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Introduction In January 2019, the West Virginia Bureau for Public Health detected increased HIV diagnoses among people who inject drugs in Cabell County. Responding to HIV clusters and outbreaks is 1 of the 4 pillars of the Ending the HIV Epidemic in the U.S. initiative and requires activities from the Diagnose, Treat, and Prevent pillars. This article describes the design and implementation of a comprehensive response, featuring interventions from all pillars. Methods This study used West Virginia Bureau for Public Health data to identify HIV diagnoses during January 1, 2018–October 9, 2019 among (1) people who inject drugs linked to Cabell County, (2) their sex or injecting partners, or (3) others with an HIV sequence linked to Cabell County people who inject drugs. Surveillance data, including HIV-1 polymerase sequences, were analyzed to estimate the transmission rate and timing of infections using molecular clock phylogenetic analysis. Federal, state, and local partners designed and implemented a comprehensive response during January 2019–October 2019. Results Of 82 people identified in the outbreak, most were male (60%), were White (91%), and reported unstable housing (80%). In a large molecular cluster containing 56 of 60 (93%) available sequences, 93% of inferred transmissions occurred after January 1, 2018. HIV testing, HIV pre-exposure prophylaxis, and syringe services were rapidly expanded, leading to improved linkage to HIV care and viral suppression. Conclusions Evidence of rapid transmission in this outbreak galvanized robust collaboration among federal, state, and local partners, leading to critical improvements in HIV prevention and care services. HIV outbreak response requires increased coordination and creativity to improve service delivery to people affected by rapid HIV transmission.

To evaluate HIV care continuum trends over time among women with HIV (WWH).The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV in the United States.We used 2015-2019 MMP data collected from 5139 adults with diagnosed HIV infection who identified as cisgender women. We calculated weighted percentages with 95% confidence intervals (CIs) for all characteristics and estimated annual percentage change (EAPC) and the associated 95% CI to assess trends. EAPCs were considered meaningful from a public health perspective if at least 1% with P values less than 0.05.Among cisgender women with diagnosed HIV infection during 2015-2019, 58.8% were Black or African American (95% CI 54.4-63.3), 19% were Hispanic/Latina (95% CI 14.7-23.2), and 16% were Non-Hispanic White (95% CI 14.1-17.9) persons. There was a meaningful increase in the percentage who ever had stage 3 HIV disease from 55.8% (95% CI 51.0-60.5) in 2015 to 61.5% (95% CI 58.1-64.8) in 2019 (EAPC 1.7%; CI 1.5-1.9; P 0.001). There were no meaningful changes over time among women, overall, in retention in care, antiretroviral therapy (ART) prescription, ART adherence, missed appointments, or recent or sustained viral suppression.The HIV care continuum outcomes among WWH did not meaningfully improve from 2015 to 2019, raising a concern that Ending the HIV Epidemic in the US (EHE) initiative goals will not be met. To improve health and reduce transmission of HIV among WWH, multifaceted interventions to retain women in care, increase ART adherence, and address social determinants of health are urgently needed.

Background Physical activity (PA) provides numerous health benefits relevant to the COVID-19 pandemic. However, concerns exist that PA levels may have decreased during the pandemic thus exacerbating health disparities. This study aims to determine changes in and locations for PA and reasons for decreased PA during the pandemic. Methods Reported percentage of changes in and locations for PA and reasons for decreased PA were examined in 3829 US adults who completed the 2020 SummerStyles survey. Results Overall, 30% reported less PA, and 50% reported no change or no activity during the pandemic; percentages varied across subgroups. Adults who were non-Hispanic Black (Black) or Hispanic (vs. non-Hispanic White, (White)) reported less PA. Fewer Black adults (vs. White) reported doing most PA in their neighborhood. Concern about exposure to the virus (39%) was the most common reason adults were less active. Conclusions In June 2020, nearly one-third of US adults reported decreased PA; 20% reported increased PA. Decreased activity was higher among Black and Hispanic compared to White adults; these two groups have experienced disproportionate COVID-19 impacts. Continued efforts are needed to ensure everyone has access to supports that allow them to participate in PA while still following guidance to prevent COVID-19 transmission.

To assess disruption in healthcare services for HIV treatment by national emergency in response to the coronavirus disease 2019 (COVID-19) pandemic in the United States.Time-series analysis.We analyzed the IQVIA Real World Data-Longitudinal Prescriptions Database and calculated time trends in the weekly number of persons with active antiretroviral prescriptions for HIV treatment, and of persons who obtained antiretroviral prescriptions during January 2017-March 2021. We used interrupted time-series models to estimate the impact of the COVID-19 pandemic on antiretroviral therapy (ART) use between March 2020 and March 2021.We found that the weekly number of persons with active antiretroviral prescriptions decreased by an average 2.5% (95% confidence interval [CI]: -3.8% to -1.1%), compared to predicted use, during March 2020 through March 2021. The weekly number of persons who obtained antiretroviral prescriptions decreased 4.5% (95% CI: -6.0% to -3.0%), compared to the predicted number. Men, persons aged ≤34 years, privately insured persons, and persons in medication assistance programs had greater decreases than other groups.We demonstrated a decrease in the number of persons with active antiretroviral prescriptions during the first year of the COVID-19 pandemic and the number did not return to levels expected in the absence of the pandemic. Disruptions in HIV care and decreased ART may lead to lower levels of viral suppression and immunologic control, and increased HIV transmission in the community.

We compared the characteristics of hospitalized and nonhospitalized patients who had coronavirus disease in Atlanta, Georgia, USA. We found that risk for hospitalization increased with a patient's age and number of concurrent conditions. We also found a potential association between hospitalization and high hemoglobin A1c levels in persons with diabetes.

Background The HIV Medicine Association of the Infectious Disease Society of America publishes Primary Care Guidance for Persons with Human Immunodeficiency Virus. We assessed receipt of recommended baseline tests among newly diagnosed patients initiating HIV care. Methods The Medical Monitoring Project is a Centers for Disease Control and Prevention survey designed to produce nationally representative estimates of behavioral and clinical characteristics of adults with diagnosed HIV in the United States. We analyzed data for 725 participants in the 2015–2019 data collection cycles who received an HIV diagnosis within the past 2 years and had ≥1 HIV provider visit. We estimated the prevalence of having recommended tests after the first HIV provider visit and between 3 months before and 3/6 months after the first HIV provider visit and estimated prevalence differences of having 4 combinations of tests by sociodemographic and clinical characteristics. Results Within 6 months of care initiation, HIV monitoring tests were performed for 91.3% (95% CI, 88.7%–93.8%) of patients; coinfection blood tests, 27.5% (95% CI, 22.5%–32.4%); site-based STI tests, 59.7% (95% CI, 55.4%–63.9%); and blood chemistry and hematology tests, 50.8% (95% CI, 45.8%–55.8%). Patients who were younger, gay, or bisexual were more likely to receive site-based STI tests, and patients receiving care at Ryan White HIV/AIDS Program (RWHAP)–funded facilities were more likely than patients at non-RWHAP-funded facilities to receive all test combinations. Conclusions Receipt of recommended baseline tests among patients initiating HIV care was suboptimal but was more likely among patients at RWHAP-funded facilities. Embedding clinical decision support in HIV provider workflow could increase recommended baseline testing.

Long-standing social inequities and health disparities have resulted in increased risk for coronavirus disease 2019 (COVID-19) infection, severe illness, and death among racial and ethnic minority populations. The Health Resources and Services Administration (HRSA) Health Center Program supports nearly 1,400 health centers that provide comprehensive primary health care* to approximately 30 million patients in 13,000 service sites across the United States.† In 2019, 63% of HRSA health center patients who reported race and ethnicity identified as members of racial ethnic minority populations (1). Historically underserved communities and populations served by health centers have a need for access to important information and resources for preventing exposure to SARS-CoV-2, the virus that causes COVID-19, to testing for those at risk, and to follow-up services for those with positive test results.§ During the COVID-19 public health emergency, health centers¶ have provided and continue to provide testing and follow-up care to medically underserved populations**; these centers are capable of reaching areas disproportionately affected by the pandemic.†† HRSA administers a weekly, voluntary Health Center COVID-19 Survey§§ to track health center COVID-19 testing capacity and the impact of COVID-19 on operations, patients, and personnel. Potential respondents can include up to 1,382 HRSA-funded health centers.¶¶ To assess health centers' capacity to reach racial and ethnic minority groups at increased risk for COVID-19 and to provide access to testing, CDC and HRSA analyzed survey data for the weeks June 5-October 2, 2020*** to describe all patients tested (3,194,838) and those who received positive SARS-CoV-2 test results (308,780) by race/ethnicity and state of residence. Among persons with known race/ethnicity who received testing (2,506,935), 36% were Hispanic/Latino (Hispanic), 38% were non-Hispanic White (White), and 20% were non-Hispanic Black (Black); among those with known race/ethnicity with positive test results, 56% were Hispanic, 24% were White, and 15% were Black. Improving health centers' ability to reach groups at increased risk for COVID-19 might reduce transmission by identifying cases and supporting contact tracing and isolation. Efforts to improve coordination of COVID-19 response-related activities between state and local public health departments and HRSA-funded health centers can increase access to testing and follow-up care for populations at increased risk for COVID-19.

Background Coronavirus disease (COVID-19) can cause severe illness and death. Predictors of poor outcome collected on hospital admission may inform clinical and public health decisions. Methods We conducted a retrospective observational cohort investigation of 297 adults admitted to 8 academic and community hospitals in Georgia, United States, during March 2020. Using standardized medical record abstraction, we collected data on predictors including admission demographics, underlying medical conditions, outpatient antihypertensive medications, recorded symptoms, vital signs, radiographic findings, and laboratory values. We used random forest models to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for predictors of invasive mechanical ventilation (IMV) and death. Results Compared with age Conclusions After adjustment for patient and clinical characteristics, older age was the strongest predictor of death, exceeding comorbidities, abnormal vital signs, and laboratory test abnormalities. That coronary artery disease, but not chronic lung disease, was associated with death among hospitalized patients warrants further investigation, as do associations between certain antihypertensive medications and death.

SARS-CoV-2, the novel coronavirus that causes coronavirus disease 2019 (COVID-19), was first detected in the United States during January 2020 (1). Since then, >980,000 cases have been reported in the United States, including >55,000 associated deaths as of April 28, 2020 (2). Detailed data on demographic characteristics, underlying medical conditions, and clinical outcomes for persons hospitalized with COVID-19 are needed to inform prevention strategies and community-specific intervention messages. For this report, CDC, the Georgia Department of Public Health, and eight Georgia hospitals (seven in metropolitan Atlanta and one in southern Georgia) summarized medical record-abstracted data for hospitalized adult patients with laboratory-confirmed* COVID-19 who were admitted during March 2020. Among 305 hospitalized patients with COVID-19, 61.6% were aged

BACKGROUND The Cooperative Re-Engagement Controlled Trial (CoRECT) is a randomized controlled trial that uses a combined health department-provider data to care (D2C) model to identify out-of-care HIV-infected persons. We present cost data for programmatic aspects of the trial during the start-up period (first 30 days of the study). METHODS We used microcosting methods to estimate health department start-up costs. We collected start-up cost data between September 2016 and December 2016; 3 health departments completed a form to capture expenses for the initial 30 days of study implementation; the start date varied by health department. All costs are expressed in 2016 US dollars. RESULTS Among the 3 health departments, the total start-up costs ranged from $14,145 to $26,058. Total start-up labor hours ranged from 224 to 640 hours. CONCLUSIONS As D2C expands nationally with cooperative agreement, PS 18-1802 health departments may be able to use a similar analysis to consider the labor, time, and resources needed to implement D2C within their jurisdiction.

We characterize the association between engagement in care and durable viral suppression among persons newly diagnosed with HIV infection. Persons newly diagnosed with HIV with unsuppressed viral loads when they initiated care at one of six HIV clinics in the US were observed for up to 24 months. We describe the percentage who achieved durable viral suppression and number of days to achieve durable viral suppression. These outcomes were examined by the proportion of scheduled primary care appointments kept and demographic variables. Overall, 62% of patients achieved durable viral suppression and it took 174 days for 50% of patients to reach the beginning of the event. As the proportion of kept medical appointments increased, the proportion who achieved durable viral suppression increased, with 84% of patients who kept >75% of their appointments achieving the outcome. Higher adherence to appointments shortened the time to the beginning of durable viral suppression. Age, race/ethnicity, and risk factor for acquiring HIV infection were correlated with the outcomes. Adherence to primary care appointments is strongly associated with achieving durable viral suppression in persons newly diagnosed with HIV. Identifying and addressing patient barriers and unmet needs may increase the number who achieve durable viral suppression.

Background The epidemiological features and outcomes of hospitalized adults with coronavirus disease 2019 (COVID-19) have been described; however, the temporal progression and medical complications of disease among hospitalized patients require further study. Detailed descriptions of the natural history of COVID-19 among hospitalized patients are paramount to optimize health care resource utilization, and the detection of different clinical phenotypes may allow tailored clinical management strategies. Methods This was a retrospective cohort study of 305 adult patients hospitalized with COVID-19 in 8 academic and community hospitals. Patient characteristics included demographics, comorbidities, medication use, medical complications, intensive care utilization, and longitudinal vital sign and laboratory test values. We examined laboratory and vital sign trends by mortality status and length of stay. To identify clinical phenotypes, we calculated Gower’s dissimilarity matrix between each patient’s clinical characteristics and clustered similar patients using the partitioning around medoids algorithm. Results One phenotype of 6 identified was characterized by high mortality (49%), older age, male sex, elevated inflammatory markers, high prevalence of cardiovascular disease, and shock. Patients with this severe phenotype had significantly elevated peak C-reactive protein creatinine, D-dimer, and white blood cell count and lower minimum lymphocyte count compared with other phenotypes (P Conclusions Among a cohort of hospitalized adults, we identified a severe phenotype of COVID-19 based on the characteristics of its clinical course and poor prognosis. These findings need to be validated in other cohorts, as improved understanding of clinical phenotypes and risk factors for their development could help inform prognosis and tailored clinical management for COVID-19.

Background Persons who inject drugs (PWID) have frequent healthcare encounters related to their injection drug use (IDU) but are often not tested for human immunodeficiency virus (HIV). We sought to quantify missed opportunities for HIV testing during an HIV outbreak among PWID. Methods PWID with HIV diagnosed in 5 Cincinnati/Northern Kentucky counties during January 2017–September 2018 who had ≥1 encounter 12 months prior to HIV diagnosis in 1 of 2 Cincinnati/Northern Kentucky area healthcare systems were included in the analysis. HIV testing and encounter data were abstracted from electronic health records. A missed opportunity for HIV testing was defined as an encounter for an IDU-related condition where an HIV test was not performed and had not been performed in the prior 12 months. Results Among 109 PWID with HIV diagnosed who had ≥1 healthcare encounter, 75 (68.8%) had ≥1 IDU-related encounters in the 12 months before HIV diagnosis. These 75 PWID had 169 IDU-related encounters of which 86 (50.9%) were missed opportunities for HIV testing and occurred among 46 (42.2%) PWID. Most IDU-related encounters occurred in the emergency department (118/169; 69.8%). Using multivariable generalized estimating equations, HIV testing was more likely in inpatient compared with emergency department encounters (adjusted relative risk [RR], 2.72; 95% confidence interval [CI], 1.70–4.33) and at the healthcare system receiving funding for emergency department HIV testing (adjusted RR, 1.76; 95% CI, 1.10–2.82). Conclusions PWID have frequent IDU-related encounters in emergency departments. Enhanced HIV screening of PWID in these settings can facilitate earlier diagnosis and improve outbreak response.

Background: Persons with HIV (PWH), aware of their HIV infection but not in care account for an estimated 42.6% of HIV transmissions in the United States. Health departments and clinics implemented a collaborative data-to-care strategy to identify persons newly out-of-care with the objective of increasing re-engagement, retention in medical care, and viral load suppression Methods: A multi-site, prospective randomised trial was conducted to identify newly out-of-care PWH using surveillance and clinic data in Connecticut (CT), Massachusetts (MA) and Philadelphia (PHL). All out-of-care participants were randomised to receive standard of care or an active public health intervention. Re-engagement in care was defined as having a documented CD4 count and/or HIV viral load within 90 days of randomization. Retention was defined as having at least two CD4 count and/or HIV viral load results ≥ 3 months apart within 12 months of randomization, and viral load suppression as having a viral load

Ocular syphilis, a manifestation of Treponema pallidum infection, can cause a variety of ocular signs and symptoms, including eye redness, blurry vision, and vision loss. Although syphilis is nationally notifiable, ocular manifestations are not reportable to CDC. Syphilis rates have increased in the United States since 2000. After ocular syphilis clusters were reported in early 2015, CDC issued a clinical advisory (1) in April 2015 and published a description of the cases in October 2015 (2). Because of concerns about an increase in ocular syphilis, eight jurisdictions (California, excluding Los Angeles and San Francisco, Florida, Indiana, Maryland, New York City, North Carolina, Texas, and Washington) reviewed syphilis surveillance and case investigation data from 2014, 2015, or both to ascertain syphilis cases with ocular manifestations. A total of 388 suspected ocular syphilis cases were identified, 157 in 2014 and 231 in 2015. Overall, among total syphilis surveillance cases in the jurisdictions evaluated, 0.53% in 2014 and 0.65% in 2015 indicated ocular symptoms. Five jurisdictions described an increase in suspected ocular syphilis cases in 2014 and 2015. The predominance of cases in men (93%), proportion of those who are men who have sex with men (MSM), and percentage who are HIV-positive (51%) are consistent with the epidemiology of syphilis in the United States. It is important for clinicians to be aware of potential visual complications related to syphilis infections. Prompt identification of potential ocular syphilis, ophthalmologic evaluation, and appropriate treatment are critical to prevent or manage visual symptoms and sequelae of ocular syphilis.

CDC has updated its interim guidance for persons with possible Zika virus exposure who are planning to conceive (1) and interim guidance to prevent transmission of Zika virus through sexual contact (2), now combined into a single document. Guidance for care for pregnant women with possible Zika virus exposure was previously published (3). Possible Zika virus exposure is defined as travel to or residence in an area of active Zika virus transmission (http://www.cdc.gov/zika/geo/index.html), or sex* without a condom† with a partner who traveled to or lived in an area of active transmission. Based on new though limited data, CDC now recommends that all men with possible Zika virus exposure who are considering attempting conception with their partner, regardless of symptom status,§ wait to conceive until at least 6 months after symptom onset (if symptomatic) or last possible Zika virus exposure (if asymptomatic). Recommendations for women planning to conceive remain unchanged: women with possible Zika virus exposure are recommended to wait to conceive until at least 8 weeks after symptom onset (if symptomatic) or last possible Zika virus exposure (if asymptomatic). Couples with possible Zika virus exposure, who are not pregnant and do not plan to become pregnant, who want to minimize their risk for sexual transmission of Zika virus should use a condom or abstain from sex for the same periods for men and women described above. Women of reproductive age who have had or anticipate future Zika virus exposure who do not want to become pregnant should use the most effective contraceptive method that can be used correctly and consistently. These recommendations will be further updated when additional data become available.

United States surveillance data demonstrate that congenital syphilis cases are increasing. We performed an analysis of commercially insured pregnant females using MarketSan to determine syphilis screening rates at different prenatal stages; 85% of pregnant women in this population had a syphilis test performed at least once during the prenatal period.

Background Differences by sex in cardiovascular comorbid conditions among human immunodeficiency virus (HIV)–infected persons aged 50–64 years have been understudied; even fewer data are available for persons aged ≥65 years. Methods We used matched interview and medical record abstraction data from the 2009–2012 data cycles of the Medical Monitoring Project, a nationally representative sample of HIV-infected adults in care. We included men and women aged 50–64 and ≥65 years at time of interview. We calculated weighted prevalence estimates and used logistic regression to compute adjusted prevalence differences and 95% confidence intervals (CIs) assessing sex differences in various characteristics and cardiovascular comorbid conditions. Comorbid conditions included overweight/obesity (body mass index ≥25), abnormal total cholesterol level (defined as ≥200 mg/dL), diagnosed diabetes mellitus, or diagnosed hypertension. Results Of 7436 participants, 89.5% were aged 50–64 years and 10.4% aged ≥65 years, 75.1% were men, 40.4% (95% CI, 33.5%–47.2%) were non-Hispanic black, 72.0% (70.4%–73.6%) had HIV infection diagnosed ≥10 years earlier. After adjustment for sociodemographic and behavioral factors, women aged 50–64 years were more likely than men to be obese (adjusted prevalence difference, 8.4; 95% CI, 4.4–12.3), have hypertension (3.9; .1–7.6), or have high total cholesterol levels (9.9; 6.2–13.6). Women aged ≥65 years had higher prevalences of diabetes mellitus and high total cholesterol levels than men. Conclusions Cardiovascular comorbid conditions were prevalent among older HIV-infected persons in care; disparities existed by sex. Closer monitoring and risk-reduction strategies for cardiovascular comorbid conditions are warranted for older HIV-infected persons, especially older women.

Genital herpes simplex virus type 2 (HSV-2) is one of the most prevalent sexually transmitted infections in the United States. We sought to assess differences in HSV-2 seroprevalence among non-Hispanic blacks and non-Hispanic whites and describe trends over time from 1988 to 2010.Data from National Health and Nutrition Examination Surveys (NHANES) were used to determine national HSV-2 seroprevalence estimates from National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2002, 2003 to 2006, and 2007 to 2010. Persons aged 14 to 49 years were included in the analyses. Race/Ethnicity was defined by self-report as non-Hispanic white or non-Hispanic black. Purified glycoprotein specific for HSV-2 was used to detect type-specific antibodies using an immunodot assay. The same assay was used in all surveys. History of diagnosed genital herpes was self-reported.Overall, HSV-2 seroprevalence decreased in the United States between 1988 to 1994 and 2007 to 2010, from 21.2% to 15.5%. Among non-Hispanic white females, HSV-2 seroprevalence decreased from 19.5% (1988-1994) to 15.3% (2007-2010; P0.001); HSV-2 seroprevalence remained stable among non-Hispanic black females, 52.5% (1988-1994) to 49.9% (2007-2010; P = 0.1). The female black/white prevalence ratio was 2.7 (95% confidence interval [CI], 2.4-3.0) in 1988 to 1994 increasing to 3.3 (95% CI, 2.9-3.7) in 2007 to 2010 (P = 0.01). Among males, the black/white prevalence ratio was 2.4 (95% CI, 1.9-2.9) in 1988 to 1994 increasing to 4.4 (95% CI, 3.3-5.8) in 2007 to 2010 (P = 0.001). The overall percentage of HSV-2-seropositive survey participants who reported never being told by a doctor or health care professional that they had genital herpes did not change significantly between 1988 to 1994 and 2007 to 2010 and remained high (90.7% and 87.4%, respectively).Although HSV-2 seroprevalence decreased overall, the decrease was most marked among non-Hispanic whites, and racial disparities significantly increased over time. These persistent disparities demonstrate the need for innovative prevention strategies among this at-risk population.

We investigated an increase in Trichosporon asahii isolates among inpatients. We identified 63 cases; 4 involved disseminated disease. Trichosporon species was recovered from equipment cleaning rooms, washbasins, and fomites, which suggests transmission through washbasins. Patient washbasins should be single-patient use only; adherence to appropriate hospital disinfection guidelines was recommended.

Syphilis can have many clinical manifestations, including eye involvement, or "ocular syphilis." In 2015, an increase in reported cases of ocular syphilis and potential case clusters raised concern for an oculotropic strain of Treponema pallidum, the infectious agent of syphilis. Molecular typing was used to examine strains found in cases of ocular syphilis in the United States.In 2015, after a clinical advisory issued by the Centers for Disease Control and Prevention, pretreatment clinical specimens from US patients with ocular syphilis were sent to a research laboratory for molecular analysis of T. pallidum DNA. Molecular typing was conducted on these specimens, and results were compared with samples collected from Seattle patients diagnosed with syphilis, but without ocular symptoms.Samples were typed from 18 patients with ocular syphilis and from 45 patients with syphilis, but without ocular symptoms. Clinical data were available for 14 ocular syphilis patients: most were men, human immunodeficiency virus-infected, and had early syphilis. At least 5 distinct strain types of Treponema pallidum were identified in these patients, and 9 types were identified in the Seattle nonocular patients. 14d/g was the most common type in both groups. An unusual strain type was detected in a small cluster of ocular syphilis patients in Seattle.Ocular syphilis is a serious sequela of syphilis. In this preliminary study, clear evidence of a predominant oculotropic strain causing ocular syphilis was not detected. Identification of cases and prompt treatment is critical in the management of ocular syphilis.

We adapted a published model to estimate the costs and benefits of screening men who have sex with men for syphilis, including the benefits of preventing syphilis-attributable human immunodeficiency virus. The cost per quality-adjusted life year gained by screening was

Substantial increases in syphilis during 2008–2013 were reported in the US Pacific Northwest state of Oregon, especially among men who have sex with men (MSM). The authors aimed to characterize the ongoing epidemic and identify possible gaps in clinical management of early syphilis (primary, secondary, and latent syphilis ≤1 year) among MSM in Multnomah County, Oregon to inform public health efforts. Administrative databases were used to examine trends in case characteristics during 2008–2013. Medical records were abstracted for cases occurring in 2013 to assess diagnosis, treatment, and screening practices. Early syphilis among MSM increased from 21 cases in 2008 to 229 in 2013. The majority of cases occurred in HIV-infected patients (range: 55.6%–69.2%) diagnosed with secondary syphilis (range: 36.2%–52.4%). In 2013, 119 (51.9%) cases were diagnosed in public sector medical settings and 110 (48.0%) in private sector settings. Over 80% of HIV-infected patients with syphilis were in HIV care. Although treatment was adequate and timely among all providers, management differed by provider type. Among HIV-infected patients, a larger proportion diagnosed by public HIV providers than private providers were tested for syphilis at least once in the previous 12 months (89.6% vs. 40.0%; p < 0.001). The characteristics of MSM diagnosed with early syphilis in Multnomah County remained largely unchanged during 2008–2013. Syphilis control measures were well established, but early syphilis among MSM continued to increase. The results suggest a need to improve syphilis screening among private clinics, but few gaps in clinical management were identified.

Mucormycosis is a fungal infection caused by environmentally acquired molds. We investigated a cluster of cases of cutaneous mucormycosis among persons injured during the May 22, 2011, tornado in Joplin, Missouri.We defined a case as a soft-tissue infection in a person injured during the tornado, with evidence of a mucormycete on culture or immunohistochemical testing plus DNA sequencing. We conducted a case-control study by reviewing medical records and conducting interviews with case patients and hospitalized controls. DNA sequencing and whole-genome sequencing were performed on clinical specimens to identify species and assess strain-level differences, respectively.A total of 13 case patients were identified, 5 of whom (38%) died. The patients had a median of 5 wounds (range, 1 to 7); 11 patients (85%) had at least one fracture, 9 (69%) had blunt trauma, and 5 (38%) had penetrating trauma. All case patients had been located in the zone that sustained the most severe damage during the tornado. On multivariate analysis, infection was associated with penetrating trauma (adjusted odds ratio for case patients vs. controls, 8.8; 95% confidence interval [CI], 1.1 to 69.2) and an increased number of wounds (adjusted odds ratio, 2.0 for each additional wound; 95% CI, 1.2 to 3.2). Sequencing of the D1-D2 region of the 28S ribosomal DNA yielded Apophysomyces trapeziformis in all 13 case patients. Whole-genome sequencing showed that the apophysomyces isolates were four separate strains.We report a cluster of cases of cutaneous mucormycosis among Joplin tornado survivors that were associated with substantial morbidity and mortality. Increased awareness of fungi as a cause of necrotizing soft-tissue infections after a natural disaster is warranted.

Early syphilis in Multnomah County, Oregon, USA, increased 16-fold during 2007-2013. Cases predominantly occurred among men who have sex with men (MSM); 55% were HIV coinfected. We conducted a case-control study to evaluate the association between meeting sex partners online and early syphilis.Cases subjects (cases) were Multnomah County resident, English speaking, MSM, aged ≥18 years with laboratory-confirmed early syphilis reported 1 January to 31 December 2013. We recruited two MSM controls subjects (controls) per case, frequency matched by HIV status and age. Participants completed self-administered questionnaires. We performed multivariable logistic regression.Seventy per cent (40/57) of cases and 42% (50/119) of controls met partners online (p0.001). Cases more frequently met partners online (adjusted OR (aOR)=3.0; 95% CI 1.2 to 6.7), controlling for presumptive confounders. Cases reported more partners than controls (medians 5, 2; p0.001). When including number of partners, aOR decreased to 1.4 (95% CI 0.5 to 3.9).Early syphilis was associated with meeting partners online. We believe this association may be related to number of sex partners acting as an intermediate variable between use of online resources to meet sex partners and early syphilis. Online meet-up sites might represent areas for public health interventions targeting at-risk individuals.

Syphilis is a systemic disease caused by the spirochete Treponema pallidum that is usually acquired through sexual exposure.

Sexually transmitted diseases (STDs) and their associated syndromes are extremely common in clinical practice. Early diagnosis, appropriate treatment, and partner management are important to ensure sexual, physical, and reproductive health in our patients.

From December 1, 2014, to January 30, 2015, in King County, Washington, four cases of ocular syphilis, defined as clinical signs or symptoms consistent with ocular disease (e.g., uveitis or vision loss) in a person with laboratory-confirmed syphilis of any stage, were reported. All four cases occurred in men who have sex with men (MSM), two of whom were sex partners. Median age of the four patients was 39 years (range = 29–52 years). Three of the patients were infected with human immunodeficiency virus (HIV). Among the three HIV-infected patients, the median CD4 count was 111 cells/ml, and the median HIV-RNA was 34,740 copies/ml. All four patients had visual symptoms, including vision loss, flashing lights, and blurry vision. Ophthalmologic examinations were performed and all four were diagnosed with uveitis. All four patients had positive serum from rapid plasma reagin (RPR) testing (titer range = 1:256–1:4096). Based on history, one patient had late latent syphilis, and the remaining three received diagnoses of early latent syphilis. The three patients with early latent syphilis had cerebrospinal fluid (CSF) analysis performed; two had positive CSF in venereal disease research laboratory (VDRL) testing. Three patients received treatment with aqueous crystalline penicillin G for 14 days, and one was treated with 10 days of procaine penicillin and probenecid. All four patients had initial improvement in ocular symptoms after treatment. However, one patient still had a blind spot in one eye 1 month after treatment, and two patients were considered legally blind after 5 months; the fourth patient was lost to follow-up. Public Health–Seattle & King County has estimated that approximately 6–12 cases of symptomatic ocular syphilis occur annually in the county (1). The occurrence of four cases within 2 months led to a clinical advisory to medical providers and west coast health departments. Following the clinical advisory from King County, the San Francisco Department of Public Health identified eight cases of ocular syphilis reported from December 15, 2014, to March 25, 2015. Seven cases (88%) were in males; six (75%) were in MSM. No epidemiologic links were identified among the patients. Median age of the patients was 52 years (range = 35–58 years). Seven (88%) were HIV-infected (six MSM and one female commercial sex worker). Four patients had CD4 and HIV-RNA lab data available; median CD4 count was 291 cells/ml, median HIV-RNA was 84,500 copies/ml. Ophthalmologic examinations were performed on all eight patients, and records were reviewed for five. Diagnoses included ischemic optic neuropathy, uveitis, and retinal detachment. All patients had positive serum RPR (titer range = 1:256–1:8192); two had an initial false negative RPR because of the prozone effect. Three patients had a rash consistent with secondary syphilis, four had early latent syphilis, and one had late latent syphilis. Four cases had CSF analysis, three with a positive CSF VDRL result. All eight patients received aqueous crystalline penicillin G for 14 days. Following treatment, seven patients had improvement in ocular symptoms, and one patient had permanent visual loss in one eye after 3 months. Ocular syphilis, a clinical manifestation of neurosyphilis, typically occurs during early syphilis; uveitis is the most common presentation (2–4). For sexually active persons, the following steps can reduce the risk for syphilis: 1) being in a long-term mutually monogamous relationship with a partner who has been tested and has not tested positive for early syphilis; 2) using latex condoms correctly every time they have sex; and 3) for MSM, having annual screening for syphilis, and more frequent screening for MSM at greater risk. All patients who receive a diagnosis of syphilis should be asked screening questions to identify visual, hearing, or neurologic symptoms and receive a careful neurologic exam. Patients with ocular symptoms consistent with syphilis should be serologically evaluated for syphilis. An immediate ophthalmologic evaluation and CSF examination is recommended for patients with syphilis and ocular complaints. However, a normal CSF examination can occur with ocular syphilis. Ocular syphilis cases should be managed according to the treatment recommendations for neurosyphilis, regardless of CSF results, and patients should be tested for HIV (5). Cases of ocular syphilis should be reported to the state or local health department within 24 hours of diagnosis (6). For questions about possible ocular syphilis cases please contact Sara E. Oliver, MD, at 404-639-1204 or at vog.cdc@4oxy.

Background An estimated 120,000 HIV-associated cryptococcal meningitis (CM) cases occur each year in South and Southeast Asia; early treatment may improve outcomes. The World Health Organization (WHO) recently recommended screening HIV-infected adults with CD4

Case reports of Apophysomyces spp. in immunocompetent hosts have been a result of traumatic deep implantation of Apophysomyces spp. spore-contaminated soil or debris. On May 22, 2011 a tornado occurred in Joplin, MO, leaving 13 tornado victims with Apophysomyces trapeziformis infections as a result of lacerations from airborne material. We used whole genome sequence typing (WGST) for high-resolution phylogenetic SNP analysis of 17 outbreak Apophysomyces isolates and five additional temporally and spatially diverse Apophysomyces control isolates (three A. trapeziformis and two A. variabilis isolates). Whole genome SNP phylogenetic analysis revealed three clusters of genotypically related or identical A. trapeziformis isolates and multiple distinct isolates among the Joplin group; this indicated multiple genotypes from a single or multiple sources. Though no linkage between genotype and location of exposure was observed, WGST analysis determined that the Joplin isolates were more closely related to each other than to the control isolates, suggesting local population structure. Additionally, species delineation based on WGST demonstrated the need to reassess currently accepted taxonomic classifications of phylogenetic species within the genus Apophysomyces.