these 174 possible outbreaks investigated, 56 were excluded from this analysis because they occurred in a single state, were linked to international travel, or were pseudo-outbreaks (e.g., a group of similar isolates resulting from laboratory media contamination rather than infection in patients). Of the remaining 118 possible multistate outbreaks, 50 were determined to be outbreaks and 39 were solved (18 with a confirmed food source, 10 with a suspected food source, 10 with a confirmed animal source, and one with a suspected animal source). Sprouts were the most commonly implicated food category in solved multistate foodborne outbreaks (five). Chicken was the source of the most foodborne outbreak-related illnesses (134). Three outbreaks involved novel food-pathogen pairs: flour and STEC, frozen vegetables and L. monocytogenes, and bagged salad and L. monocytogenes. Eleven outbreaks were attributed to contact with animals (10 attributed to contact with backyard poultry and one to small turtles). Thirteen of 18 multistate foodborne disease outbreaks with confirmed sources resulted in product action, including 10 outbreaks with recalls, two with market withdrawals, and one with an FSIS public health alert. Twenty outbreaks, including 11 foodborne and nine animal-contact outbreaks, were announced to the public by CDC via its website, Facebook, and Twitter. These announcements resulted in approximately 910,000 webpage views, 55,000 likes, 66,000 shares, and 5,800 retweets. Interpretation During the 2016 reporting period, investigations of possible multistate outbreaks occurred frequently, were resource intensive, and required a median of 37 days of investigation. Fewer than half (42%) of the 118 possible outbreaks investigated were determined to have sufficient data to meet the definition of a multistate outbreak. Moreover, of the 50 outbreaks with sufficient data, approximately three fourths were solved. Public health action Close collaboration among CDC, FDA, FSIS and state and local health and agriculture partners is central to successful outbreak investigations. Identification of novel outbreak sources and trends in sources provides insights into gaps in food safety and safe handling of animals, which helps focus prevention strategies. Summarizing investigations of possible multistate outbreaks can provide insights into the investigative process, improve future investigations, and help prevent illnesses. Although identifying and investigating possible multistate outbreaks require substantial resources and investment in public health infrastructure, they are important in determining outbreak sources and implementing prevention and control measures.

Campylobacter causes an estimated 1.3 million diarrheal illnesses in the United States annually (1). In August 2017, the Florida Department of Health notified CDC of six Campylobacter jejuni infections linked to company A, a national pet store chain based in Ohio. CDC examined whole-genome sequencing (WGS) data and identified six isolates from company A puppies in Florida that were highly related to an isolate from a company A customer in Ohio. This information prompted a multistate investigation by local and state health and agriculture departments and CDC to identify the outbreak source and prevent additional illness. Health officials from six states visited pet stores to collect puppy fecal samples, antibiotic records, and traceback information. Nationally, 118 persons, including 29 pet store employees, in 18 states were identified with illness onset during January 5, 2016-February 4, 2018. In total, six pet store companies were linked to the outbreak. Outbreak isolates were resistant by antibiotic susceptibility testing to all antibiotics commonly used to treat Campylobacter infections, including macrolides and quinolones. Store record reviews revealed that among 149 investigated puppies, 142 (95%) received one or more courses of antibiotics, raising concern that antibiotic use might have led to development of resistance. Public health authorities issued infection prevention recommendations to affected pet stores and recommendations for testing puppies to veterinarians. This outbreak demonstrates that puppies can be a source of multidrug-resistant Campylobacter infections in humans, warranting a closer look at antimicrobial use in the commercial dog industry.

Background During the 2014-2015 US influenza season, 320 cases of non-mumps parotitis (NMP) among residents of 21 states were reported to the Centers for Disease Control and Prevention (CDC). We conducted an epidemiologic and laboratory investigation to determine viral etiologies and clinical features of NMP during this unusually large occurrence. Methods NMP was defined as acute parotitis or other salivary gland swelling of >2 days duration in a person with a mumps- negative laboratory result. Using a standardized questionnaire, we collected demographic and clinical information. Buccal samples were tested at the CDC for selected viruses, including mumps, influenza, human parainfluenza viruses (HPIVs) 1-4, adenoviruses, cytomegalovirus, Epstein-Barr virus (EBV), herpes simplex viruses (HSVs) 1 and 2, and human herpes viruses (HHVs) 6A and 6B. Results Among the 320 patients, 65% were male, median age was 14.5 years (range, 0-90), and 67% reported unilateral parotitis. Commonly reported symptoms included sore throat (55%) and fever (48%). Viruses were detected in 210 (71%) of 294 NMP patients with adequate samples for testing, ≥2 viruses were detected in 37 samples, and 248 total virus detections were made among all samples. These included 156 influenza A(H3N2), 42 HHV6B, 32 EBV, 8 HPIV2, 2 HPIV3, 3 adenovirus, 4 HSV-1, and 1 HSV-2. Influenza A(H3N2), HHV6B, and EBV were the most frequently codetected viruses. Conclusions Our findings suggest that, in addition to mumps, clinicians should consider respiratory viral (influenza) and herpes viral etiologies for parotitis, particularly among patients without epidemiologic links to mumps cases or outbreaks.

Background Few data exist describing healthcare-seeking behaviors among persons with influenza-like illness (ILI) or adherence to influenza antiviral treatment recommendations. Methods We analyzed adult responses to the Behavioral Risk Factor Surveillance System in 31 states and the District of Columbia (DC) and pediatric responses in 25 states and DC for January-April 2011 by demographics and underlying health conditions. Results Among 75 088 adult and 15 649 child respondents, 8.9% and 33.9%, respectively, reported ILI. ILI was more frequent among adults with asthma (16%), chronic obstruction pulmonary disease (COPD; 26%), diabetes (12%), heart disease (19%), kidney disease (16%), or obesity (11%). Forty-five percent of adults and 57% of children sought healthcare for ILI. Thirty-five percent of adults sought care ≤ 2 days after ILI onset. Seeking care ≤ 2 days was more frequent among adults with COPD (48%) or heart disease (55%). Among adults with a self-reported physician diagnosis of influenza, 34% received treatment with antiviral medications. The only underlying health condition with a higher rate of treatment was diabetes (46%). Conclusions Adults with underlying health conditions were more likely to report ILI, but the majority did not seek care promptly, missing opportunities for early influenza antiviral treatment.

BACKGROUND: In 2017, we conducted a multistate investigation to determine the source of an outbreak of Shiga toxin-producing Escherichia coli (STEC) O157:H7 infections, which occurred primarily in children. METHODS: We defined a case as infection with an outbreak strain of STEC O157:H7 with illness onset between January 1 and April 30, 2017. Case-patients were interviewed to identify common exposures. Traceback and facility investigations were conducted; food samples were tested for STEC. RESULTS: We identified 32 cases from 12 states. Twenty-six (81%) cases occurred in children

In August 2011, one of the earliest cases of influenza A(H3N2) variant [A(H3N2)v] virus infection was hospitalized with severe illness. To investigate the potential for healthcare-associated transmission of influenza A(H3N2)v, we evaluated both healthcare providers and patient contacts of the case. We found that healthcare-associated transmission was unlikely.

Objective.To assess the knowledge, attitudes, and practices of infection control among staff in a residential care facility for children and young adults with neurologic and neurodevelopmental conditions.Design.Self-administered survey.Setting.Residential care facility (facility A).Participants.Facility A staff (N = 200).Methods.We distributed a survey to staff at facility A. We classified staff with direct care responsibilities as clinical (ie, physicians, nurses, and therapists) or nonclinical (ie, habilitation assistants, volunteers, and teachers) and used X2 tests to measure differences between staff agreement to questions.Results.Of 248 surveys distributed, 200 (81%) were completed; median respondent age was 36 years; 85% were female; and 151 were direct care staff (50 clinical, 101 nonclinical). Among direct care staff respondents, 86% agreed they could identify residents with respiratory symptoms, 70% stayed home from work when ill with respiratory infection, 64% agreed that facility administration encouraged them to stay home when ill with respiratory infection, and 72% reported that ill residents with respiratory infections were separated from well residents. Clinical and nonclinical staff differed in agreement about using waterless hand gel as a substitute for handwashing (96% vs 78%; P = .005) and whether handwashing was done after touching residents (92% vs 75%; P = .04).Conclusions.Respondents' knowledge, attitudes, and practices regarding infection control could be improved, especially among nonclinical staff. Facilities caring for children and young adults with neurologic and neurodevelopmental conditions should encourage adherence to infection control best practices among all staff having direct contact with residents.

Background Because pneumococcal pneumonia was prevalent during previous influenza pandemics, we evaluated invasive pneumococcal pneumonia (IPP) rates during the 2009 influenza A(H1N1) pandemic. Methods We identified laboratory-confirmed, influenza-associated hospitalizations and IPP cases (pneumococcus isolated from normally sterile sites with discharge diagnoses of pneumonia) using active, population-based surveillance in the United States. We compared IPP rates during peak pandemic months (April 2009-March 2010) to mean IPP rates in nonpandemic years (April 2004-March 2009) and, using Poisson models, to 2006-2008 influenza seasons. Results Higher IPP rates occurred during the peak pandemic month compared to nonpandemic periods in 5-24 (IPP rate per 10 million: 48 vs 9 (95% confidence interval [CI], 5-13), 25-49 (74 vs 53 [CI, 41-65]), 50-64 (188 vs 114 [CI, 85-143]), and ≥65-year-olds (229 vs 187 [CI, 159-216]). In the models with seasonal influenza rates included, observed IPP rates during the pandemic peak were within the predicted 95% CIs, suggesting this increase was not greater than observed with seasonal influenza. Conclusions The recent influenza pandemic likely resulted in an out-of-season IPP peak among persons ≥5 years. The IPP peak's magnitude was similar to that seen during seasonal influenza epidemics.

Such strains are uncommon causes of severe human disease but may be increasing in incidence., Clostridium difficile is a recognized pathogen in neonatal pigs and may contribute to enteritis in calves. Toxinotype V strains have been rare causes of human C. difficile–associated disease (CDAD). We examined toxinotype V in human disease, the genetic relationship of animal and human toxinotype V strains, and in vitro toxin production of these strains. From 2001 through 2006, 8 (1.3%) of 620 patient isolates were identified as toxinotype V; before 2001, 7 (

Background Nephrogenic systemic fibrosis (NSF) is a newly described disorder occurring in persons with renal failure. Gadolinium-based contrast used in magnetic resonance imaging (MRI) has been suggested as a cause. A cluster of patients with NSF was investigated to identify risk factors. Limited preliminary findings from this investigation were presented in the Morbidity and Mortality Weekly Report . Study Design Matched case-control. Setting & Participants Dialysis patients with and without a diagnosis of NSF treated at an academic medical center. Predictor Exposure to gadolinium-based contrast. Outcomes & Measurements Laboratory and clinical characteristics of NSF. Results 19 of 28 cases identified at the hospital from December 2002 to August 2006 met inclusion criteria and were matched to 57 controls. In univariate analysis, receipt of gadolinium-containing MRI contrast in the preceding year (odds ratio [OR], 7.99; 95% confidence interval, 2.22 to 28.8) was associated with NSF; the measure of association increased as cumulative dose increased. Gadodiamide exposure (OR, 9.83; 95% confidence interval, 2.09 to 46.2) was associated more strongly with NSF than gadoversetamide (OR, 1.82; 95% confidence interval, 0.33 to 10.2). Although not statistically significant, cases were more likely than controls to have undergone primarily peritoneal dialysis in the preceding 6 months. There was no significant difference in receipt of high-dose recombinant erythropoietin between cases and controls. In multivariable analysis, gadolinium contrast exposure (OR, 8.97; 95% confidence interval, 1.28 to 63.0) remained significantly associated with NSF. Limitations Retrospective design, small sample size, inability to completely evaluate erythropoietin. Conclusions Receipt of gadolinium-containing MRI contrast is associated with NSF in a dose-dependent manner. The risk associated with gadolinium may differ by contrast agent and dialysis modality. Use of gadolinium-based contrast agents should be avoided when possible in patients with renal failure.

Between March and May 2006, a Texas hospital identified five Mycobacterium mucogenicum bloodstream infections among hospitalized oncology patients using fluorescence high-performance liquid chromatography analysis of mycolic acids. Isolates from blood cultures were compared to 16 isolates from environmental sites or water associated with this ward. These isolates were further characterized by hsp65 , 16S rRNA, and rpoB gene sequencing, hsp65 PCR restriction analysis, and molecular typing methods, including repetitive element PCR, random amplified polymorphic DNA PCR, and pulsed-field gel electrophoresis (PFGE) of large restriction fragments. Three of five patient isolates were confirmed as M. mucogenicum and were in a single cluster as determined by all identification and typing methods. The remaining two patient isolates were identified as different strains of Mycobacterium phocaicum by rpoB sequence analysis. One of these matched an environmental isolate from a swab of a hand shower in the patient's room, while none of the clinical isolates of M. mucogenicum matched environmental strains. Among the other 15 environmental isolates, 11 were identified as M. mucogenicum and 4 as M. phocaicum strains, all of which were unrelated by typing methods. Although the 16S rRNA gene sequences matched for all 14 M. mucogenicum isolates, there were two each of the hsp65 and rpoB sequevars, seven PCR typing patterns, and 12 PFGE patterns. Among the seven M. phocaicum isolates were three 16S rRNA sequevars, two hsp65 sequevars, two rpoB sequevars, six PCR typing patterns, and six PFGE patterns. This outbreak represents the first case of catheter-associated bacteremia caused by M. phocaicum and the first report of clinical isolates from a U.S. hospital. The investigation highlights important differences in the available typing methods for mycobacteria and demonstrates the genetic diversity of these organisms even within narrow confines of time and space.

OBJECTIVES. In August 2005, the Centers for Disease Control and Prevention was notified of a Ralstonia species outbreak among pediatric patients receiving supplemental oxygen therapy with the Vapotherm 2000i (Vapotherm, Inc, Stevensville, MD). The Vapotherm 2000i is a reusable medical device that was used in >900 hospitals in the United States in 2005. Ralstonia are waterborne bacilli that have been implicated in hospital-acquired infections. We initiated an investigation to determine the source of the outbreak and implement infection control and prevention measures. PATIENTS AND METHODS. We performed a case-control study at 1 hospital and conducted national case findings to obtain clinical and environmental samples for laboratory analysis. Case-patients had health care–acquired Ralstonia colonization or infection. Isolates were compared by using pulsed-field gel electrophoresis. We tested manufacturer-recommended disinfection protocols for the Vapotherm 2000i under simulated-use conditions. RESULTS. Case-patients at the hospital (n = 5) were more likely to have received Vapotherm therapy than controls. Nationally, Ralstonia mannitolilytica was confirmed in 38 patients (aged 5 days to 7 years); 35 (92%) of the patients were exposed to the Vapotherm 2000i before recovery of the organism. Pulsed-field gel electrophoresis showed related R mannitolilytica strains from isolates sent from 18 hospitals in 12 states. A Vapotherm machine reprocessed with a protocol proposed by the manufacturer grew Ralstonia spp after 7 days of simulated use. In December 2005, Vapotherm recalled the 2000i. CONCLUSIONS. Our findings suggest intrinsic contamination of Vapotherm devices with Ralstonia spp. New medical devices may provide therapy equivalent to current devices yet pose novel reprocessing challenges.

Background Influenza and pneumonia combined are the leading causes of death due to infectious diseases in the United States. We describe factors associated with pneumonia among adults hospitalized with influenza. Methods Through the Emerging Infections Program, we identified adults ≥ 18 years, who were hospitalized with laboratory-confirmed influenza during October 2005 through April 2008, and had a chest radiograph (CXR) performed. Pneumonia was defined as the presence of a CXR infiltrate and either an ICD-9-CM code or discharge summary diagnosis of pneumonia. Results Among 4,765 adults hospitalized with influenza, 1392 (29 %) had pneumonia. In multivariable analysis, factors associated with pneumonia included: age ≥ 75 years, adjusted odds ratio (AOR) 1.27 (95 % confidence interval 1.10–1.46), white race AOR 1.24 (1.03–1.49), nursing home residence AOR 1.37 (1.14–1.66), chronic lung disease AOR 1.37 (1.18–1.59), immunosuppression AOR 1.45 (1.19–1.78), and asthma AOR 0.76 (0.62–0.92). Patients with pneumonia were significantly more likely to require intensive care unit (ICU) admission (27 % vs. 10 %), mechanical ventilation (18 % vs. 5 %), and to die (9 % vs. 2 %). Conclusions Pneumonia was present in nearly one-third of adults hospitalized with influenza and was associated with ICU admission and death. Among patients hospitalized with influenza, older patients and those with certain underlying conditions are more likely to have pneumonia. Pneumonia is common among adults hospitalized with influenza and should be evaluated and treated promptly. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1004-y) contains supplementary material, which is available to authorized users.

Background Variant influenza virus infections are rare but may have pandemic potential if person-to-person transmission is efficient. We describe the epidemiology of a multistate outbreak of an influenza A(H3N2) variant virus (H3N2v) first identified in 2011. Methods We identified laboratory-confirmed cases of H3N2v and used a standard case report form to characterize illness and exposures. We considered illness to result from person-to-person H3N2v transmission if swine contact was not identified within 4 days prior to illness onset. Results From 9 July to 7 September 2012, we identified 306 cases of H3N2v in 10 states. The median age of all patients was 7 years. Commonly reported signs and symptoms included fever (98%), cough (85%), and fatigue (83%). Sixteen patients (5.2%) were hospitalized, and 1 fatal case was identified. The majority of those infected reported agricultural fair attendance (93%) and/or contact with swine (95%) prior to illness. We identified 15 cases of possible person-to-person transmission of H3N2v. Viruses recovered from patients were 93%-100% identical and similar to viruses recovered from previous cases of H3N2v. All H3N2v viruses examined were susceptible to oseltamivir and zanamivir and resistant to adamantane antiviral medications. Conclusions In a large outbreak of variant influenza, the majority of infected persons reported exposures, suggesting that swine contact at an agricultural fair was a risk for H3N2v infection. We identified limited person-to-person H3N2v virus transmission, but found no evidence of efficient or sustained person-to-person transmission. Fair managers and attendees should be aware of the risk of swine-to-human transmission of influenza viruses in these settings.

BACKGROUND Thirteen human infections with an influenza A(H3N2) variant (H3N2v) virus containing a combination of gene segments not previously associated with human illness were identified in the United States from August 2011 to April 2012. Because laboratory confirmation of influenza virus infection is only performed for a minority of ill persons and routine clinical tests may not identify H3N2v virus, the count of laboratory-confirmed H3N2v virus infections underestimates the true burden of illness. METHODS To account for this underascertainment, we adapted a multiplier model created at the beginning of the influenza A(H1N1) 2009 pandemic to estimate the true burden of H3N2v illness. Data to inform each of these parameters came from the literature and from special projects conducted during the 2009 H1N1 pandemic and the 2010-2011 influenza season. The multipliers were calculated as the simple inverses of the proportions at each step, and we accounted for variability and uncertainty in model parameters by using a probabilistic or Monte Carlo approach. RESULTS We estimate that the median multiplier for children was 200 (90% range, 115-369) and for adults was 255 (90% range, 152-479) and that 2055 (90% range, 1187-3800) illnesses from H3N2v virus infections may have occurred from August 2011 to April 2012, suggesting that the new virus was more widespread than previously thought. CONCLUSIONS Illness from this variant influenza virus was more frequent than previously thought. Continued surveillance is needed to ensure timely detection and response to H3N2v virus infections.

Seasonal influenza is responsible for more than 200,000 hospitalizations each year in the United States. Although hospital-onset (HO) influenza contributes to morbidity and mortality among these patients, little is known about its overall epidemiology.We describe patients with HO influenza in the United States during the 2010-2011 influenza season and compare them with community-onset (CO) cases to better understand factors associated with illness.We identified laboratory-confirmed, influenza-related hospitalizations using the Influenza Hospitalization Surveillance Network (FluSurv-NET), a network that conducts population-based surveillance in 16 states. CO cases had laboratory confirmation ≤ 3 days after hospital admission; HO cases had laboratory confirmation3 days after admission.We identified 172 (2.8%) HO cases among a total of 6,171 influenza-positive hospitalizations. HO and CO cases did not differ by age (P = .22), sex (P = .29), or race (P = .25). Chronic medical conditions were more common in HO cases (89%) compared with CO cases (78%) (P.01), and a greater proportion of HO cases (42%) than CO cases (17%) were admitted to the intensive care unit (P.01). The median length of stay after influenza diagnosis of HO cases (7.5 days) was greater than that of CO cases (3 days) (P.01).HO cases had greater length of stay and were more likely to be admitted to the intensive care unit or die compared with CO cases. HO influenza may play a role in the clinical outcome of hospitalized patients, particularly among those with chronic medical conditions.

SUMMARYWe analysed a cross-sectional telephone survey of U.S. adults to assess the impact of selected characteristics on healthcare-seeking behaviours and treatment practices of people with influenza-like illness (ILI) from September 2009 to March 2010. Of 216 431 respondents, 8·1% reported ILI. After adjusting for selected characteristics, respondents aged 18–64 years with the following factors were more likely to report ILI: a diagnosis of asthma [adjusted odds ratio (aOR) 1·88, 95% CI 1·67–2·13] or heart disease (aOR 1·41, 95% CI 1·17–1·70), being disabled (aOR 1·75, 95% CI 1·57–1·96), and reporting financial barriers to healthcare access (aOR 1·63, 95% CI 1·45–1·82). Similar associations were seen in respondents aged ⩾65 years. Forty percent of respondents with ILI sought healthcare, and 14% who sought healthcare reported receiving influenza antiviral treatment. Treatment was not more frequent in patients with high-risk conditions, except those aged 18–64 years with heart disease (aOR 1·90, 95% CI 1·03–3·51). Of patients at high risk for influenza complications, self-reported ILI was greater but receipt of antiviral treatment was not, despite guidelines recommending their use in this population.

Avoiding or limiting contact with swine at agricultural events may help prevent A(H3N2)v virus infections in such settings., During August 2011, influenza A (H3N2) variant [A(H3N2)v] virus infection developed in a child who attended an agricultural fair in Pennsylvania, USA; the virus resulted from reassortment of a swine influenza virus with influenza A(H1N1)pdm09. We interviewed fair attendees and conducted a retrospective cohort study among members of an agricultural club who attended the fair. Probable and confirmed cases of A(H3N2)v virus infection were defined by serology and genomic sequencing results, respectively. We identified 82 suspected, 4 probable, and 3 confirmed case-patients who attended the fair. Among 127 cohort study members, the risk for suspected case status increased as swine exposure increased from none (4%; referent) to visiting swine exhibits (8%; relative risk 2.1; 95% CI 0.2–53.4) to touching swine (16%; relative risk 4.4; 95% CI 0.8–116.3). Fairs may be venues for zoonotic transmission of viruses with epidemic potential; thus, health officials should investigate respiratory illness outbreaks associated with agricultural events.

Objectives. The purpose of our study was to more accurately characterize people reporting influenza-like illness (ILI) and evaluate trends in health care seeking and influenza diagnosis and treatment during the 2009 influenza pandemic. Methods. From September 2009 to March 2010, we ascertained ILI (fever with cough or sore throat), health care seeking, and clinical diagnosis and treatment of influenza with influenza antiviral drugs among adults in 51 jurisdictions, and ILI and health care seeking among children in 41 jurisdictions. Results. Among 216 431 adults and 43 511 children, 8.1% and 28.4% reported ILI, respectively. ILI peaked during November interviews and was higher among young people and American Indian/Alaska Natives. Of those with ILI, 40% of adults and 56% of children reported seeking health care; 26% of adults who sought care reported receiving a diagnosis of influenza. Of adults reporting an influenza diagnosis, 36% were treated with influenza antiviral drugs; treatment was highest among adults aged 18 to 49 years. Conclusions. Analysis of ILI data from the Behavioral Risk Factor Surveillance System enabled a better understanding of the factors associated with self-reported ILI, health care seeking, and clinical influenza diagnosis and treatment, and will help inform year-to-year influenza trends.

Please cite this paper as: Jhung et al. (2011) Preliminary results of 2009 pandemic influenza surveillance in the United States using the Aggregate Hospitalization and Death Reporting Activity. Influenza and Other Respiratory Viruses 5(5), 321–327. Background To augment established influenza surveillance systems in the United States, the Centers for Disease Control and Prevention and the Council of State and Territorial Epidemiologists implemented the Aggregate Hospitalization and Death Reporting Activity (AHDRA) in August 2009. The AHDRA was designed to meet increased demands for timely and detailed information describing illness severity during the 2009 H1N1 influenza A (pH1N1) pandemic response. Objectives We describe the implementation of AHDRA and provide preliminary results from this new surveillance activity. Methods All 50 US states were asked to report influenza‐associated hospitalizations and deaths to AHDRA each week using either a laboratory‐confirmed or syndromic surveillance definition. Aggregate counts were used to calculate age‐specific weekly and cumulative rates per 100 000, and laboratory‐confirmed reports were used to estimate the age distribution of pH1N1 influenza‐associated hospitalizations and deaths. Results From August 30, 2009, through April 6, 2010, AHDRA identified 41 689 laboratory‐confirmed influenza‐associated hospitalizations and 2096 laboratory‐confirmed influenza‐associated deaths. Aggregate Hospitalization and Death Reporting Activity rates peaked earlier than hospitalization and death rates seen in previous influenza seasons with other surveillance systems, and the age distribution of cases revealed a tendency for hospitalizations and deaths to occur in persons

In May 2009, we investigated a hospital outbreak of pandemic H1N1 (pH1N1) infection among healthcare personnel (HCP). Thirteen (65%) of 20 HCP with pH1N1 infection had healthcare-associated cases, which were primarily attributed to transmission among HCP. Eleven (55%) of HCP with pH1N1 infection worked for 1 day or more after the onset of illness. Personnel working with mild illness may have contributed to transmission among HCP.

To calculate the burden of 2009 pandemic influenza A (pH1N1) in the United States, we extrapolated from the Centers for Disease Control and Prevention's Emerging Infections Program laboratory-confirmed hospitalizations across the entire United States, and then corrected for underreporting. From 12 April 2009 to 10 April 2010, we estimate that approximately 60.8 million cases (range: 43.3-89.3 million), 274,304 hospitalizations (195,086-402,719), and 12,469 deaths (8868-18,306) occurred in the United States due to pH1N1. Eighty-seven percent of deaths occurred in those under 65 years of age with children and working adults having risks of hospitalization and death 4 to 7 times and 8 to 12 times greater, respectively, than estimates of impact due to seasonal influenza covering the years 1976-2001. In our study, adults 65 years of age or older were found to have rates of hospitalization and death that were up to 75% and 81%, respectively, lower than seasonal influenza. These results confirm the necessity of a concerted public health response to pH1N1.

After identification of pandemic 2009 influenza (pH1N1) in the United States, the Centers for Disease Control and Prevention (CDC) worked with state and local health officials to characterize infections among healthcare personnel (HCP). Detailed information, including likely routes of exposure, was reported for 70 HCP from 22 states. Thirty-five cases (50%) were classified as being infected in healthcare settings, 18 cases (26%) were considered to have been infected in community settings, and no definitive source was identified for 17 cases (24%). Of the 23 HCP infected by ill patients, only 20% reported using an N95 respirator or surgical mask during all encounters and more than half worked in outpatient clinics. In addition to community transmission, likely patient-to-HCP and HCP-to-HCP transmission were identified in healthcare settings, highlighting the need for comprehensive infection control strategies including administration of influenza vaccine, appropriate management of ill HCP, and adherence to infection control precautions.

Background: Adverse drug events (ADEs) are an important cause of patient injury. Although most medications are prescribed and used in the outpatient setting, prevention efforts focus on the inpatient setting, partly because of limited data on outpatient events. We describe and evaluate a new system for surveillance of outpatient ADEs treated in hospital emergency departments (EDs). Methods: We used guidelines for evaluating public health surveillance systems, developed by the Centers for Disease Control and Prevention, to assess the performance of the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project (NEISS-CADES) from January 1, 2004 through December 31, 2004. Results: NEISS-CADES is a nationally representative surveillance system that identifies ADEs using ED clinical records. Of 10,383 reports in 2004, 100% listed patient age, sex, and disposition; 98% listed the implicated drugs. A 6-hospital evaluation of data quality, completeness, and other system attributes showed that NEISS-CADES data accurately reflected clinical records with respect to patient age and sex (100%), primary diagnosis (93%), implicated drugs (93%), primary treatments (80%), and diagnostic testing (61%). Sensitivity of case identification was estimated to be at least 0.33; estimated positive predictive value was 0.92. Data collection does not require additional work by clinical staff and has been well accepted by participating institutions. Conclusions: NEISS-CADES provides detailed and timely information on outpatient ADEs treated in EDs and identifies specific drugs and circumstances associated with these injuries. Findings from NEISS-CADES can help design and prioritize patient safety interventions for outpatient ADEs.

To the Editor: On February 9, 2006, a Food and Drug Administration (FDA) advisory panel recommended that stimulant drugs prescribed for attention deficit–hyperactivity disorder (ADHD) carry warnings about the potential for an increased risk of sudden death and cardiovascular problems such as hypertension, cardiac arrest, arrhythmias, and stroke.1 Although stimulant drugs are known to cause adverse cardiovascular effects,2,3 little is known about the incidence and type of adverse events in the community setting. To explore this issue, we examined adverse events from stimulant medications prescribed for the treatment of ADHD. We used data from the National Electronic Injury Surveillance . . .

In January 2017, CDC identified a cluster of Salmonella enterica serotype Newport infections with isolates sharing an indistinguishable pulsed-field gel electrophoresis (PFGE) pattern, JJPX01.0010 (pattern 10), through PulseNet, the national molecular subtyping network for foodborne disease surveillance. This report summarizes the investigation by CDC, state and local health and agriculture departments, and the U.S. Department of Agriculture's Food Safety and Inspection Service (USDA-FSIS) and discusses the possible role of dairy cows as a reservoir for strains of Salmonella that persistently cause human illness. This investigation combined epidemiologic and whole genome sequencing (WGS) data to link the outbreak to contaminated ground beef; dairy cows were hypothesized to be the ultimate source of Salmonella contamination.