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We describe the epidemiology of COVID-19 exposure, preceding illness, and SARS-CoV-2 testing in a large population with MIS-C during the first 18 months of the COVID-19 pandemic. The majority of cases had exposure, preceding illness, or positive SARS-CoV-2 testing 4-8 weeks before MIS-C onset. Serology can help establish epidemiological link to COVID-19 when past infection or exposure are unknown.

Background The prevalence of current or past coronavirus disease 2019 in skilled nursing facility (SNF) residents is unknown because of asymptomatic infection and constrained testing capacity early in the pandemic. We conducted a seroprevalence survey to determine a more comprehensive prevalence of past coronavirus disease 2019 in Los Angeles County SNF residents and staff members. Methods We recruited participants from 24 facilities; participants were requested to submit a nasopharyngeal swab sample for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) testing and a serum sample for detection of SARS-CoV-2 antibodies. All participants were cross-referenced with our surveillance database to identify persons with prior positive SARS-CoV-2 results. Results From 18 August to 24 September 2020, we enrolled 3305 participants (1340 residents and 1965 staff members). Among 856 residents providing serum samples, 362 (42%) had current or past SARS-CoV-2 infection. Of the 346 serology-positive residents, 199 (58%) did not have a documented prior positive SARS-CoV-2 PCR result. Among 1806 staff members providing serum, 454 (25%) had current or past SARS-CoV-2 infection. Of the 447 serology-positive staff members, 353 (79%) did not have a documented prior positive SARS-CoV-2 PCR result. Conclusions Past testing practices and policies missed a substantial number of SARS-CoV-2 infections in SNF residents and staff members.

Prompt and accurate detection of SARS-CoV-2, the virus that causes COVID-19, has been important during public health responses for containing the spread of COVID-19, including in hospital settings (1-3). In vitro diagnostic nucleic acid amplification tests (NAAT), such as real-time reverse transcription-polymerase chain reaction (RT-PCR) can be expensive, have relatively long turnaround times, and require experienced laboratory personnel.* Antigen detection tests can be rapidly and more easily performed and are less expensive. The performance† of antigen detection tests, compared with that of NAATs, is an area of interest for the rapid diagnosis of SARS-CoV-2 infection. The Quidel Sofia 2 SARS Antigen Fluorescent Immunoassay (FIA) (Quidel Corporation) received Food and Drug Administration Emergency Use Authorization for use in symptomatic patients within 5 days of symptom onset (4). The reported test positive percentage agreement§ between this test and an RT-PCR test result is 96.7% (95% confidence interval [CI] = 83.3%-99.4%), and the negative percentage agreement is 100.0% (95% CI = 97.9%-100.0%) in symptomatic patients.¶ However, performance in asymptomatic persons in a university setting has shown lower sensitivity (5); assessment of performance in a clinical setting is ongoing. Data collected during June 30-August 31, 2020, were analyzed to compare antigen test performance with that of RT-PCR in a hospital setting. Among 1,732 paired samples from asymptomatic patients, the antigen test sensitivity was 60.5%, and specificity was 99.5% when compared with RT-PCR. Among 307 symptomatic persons, sensitivity and specificity were 72.1% and 98.7%, respectively. Health care providers must remain aware of the lower sensitivity of this test among asymptomatic and symptomatic persons and consider confirmatory NAAT testing in high-prevalence settings because a false-negative result might lead to failures in infection control and prevention practices and cause delays in diagnosis, isolation, and treatment.

Worksites with on-site operations have experienced coronavirus disease (COVID-19) outbreaks. We analyzed data for 698 nonresidential, nonhealthcare worksite COVID-19 outbreaks investigated in Los Angeles County, California, USA, during March 19, 2020‒September 30, 2020, by using North American Industry Classification System sectors and subsectors. Nearly 60% of these outbreaks occurred in 3 sectors: manufacturing (n = 184, 26.4%), retail trade (n = 137, 19.6%), and transportation and warehousing (n = 73, 10.5%). The largest number of outbreaks and largest number and highest incidence rate of outbreak-associated cases occurred in manufacturing. Furthermore, 7 of the 10 industry subsectors with the highest incidence rates were within manufacturing. Approximately 70% of outbreak-associated case-patients reported Hispanic ethnicity. Facilities employing more on-site staff had larger and longer outbreaks. Identification of highly affected industry sectors and subsectors is necessary for targeted public health planning, outreach, and response, including ensuring vaccine access, to reduce burden of COVID-19 in vulnerable workers.

In March 2018, the US Food and Drug Administration (FDA), US Centers for Disease Control and Prevention, California Department of Public Health, Los Angeles County Department of Public Health and Pennsylvania Department of Health initiated an investigation of an outbreak of Burkholderia cepacia complex (Bcc) infections. Sixty infections were identified in California, New Jersey, Pennsylvania, Maine, Nevada and Ohio. The infections were linked to a no-rinse cleansing foam product (NRCFP), produced by Manufacturer A, used for skin care of patients in healthcare settings. FDA inspected Manufacturer A's production facility (manufacturing site of over-the-counter drugs and cosmetics), reviewed production records and collected product and environmental samples for analysis. FDA's inspection found poor manufacturing practices. Analysis by pulsed-field gel electrophoresis confirmed a match between NRCFP samples and clinical isolates. Manufacturer A conducted extensive recalls, FDA issued a warning letter citing the manufacturer's inadequate manufacturing practices, and federal, state and local partners issued public communications to advise patients, pharmacies, other healthcare providers and healthcare facilities to stop using the recalled NRCFP. This investigation highlighted the importance of following appropriate manufacturing practices to minimize microbial contamination of cosmetic products, especially if intended for use in healthcare settings.

The objective of the Los Angeles County, California (LAC), health care personnel (HCP) influenza vaccination improvement intervention was to increase HCP influenza vaccination coverage during the 2016–2017 influenza season via targeted outreach to LAC acute care hospitals. We selected 13 facilities for intervention and received tailored recommendations from a menu of evidence-based practices. Following the season, each hospital in the intervention group experienced a significant increase in vaccination coverage, which increased the LAC countywide average for all hospitals by 5%, from 74% to 79%.

Across the world, healthcare workers (HCW) are at a greater risk of infection by coronavirus disease 2019 (COVID-19) due to the nature of their work. The Los Angeles County Department of Public Health (LAC DPH) set out to understand the impact of COVID-19 on healthcare facilities and HCWs by tracking and analyzing data from case-patient interviews of HCWs. As of 31 May, over 3 months into the pandemic, nearly 5500 positive HCWs were reported to LAC DPH, representing 9.6% of all cases. Cases reported working in 27 different setting types, including outpatient medical offices, correctional facilities, emergency medical services, and so forth, with the highest proportion from long-term care facilities (46.6%) and hospitals (27.7%). Case patients included both clinical and nonclinical roles, with nearly half (49.4%) of positive HCWs being nurses. Over two-thirds of HCWs (68.6%) worked at some point during their infectious period, and nearly half (47.9%) reported a known exposure to a positive patient and/or coworker within their facility. Overall, compared to all LAC cases, HCWs reported lower rates of hospitalization (5.3% vs 12.2%) and death (0.7% vs 4.3%) from COVID-19. There are many factors that increase HCWs risk of infection, including high-risk work environment, limited supply of personal protective equipment, and even pressure to help and work during a pandemic. In response to these data, LAC DPH created resources and provided guidance for healthcare facilities to best protect their patients and staff during the COVID-19 pandemic.

IntroductionMore than 93,000 cases of coronavirus disease (COVID-19) have been reported worldwide. We describe the epidemiology, clinical course, and virologic characteristics of the first 12 U.S. patients with COVID-19.MethodsWe collected demographic, exposure, and clinical information from 12 patients confirmed by CDC during January 20–February 5, 2020 to have COVID-19. Respiratory, stool, serum, and urine specimens were submitted for SARS-CoV-2 rRT-PCR testing, virus culture, and whole genome sequencing.ResultsAmong the 12 patients, median age was 53 years (range: 21–68); 8 were male, 10 had traveled to China, and two were contacts of patients in this series. Commonly reported signs and symptoms at illness onset were fever (n=7) and cough (n=8). Seven patients were hospitalized with radiographic evidence of pneumonia and demonstrated clinical or laboratory signs of worsening during the second week of illness. Three were treated with the investigational antiviral remdesivir. All patients had SARS-CoV-2 RNA detected in respiratory specimens, typically for 2–3 weeks after illness onset, with lowest rRT-PCR Ct values often detected in the first week. SARS-CoV-2 RNA was detected after reported symptom resolution in seven patients. SARS-CoV-2 was cultured from respiratory specimens, and SARS-CoV-2 RNA was detected in stool from 7/10 patients.ConclusionsIn 12 patients with mild to moderately severe illness, SARS-CoV-2 RNA and viable virus were detected early, and prolonged RNA detection suggests the window for diagnosis is long. Hospitalized patients showed signs of worsening in the second week after illness onset.

Coronavirus disease 2019 (COVID-19), the respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China and has since become pandemic. In response to the first cases identified in the United States, close contacts of confirmed COVID-19 cases were investigated to enable early identification and isolation of additional cases and to learn more about risk factors for transmission. Close contacts of nine early travel-related cases in the United States were identified and monitored daily for development of symptoms (active monitoring). Selected close contacts (including those with exposures categorized as higher risk) were targeted for collection of additional exposure information and respiratory samples. Respiratory samples were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction at the Centers for Disease Control and Prevention. Four hundred four close contacts were actively monitored in the jurisdictions that managed the travel-related cases. Three hundred thirty-eight of the 404 close contacts provided at least basic exposure information, of whom 159 close contacts had ≥1 set of respiratory samples collected and tested. Across all actively monitored close contacts, two additional symptomatic COVID-19 cases (i.e., secondary cases) were identified; both secondary cases were in spouses of travel-associated case patients. When considering only household members, all of whom had ≥1 respiratory sample tested for SARS-CoV-2, the secondary attack rate (i.e., the number of secondary cases as a proportion of total close contacts) was 13% (95% CI: 4-38%). The results from these contact tracing investigations suggest that household members, especially significant others, of COVID-19 cases are at highest risk of becoming infected. The importance of personal protective equipment for healthcare workers is also underlined. Isolation of persons with COVID-19, in combination with quarantine of exposed close contacts and practice of everyday preventive behaviors, is important to mitigate spread of COVID-19.

Background: Outbreaks of infections in healthcare negatively impact patient outcomes and experience. Transparency is critical to engendering trust and optimizing health. Consistent guidance is not available regarding when to report a possible outbreak of healthcare-associated infections (HAIs) to public health and when to notify a limited population or to publicly disclose the occurrence of HAI. Recent analyses of state public health policies revealed that most states address reporting of outbreaks using terms such as clusters, unusual occurrences, or incidences over baseline. Specific wording about healthcare outbreaks or guidance for notifying patients or public is often absent. Thus, HAI outbreak notification and disclosure guidance and practices vary significantly around the country. A best-practice guidance document will provide clarity for when such reporting should occur. Methods: The Council for Outbreak Response: HAI and Antimicrobial-Resistant Pathogens (CORHA) has undertaken the task of developing this guidance by forming a multidiscipline policy work group with representation from its partner organizations. This work group has been tasked with creating a general framework that will guide notification and disclosure in the context of a possible HAI outbreak. The draft guidance document has been developed over several months of telephone and in-person conferences among work group members. Results: The standardized actions stemming from the guiding principles and recommended practices for conducting step 1 (immediate notification, initial and critical communications that occur when an outbreak is first suspected), were arranged in a table format with rows representing stakeholders and constituents to be notified and columns demonstrating the actions to be taken (Fig. 1). As an investigation progresses, notification should be revisited, especially if an investigation’s scope expands. The principles and practices for step 2 (expanded notification) have also been drafted in a table format. Next, the draft guidance addresses step 3 (public disclosure), outlining indications, practical guidance, and considerations in an outline and/or summary format. Real-world examples demonstrating application of the framework are being developed as supplementary resources to the framework. Current work group activities include engaging bioethicists, media reporters and patient advocates to review and comment on the guidance to ensure that it is clear, consistent and practical. Discussion: The draft guidance provides a framework for standardized actions for HAI outbreak notification and disclosure in a stepwise fashion, modeling public health practices and grounded in bioethical principles. The final product will provide valuable, practical advice for effectively sharing information with affected or potentially affected individuals and their caregivers in a timely manner.Funding: NoneDisclosures: Dawn Terashita reports that her spouse has received honoraria rom the speaker’s bureaus of Novo Nordisk and Abbott.

Context Infectious disease threats, high incidence/prevalence of health care-associated infections, and multidrug-resistant organisms challenge hospitals to improve infection prevention/control strategies and infectious disease preparedness/response efforts. Program The Los Angeles County (LAC) Department of Public Health (DPH), Hospital Outreach Unit (HOU) addressed this need with the liaison public health nurse (LPHN) project, which is designed to strengthen capacity and bridge the care continuum with hospitals to prevent/control infectious disease. Implementation The project utilizes 5 LPHNs who interface with LAC hospitals to improve reporting of infectious disease/hospital outbreaks, strengthen the surveillance infrastructure, and enhance communication/collaboration. The LPHNs communicate regularly and meet one-on-one with hospital infection preventionists with focused discussion, consultation, and assessment of infectious disease, participate in joint infection control meetings/conferences/calls, outreach on joint public health projects, and educate/train hospital staff. Evaluation Within the first 7 years of implementation (2003) of the unit, reporting of hospital outbreaks increased 27%; hospitals reporting infectious disease via a county reporting system increased 95% during the same period. Currently, 64% of hospitals are reporting via the electronic laboratory reporting system (automated transmission to public health of reportable laboratory findings). In addition, the number of hospital infection control committee meetings LPHNs were invited to increased 96% during the first 7 years. The LPHNs/HOU participate(d) in 9 joint infection prevention/control projects with hospitals. Discussion The threat of emerging infectious disease, health care-associated infections, and multidrug-resistant organisms is an ongoing challenge. Preventing infectious disease requires innovative approaches to effect and empower hospitals to respond. The LAC DPH LPHN project has proved to be an invaluable resource and key component to enable effective communication/collaboration to improve infection prevention and control strategies/preparedness efforts and protect the public's health from infectious disease.

Microbiological testing, including interpretation of antimicrobial susceptibility testing results using current breakpoints, is crucial for clinical care and infection control. Continued use of obsolete Enterobacteriaceae carbapenem breakpoints is common in clinical laboratories. The purposes of this study were (i) to determine why laboratories failed to update breakpoints and (ii) to provide support for breakpoint updates. The Los Angeles County Department of Public Health conducted a 1-year outreach program for 41 hospitals in Los Angeles County that had reported, in a prior survey of California laboratories, using obsolete Enterobacteriaceae carbapenem breakpoints. In-person interviews with hospital stakeholders and customized expert guidance and resources were provided to aid laboratories in updating breakpoints, including support from technical representatives from antimicrobial susceptibility testing device manufacturers. Forty-one hospitals were targeted, 7 of which had updated breakpoints since the prior survey. Of the 34 remaining hospitals, 27 (79%) assumed that their instruments applied current breakpoints, 17 (50%) were uncertain how to change breakpoints, and 10 (29%) lacked resources to perform a validation study for off-label use of the breakpoints on their systems. Only 7 hospitals (21%) were familiar with the FDA/CDC Antibiotic Resistance Isolate Bank. All hospitals launched a breakpoint update process; 16 (47%) successfully updated breakpoints, 12 (35%) received isolates from the CDC in order to validate breakpoints on their systems, and 6 (18%) were planning to update within 1 year. The public health intervention was moderately successful in identifying and overcoming barriers to updating Enterobacteriaceae carbapenem breakpoints in Los Angeles hospitals. However, the majority of targeted hospitals continued to use obsolete breakpoints despite 1 year of effort. These findings have important implications for the quality of patient care and patient safety. Other public health jurisdictions may want to utilize similar resources to bridge the patient safety gap, while manufacturers, the FDA, and others determine how best to address this growing public health issue.

Background In 2017, local public health authorities in California received reports of 2 elderly patients with suspected botulism who knew each other socially. A multijurisdictional investigation was conducted to determine the source. Methods Investigators reviewed medical records, interviewed family to establish food and drink histories, and inspected a facility that produced liquid herbal tea. Clinical specimens and product were tested for botulinum neurotoxin (BoNT). Results A total of 2 confirmed botulism cases were identified with BoNT type A; both were hospitalized, 1 died. Botulism was not suspected until several days after hospital admission. Case-patients ingested single-serving prepackaged liquid herbal tea. Inspection of the tea production facility identified conditions conducive to product contamination with C botulinum and toxin production. Samples of tea tested negative for botulinum toxin. Local and state public health authorities issued alerts and the facility recalled the liquid herbal tea. Conclusions Liquid herbal tea prepackaged in sealed pouches was the likely source of this type A botulism outbreak because the 2 cases were linked socially and shared no other foods. This type of product has not previously been described in the foodborne botulism literature. In the absence of known risk factors for botulism at the time of presentation, suspicion based on clinically compatible findings is critical so that and treatment with botulinum antitoxin is not delayed. A coordinated response by public health authorities is necessary in identifying a potential food source, inspecting facilities producing the product, alerting medical providers and the public, and preventing further illness.

On June 22, 2017, the Los Angeles County Department of Public Health (LAC DPH) was notified of seven patients who were seen at an eye care clinic on June 8, 2017, and later developed symptoms of epidemic keratoconjunctivitis (EKC). EKC is a contagious, severe form of viral conjunctivitis that can cause pain and blurred vision for up to 4 weeks (1). LAC DPH conducted an investigation, which identified 17 patients with EKC, including 15 who had visited the optometry clinic and two who were household contacts of clinic patients. Observations in the clinic found deficiencies in disinfection of tonometers (an instrument connected to a slit lamp and used to test for glaucoma by measuring intraocular pressure) and multiuse eye drop administration. Staff member education and revision of disinfection practices interrupted further transmission. Patient specimens tested positive for human adenovirus (HAdV) type D53 (HAdV-53). As the first documented EKC outbreak associated with HAdV-D53 in the United States, this outbreak highlights the need for rigorous implementation of recommended infection prevention practices in eye care settings.

Background The Clinical and Laboratory Standards Institute (CLSI) revised the carbapenem breakpoints for Enterobacteriaceae in 2010. The number of hospitals that adopted revised breakpoints and the clinical impact of delayed adoption has not been explored. Methods We performed a cross-sectional, voluntary survey of microbiology laboratories from California acute care hospitals and long-term acute care hospitals (LTAC) to determine use of revised CLSI breakpoints. Carbapenem-resistant Enterobacteriaceae (CRE) clinical isolates from a single tertiary-care hospital from 2013 to 2017 were examined. All isolates with an elevated minimum inhibitory concentration (MIC; ≥2 µg/mL) to imipenem or meropenem were tested for the presence of carbapenemase genes by polymerase chain reaction (PCR). Results We received responses from 128 laboratories that serve 264/393 (67%) of hospitals and LTACs. Current CLSI carbapenem breakpoints for Enterobacteriaceae were used by 92/128 (72%) laboratories. Among laboratories that used current breakpoints, time to implementation varied from 0 to 68 months (mean, 41 months; median, 55 months). Application of historical breakpoints to isolates with a carbapenemase gene detected by PCR resulted in susceptibility rates of 8.9%, 18.6%, and 18.6% to ertapenem, imipenem, and meropenem, respectively. By current breakpoints

Background Historically, endemic Klebsiella pneumoniae carbapenemase (KPC) has accounted for the majority of carbapenem-resistant Enterobacteriaceae (CRE) in Los Angeles County (LAC). The LAC Department of Public Health (DPH) initiated enhanced CRE surveillance in 2016 to determine CRE prevalence and track emerging non-KPC resistance mechanisms (IMP, NDM, OXA, and VIM) among CRE to describe characteristics and identify local epidemiology for novel multi-drug-resistant organism (N-MDRO) infection and colonization. Methods CRE isolates were voluntarily submitted by local clinical laboratories for mechanism detection by LAC Public Health Laboratory via MALDI-TOF and Nanosphere BC-GN. Baseline isolates were collected in 2016. Results are then presented by year through 2018. For N-MDRO cases, LACDPH interviewed healthcare facility (HCF) staff and cases to obtain case characteristics. Data were analyzed via Microsoft Access and SAS. Results CRE surveillance isolates were voluntarily submitted by 31 labs representing 34% (34/96) LAC hospitals and 1 large regional lab serving 60% of skilled nursing facilities from January 2016 to December 2018. LACDPH tested 1438 CRE isolates during the study period, 1168 (81%) were carbapenemase producing (CP). The proportion of CP CRE and KPC CRE declined over the study period (Table 1). NDM was the most common non-KPC (n = 30) followed by OXA (n = 28). The proportion of CRE with no genotypic marker increased over the course of the study. Case characteristics were obtained from 41 non-KPC CP CRE cases; median age was 66 years (range: 6–94 years); 12 (29%) expired. Among the 41 cases, 20 (49%) had a central line; 11 (27%) had surgery; 14 (34%) had antibiotics in the 6 months prior to culture date. Of the 41 cases, 11 (27%) had international healthcare exposure within 12 months with an invasive procedure and/or antibiotics. Conclusion Surveillance in a large urban setting suggests the molecular epidemiology of CRE is changing, with declining prevalence of KPC, increasing metallo-β-lactamase CP, and large proportion of isolates without resistance markers detected. Given the worrisome trends in non-KPC CRE, more systematic surveillance is warranted, potentially using more robust molecular epidemiology. Disclosures All authors: No reported disclosures.

Carbapenem-resistant Enterobacteriaceae (CRE) infections are difficult to treat and pose a significant threat to public health. In July 2018, an infection preventionist (IP) notified Los Angeles County Department of Public Health (LACDPH) of eight cases of healthcare-onset carbapenem-resistant Klebsiella pneumoniae (CRKP) among residents of a 54-bed long term acute care facility (LTAC). LACDPH initiated an investigation to identify risks for infection and disrupt transmission. A case was defined as a LTAC patient with laboratory confirmation for CRKP or carbapenemase-producing organism from June 28- August 7, 2018 and no previous CRE history. LACDPH conducted two site visits of the facility to observe infection prevention practices. Medical records, staff training records, and infection prevention audits were reviewed. Facility-wide surveillance cultures were collected on three dates. The first facility-wide screening yielded 13 additional cases; no further cases were identified during subsequent screenings. Medical record review found one additional case. A total of 22 cases were identified; overall prevalence was 39%. Site observations revealed missed hand hygiene opportunities, unclear contact precaution signage, and a knowledge deficit among staff regarding CRE and control measures. LACDPH recommended enhanced environmental cleaning, infection control trainings for all staff, hand hygiene and personal protective equipment audits, placing new admissions on contact precautions pending CRE screening results, and the use of an interfacility transfer form upon discharge of all known CRE patients. We identified a high prevalence of CRE in an LTAC, a setting where patients generally have higher invasive device and antibiotic utilization than other settings. However, the implementation of evidence-based infection prevention practices enabled the facility to stop the spread of infection. Identification and containment of a CRE outbreak in a healthcare facility relies on several factors, including the collaboration of a facility's IP with the local health department and continuing frontline staff education.

Infection control (IC) in the pre-hospital care setting by EMS providers is important to protect themselves and patients receiving emergency care and being transported between healthcare facilities. From 2016-17, LAC Department of Public Health (DPH) collaborated with LAC Emergency Medical Services Agency (EMSA) to assess and improve IC among EMS providers. DPH/EMSA adapted tools from the Centers for Disease Control and Prevention designed for healthcare facilities to assess EMS IC policies and practices. Large and small EMS agencies/companies were assessed to ensure a representative sample. Policies were reviewed, and observations made by DPH/EMSA nurses during ride alongs in >2 ambulances per provider. Fourteen providers were assessed. Eleven had a designated infection control officer (DICO). Thirteen had written IC policies; 12 reviewed and updated them annually. All required IC training for new staff, but only 59% assessed skills post-training and 31% audited across four IC topics. Twelve had written policies for cleaning/disinfection. Twelve had a policy for influenza vaccination; however, the median vaccination rate was only 55% (range 1-99%). Observations showed handwashing occurred before patient contact for 7% of assessments, glove use in 100% and hand hygiene after removing gloves in 79%. Staff cleaned the ambulance after each patient encounter; cleaning high touch surfaces in 79% and replaced cleaners/disinfectants when appropriate in 89%. EMS providers are an important part of the healthcare system as they transport patients in and out of hospitals and other healthcare facilities. Overall, findings were encouraging, but ensuring up-to-date policies for all areas of IC, monitoring competencies, and observing practices to assess adherence may improve IC. In 2018, LAC hosted an IC train-the-trainer course for DICOs to bring proper IC practices back to their agencies/companies. LAC DPH and EMSA will continue to work with EMS providers to improve IC policies and practices.

Next-generation sequencing enables use of whole-genome sequence typing (WGST) as a viable and discriminatory tool for genotyping and molecular epidemiologic analysis. We used WGST to confi rm the linkage of a cluster of Coccidioides immitis isolates from 3 patients who received organ transplants from a single donor who later had positive test results for coccidioidomycosis. Isolates from the 3 patients were nearly genetically identical (a total of 3 singlenucleotide polymorphisms identifi ed among them), thereby demonstrating direct descent of the 3 isolates from an original isolate. We used WGST to demonstrate the genotypic relatedness of C. immitis isolates that were also epidemiologically linked. Thus, WGST offers unique benefi ts to public health for investigation of clusters considered to be linked to a single source.

Background Intrapartum antibiotic prophylaxis (IAP) prevents neonatal mortality from Group B Streptococcus (GBS). Clindamycin resistance among GBS isolates complicates IAP for GBS-positive women allergic to penicillin and cephalosporins. GBS screening by nucleic acid amplification tests (NAATs) provides rapid results, but no susceptibility data to inform IAP. We sought to estimate burden of clindamycin resistance among GBS in Los Angeles County (LAC). Methods Hospital antibiogram data were gathered from all LAC acute care hospitals from 2015 to 2016. Weighted averages for GBS resistance to clindamycin, erythromycin, penicillin, and TMP/SMX were calculated. Facilities which reported clindamycin susceptibilities were interviewed regarding antimicrobial susceptibility testing methods. Results A total of 2,339 GBS isolates from 22 hospitals were reported between 2015 and 2016. Thirteen hospitals tested GBS for clindamycin (nine reported in 2015 and 2016, four hospitals reported in 2016 only). Clindamycin resistance was found in 61.7% of 1,794 GBS isolates (79.3% of 891 in 2015, 44.3% of 903 in 2016). Erythromycin resistance was 42% in 735 isolates reported, 0.1% penicillin of 1,916 isolates reported, and 1.5% TMP/SMX of = 135 isolates reported. Facilities tested GBS by manual minimum inhibitory concentration (MIC) broth dilution (n = 1), automated MIC dilution (n = 4), agar plate diffusion (n = 1), and MIC dilution followed by agar plate diffusion (n = 1). Two hospitals did not perform testing on-site. Conclusion The 62% prevalence of clindamycin-resistant GBS in LAC is three-fold higher than national CDC estimates and complicates IAP for GBS-positive women allergic to penicillin and cephalosporins. These data support CDC recommendations for susceptibility testing in addition to NAAT screening which does not include assays for common determinants of clindamycin resistance, erm-methylase, mef, and isa. There is an opportunity for diagnostic manufacturers and clinical labs to help clinicians choose appropriate IAP and prevent neonatal mortality. The CDC and public health should be aware of regional variations in clindamycin resistance. Clinicians should be aware of local resistance to inform IAP stewardship recommendations. Disclosures S. Butler-Wu, BioFire (bioMerieux): Investigator, Research support.

Background Los Angeles County Department of Public Health (LAC-DPH) investigated an outbreak of epidemic keratoconjunctivitis secondary to adenovirus between June and July 2017, and all cases were linked to a single optometry clinic. The LAC-DPH aimed to determine whether sub-optimal infection prevention practices used in the implicated clinic were commonplace within other local optometry clinics. The objective of this study was to understand infection prevention practices in optometry clinics within Los Angeles County. Methods LAC-DPH conducted a survey consisting of 17 questions related to infection prevention practices among a sample of optometry providers in the county. The survey was administered online (SurveyMonkey) via emails sent to a local optometric society’s listserv and in-person at a local continuing education event for optometrists. The results were analyzed and are represented as percentages. Results There were 42 responses, 20 via the online survey (response rate 15%) and 22 via the in-person survey (response rate 22%). The majority worked in an optometry clinic: 77.5% (n = 31). More than half had no written hand-hygiene policy (58.5%, n = 24), 46.2% (n = 18) did not wear gloves while examining patients with eye drainage and about half (48.7%, n = 18) did not use droplet precautions for patients with respiratory symptoms. The vast majority used multi-dose eye-drop vials (92.5%, n = 37) but more than 40% (n = 21) did not discard the vial if the tip came into contact with conjunctiva. The majority (68.4%, n = 26) used alcohol wipes with 70% isopropyl alcohol to disinfect tonometers, while 47.4% (n = 18) used noncontact tonometers and 23.6% (n = 9) used disposable tips (options for this question were not mutually exclusive). Conclusion Infection prevention practices in optometry clinics are sub-optimal and must be improved. All optometry clinics must have a hand-hygiene policy and discard multi-dose vials which come into contact with conjunctivae. While the evidence on the best disinfectant for tonometers is limited, commonly used disinfectants like 70% alcohol wipes or 3% hydrogen peroxide have been associated with adenovirus outbreaks. Current evidence suggests that infectious spread via tonometers can be prevented by using disposable covers or by disinfection with 1:10 diluted bleach. Disclosures All authors: No reported disclosures.

Background An estimated 30% of outpatient antibiotic prescriptions are unnecessary. Antimicrobial stewardship programs (ASP) are associated with decreased antibiotic prescribing and improved patterns of antimicrobial resistance. The objective of Targeting Appropriate Prescribing in Outpatient settings (TAP OUT) is to study how public health jurisdictions may assist implementation of ASP in primary and urgent care and to measure the impact on reducing inappropriate antibiotic prescribing. Methods Los Angeles County Department of Public Health (DPH) partnered with an outpatient medical group to implement an ASP in 2017. The TAP OUT ASP included public commitment, communication skills training, clinical treatment education, and prescribing audits. Implementation characteristics were collected via key informant interviews and provider surveys and were analyzed following the Consolidated Framework for Implementation Research. Historical (November 2016–March 2017) and intervention (November 2017–March 2018) period prescribing data from electronic health records were compared with calculating antibiotic prescribing rates for uncomplicated acute upper respiratory infection (URI) encounters. Results Twenty primary care and three urgent care clinics, representing 208 providers, participated in TAP OUT. The baseline inappropriate antibiotic prescribing rate for URI was 15.5% amongst all prescribers (range: 0–100%). During the intervention period, the inappropriate prescribing rate decreased to 7.6% (51% reduction, P < 0.0001) (Figure 1). Several key implementation elements were identified, such as leadership buy-in and on-site peer champions. Visible and recurring prescribing reminders were useful. To improve adoption, the ASP was integrated into existing workflow. Costs were limited and related to information technology resources to analyze prescribing data and create feedback reports. Conclusion The TAP OUT program met all of the Centers for Disease Control and Prevention (CDC) Core Elements of Outpatient Stewardship and was associated with a decrease in inappropriately prescribed antibiotics with low implementation costs. DPH will develop a TAP OUT implementation guide and work with local providers to develop ASPs. Figures: Disclosures All authors: No reported disclosures.

Pending California legislation prompted an on-line survey of methicillin-resistant Staphylococcus aureus (MRSA) active surveillance practices administered to infection preventionists of all 102 acute care licensed hospitals in Los Angeles County. We describe reported surveillance methods. Ninety-six hospitals responded with 41% performing MRSA active surveillance. Comments indicated resistance to implementation of active surveillance because its benefits remain controversial.

Coccidioidomycosis, also known as Valley Fever, is often thought of as an endemic disease of central California exclusive of Los Angeles County. The fungus that causes Valley Fever, Coccidioides spp., grows in previously undisturbed soil of semi-arid and arid environments of certain areas of the Americas. LA County has a few large areas with such environments, particularly the Antelope Valley which has been having substantial land development. Coccidioidomycosis that is both clinically- and laboratory-confirmed is a mandated reportable disease in LA County. Population surveillance data for 1973–2011 reveals an annual rate increase from 0.87 to 3.2 cases per 100,000 population (n = 61 to 306 annual cases). In 2004, case frequency started substantially increasing with notable epidemiologic changes such as a rising 2.1 to 5.7 male-to-female case ratio stabilizing to 1.4–2.2. Additionally, new building construction in Antelope Valley greatly rose in 2003 and displayed a strong correlation (R = 0.92, Pearson p

Background Early appropriate antibiotic selection is life saving in sepsis. Facility-level antibiograms inform antibiotic selection after pathogen identification and before susceptibility results are available, but only if ≥ 30 isolates from a given species are tested in the prior year. Stenotrophomonas maltophilia (SM) has a complex resistance profile and is associated with an 8-fold mortality increase. We hypothesized that a regional antibiogram may help inform clinical decision-making for severe SM infections. Methods To generate a regional SM antibiogram, we conducted a cross-sectional, voluntary survey of 2015 cumulative facility-level antibiograms from all hospitals in LA county. Non-respondents were contacted to improve response rates. Isolates from sterile sources were pooled. Susceptibility was aggregated and percent susceptible was calculated only when all isolates were tested, i.e. not reflex testing. To identify optimal combination empiric therapy for SM infections, we generated a combination antibiogram using broth microdilution results from a single tertiary care facility in LA. Results Antibiograms were submitted by 85/100 (85%); 50 hospitals (59%) reported SM (n = 1719 isolates, Table 1). Hospitals commonly (25/50) reported data for

Background Carbapenem-resistant Enterobacteriaceae (CRE), particularly carbapenemase-producing (CP) CRE, are an urgent public health threat. CRE with blaKPC have been most commonly reported, but blaNDM and other genotypes have epidemiologic and clinical significance. We seek to define epidemiologic patterns and antimicrobial susceptibility implications of genotypic resistance (R) mechanism in LAC. Methods LAC Department of Public Health (DPH) Public Health Laboratory (PHL) conducted CRE laboratory surveillance of 31 clinical microbiology labs representing 34% (34/96) hospitals and 1 large regional lab serving 60% of SNFs from January 2015 to December 2016. Data on antimicrobial susceptibility testing (AST) was conducted by local laboratories and methodology varies by each submitting clinical lab. Isolates were sent to DPH PHL for identification of carbapenem resistance mechanism using Nanosphere Verigene BC-GN to detect carbapenemase genes; blaOXA, blaVIM, blaNDM, blaKPC, and blaIMP. Results During the study period, 843 CRE isolates were submitted to DPH for further analysis. CRE isolates were submitted from 34 hospitals (n = 604, mean 2 isolates/facility/month, range 1–7 isolates); 239 isolates submitted from regional SNF lab (range 2-54 isolates/month). Resistance mechanisms were identified in 684 Klebsiella spp., 61 E. coli, 45 Enterobacter spp., 10 Acinetobacter Baumannii, and other organisms. blaKPC was identified in 653 (77.5%) isolates, blaOXA in 17 (2%) isolates, and blaVIM in 2 isolates; 75 (9%) isolates did not have a marker detected. AST data and carbapenemase gene detection data were complete for 252 (30%) isolates, 250 isolates from hospitals and 2 SNF isolates; 29 isolates from hospitals were identified as pan-resistant, AST results for blaKPC differed from non-blaKPC isolates for tobramycin, amikacin, ciprofloxacin, aztreonam, ceftolazone tazobactam, ceftazidime avibactam (P < 0.05 for all). Conclusion CRE surveillance in a large urban setting continues to demonstrate that CRE Burden varies across individual facilities. Molecular epidemiology indicate that KPC remains the predominant carbapenemase, but NDM and other non-KPC mechanisms are recognized. Preliminary AST testing suggests that resistance mechanism has implications for antibiotic therapy. Disclosures All authors: No reported disclosures.

In March 2013, the California Department of Public Health (CDPH) identified two Doctor's First Reports of Occupational Injury or Illness (DFRs) regarding Los Angeles County residents who had worked at the same jobsite in January 2012 and had been evaluated for possible work-associated coccidioidomycosis (valley fever). Occupational exposure to Coccidioides, the causative fungi, typically is associated with soil-disrupting activities. The physicians noted that both workers were cast or crew members filming a television series episode, and the site of possible exposure was an outdoor set in Ventura County, California. On the basis of their job titles, neither would have been expected to have been engaged in soil-disrupting activities. Los Angeles County Department of Public Health (LACDPH) conducted an outbreak investigation by using CDPH-provided occupational surveillance records, traditional infectious disease surveillance, and social media searches. This report describes the results of that investigation, which identified a total of five laboratory-confirmed and five probable cases linked to this filming event. The employer and site manager were interviewed. The site manager stated that they would no longer allow soil-disruptive work at the site and would incorporate information about the potential risk for Coccidioides exposure onsite into work contracts. Public health professionals, clinicians, and the television and film industry should be aware that employees working outdoors in areas where Coccidioides is endemic (e.g., central and southern California), even those not engaged in soil-disruptive work, might be at risk for coccidioidomycosis.