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Introduction A leading cause of acute gastroenteritis, norovirus can be transmitted by infected food handlers but norovirus outbreaks are not routinely investigated in Kenya. We estimated norovirus prevalence and associated factors among food handlers in an informal urban settlement in Nairobi, Kenya. Methods We conducted a cross-sectional survey among food handlers using pretested questionnaires and collected stool specimens from food handlers which were analyzed for norovirus by conventional PCR. We observed practices that allow norovirus transmission and surveyed respondents on knowledge, attitudes, and practices in food safety. We calculated odd ratios (OR) with 95% confidence intervals (CI) to identify factors associated with norovirus infection. Variables with p Results Of samples from 283 respondents, 43 (15.2%) tested positive for norovirus. Factors associated with norovirus detection were: reporting diarrhea and vomiting within the previous month (AOR = 5.7, 95% CI = 1.2–27.4), not knowing aerosols from infected persons can contaminate food (AOR = 6.5, 95% CI = 1.1–37.5), not knowing that a dirty chopping board can contaminate food (AOR = 26.1, 95% CI = 1.6–416.7), observing respondents touching food bare-handed (AOR = 3.7, 95% CI = 1.5–11.1), and working in premises without hand washing services (AOR = 20, 95% CI = 3.4–100.0). Conclusion The norovirus infection was prevalent amongst food handlers and factors associated with infection were based on knowledge and practices of food hygiene. We recommend increased hygiene training and introduce more routine inclusion of norovirus testing in outbreaks in Kenya.

Rapid detection and response to infectious disease outbreaks requires a robust surveillance system with a sufficient number of trained public health workforce personnel. The Frontline Field Epidemiology Training Program (Frontline) is a focused 3-month program targeting local ministries of health to strengthen local disease surveillance and reporting capacities. Limited literature exists on the impact of Frontline graduates on disease surveillance completeness and timeliness reporting. Using routinely collected Ministry of Health data, we mapped the distribution of graduates between 2014 and 2017 across 47 Kenyan counties. Completeness was defined as the proportion of complete reports received from health facilities in a county compared with the total number of health facilities in that county. Timeliness was defined as the proportion of health facilities submitting surveillance reports on time to the county. Using a panel analysis and controlling for county-fixed effects, we evaluated the relationship between the number of Frontline graduates and priority disease reporting of measles. We found that Frontline training was correlated with improved completeness and timeliness of weekly reporting for priority diseases. The number of Frontline graduates increased by 700%, from 57 graduates in 2014 to 456 graduates in 2017. The annual average rates of reporting completeness increased from 0.8% in 2014 to 55.1% in 2017. The annual average timeliness reporting rates increased from 0.1% in 2014 to 40.5% in 2017. These findings demonstrate how global health security implementation progress in workforce development may influence surveillance and disease reporting.

Dadaab Refugee camp in Garissa County, Kenya, hosts nearly 340,000 refugees in five subcamps (Dagahaley, Hagadera, Ifo, Ifo2, and Kambioos) (1). On November 18 and 19, 2015, during an ongoing national cholera outbreak (2), two camp residents were evaluated for acute watery diarrhea (three or more stools in ≤24 hours); Vibrio cholerae serogroup O1 serotype Ogawa was isolated from stool specimens collected from both patients. Within 1 week of the report of index cases, an additional 45 cases of acute watery diarrhea were reported. The United Nations High Commissioner for Refugees and their health-sector partners coordinated the cholera response, community outreach and water, sanitation, and hygiene (WASH) activities; Médecins Sans Frontiéres and the International Rescue Committee were involved in management of cholera treatment centers; CDC performed laboratory confirmation of cases and undertook GIS mapping and postoutbreak response assessment; and the Garissa County Government and the Kenya Ministry of Health conducted a case-control study. To prevent future cholera outbreaks, improvements to WASH and enhanced disease surveillance systems in Dadaab camp and the surrounding area are needed.

Introduction:in 2015, a cholera outbreak was confirmed in Nairobi county, Kenya, which we investigated to identify risk factors for infection and recommend control measures. Methods:we analyzed national cholera surveillance data to describe epidemiological patterns and carried out a case-control study to find reasons for the Nairobi county outbreak. Suspected cholera cases were Nairobi residents aged >2 years with acute watery diarrhea (>4 stools/≤12 hours) and illness onset 1-14 May 2015. Confirmed cases hadVibrio choleraeisolated from stool. Case-patients were frequency-matched to persons without diarrhea (1:2 by age group, residence), interviewed using standardized questionaires. Logistic regression identified factors associated with case status. Household water was analyzed for fecal coliforms andEscherichia coli. Results:during December 2014-June 2015, 4,218 cholera cases including 282 (6.7%) confirmed cases and 79 deaths (case-fatality rate [CFR] 1.9%) were reported from 14 of 47 Kenyan counties. Nairobi county reported 781 (19.0 %) cases (attack rate, 18/100,000 persons), including 607 (78%) hospitalisations, 20 deaths (CFR 2.6%) and 55 laboratory-confirmed cases (7.0%). Seven (70%) of 10 water samples from communal water points had coliforms; one hadEscherichia coli. Factors associated with cholera in Nairobi were drinking untreated water (adjusted odds ratio [aOR] 6.5, 95% confidence interval [CI] 2.3-18.8), lacking health education (aOR 2.4, CI 1.1-7.9) and eating food outside home (aOR 2.4, 95% CI 1.2-5.7). Conclusion:we recommend safe water, health education, avoiding eating foods prepared outside home and improved sanitation in Nairobi county. Adherence to these practices could have prevented this protacted cholera outbreak.

More than 75% of emerging infectious diseases are zoonotic in origin and a transdisciplinary, multi-sectoral One Health approach is a key strategy for their effective prevention and control. In 2004, US Centers for Disease Control and Prevention office in Kenya (CDC Kenya) established the Global Disease Detection Division of which one core component was to support, with other partners, the One Health approach to public health science. After catalytic events such as the global expansion of highly pathogenic H5N1 and the 2006 East African multi-country outbreaks of Rift Valley Fever, CDC Kenya supported key Kenya government institutions including the Ministry of Health and the Ministry of Agriculture, Livestock, and Fisheries to establish a framework for multi-sectoral collaboration at national and county level and a coordination office referred to as the Zoonotic Disease Unit (ZDU). The ZDU has provided Kenya with an institutional framework to highlight the public health importance of endemic and epidemic zoonoses including RVF, rabies, brucellosis, Middle East Respiratory Syndrome Coronavirus, anthrax and other emerging issues such as anti-microbial resistance through capacity building programs, surveillance, workforce development, research, coordinated investigation and outbreak response. This has led to improved outbreak response, and generated data (including discovery of new pathogens) that has informed disease control programs to reduce burden of and enhance preparedness for endemic and epidemic zoonotic diseases, thereby enhancing global health security. Since 2014, the Global Health Security Agenda implemented through CDC Kenya and other partners in the country has provided additional impetus to maintain this effort and Kenya’s achievement now serves as a model for other countries in the region. Significant gaps remain in implementation of the One Health approach at subnational administrative levels; there are sustainability concerns, competing priorities and funding deficiencies.

Introduction Measles is targeted for elimination in the World Health Organization African Region by the year 2020. In 2011, Kenya was off track in attaining the 2012 pre-elimination goal. We describe the epidemiology of measles in Kenya and assess progress made towards elimination. Methods We reviewed national case-based measles surveillance and immunization data from January 2003 to December 2016. A case was confirmed if serum was positive for anti-measles IgM antibody, was epidemiologically linked to a laboratory-confirmed case or clinically compatible. Data on case-patient demographics, vaccination status, and clinical outcome and measles containing vaccine (MCV) coverage were analyzed. We calculated measles surveillance indicators and incidence, using population estimates for the respective years. Results The coverage of first dose MCV (MCV1) increased from 65% to 86% from 2003-2012, then declined to 75% in 2016. Coverage of second dose MCV (MCV2) remained < 50% since introduction in 2013. During 2003-2016, there were 26,188 suspected measles cases were reported, with 9043(35%) confirmed cases, and 165 deaths (case fatality rate, 1.8%). The non-measles febrile rash illness rate was consistently > 2/100,000 population, and “80% of the sub-national level investigated a case in 11 of the 14 years. National incidence ranged from 4 to 62/million in 2003-2006 and decreased to 3/million in 2016. The age specific incidence ranged from 1 to 364/million population and was highest among children aged < 1 year. Conclusion Kenya has made progress towards measles elimination. However, this progress remains at risk and the recent declines in MCV1 coverage and the low uptake in MCV2 could reverse these gains.

Background Hepatitis B virus (HBV) is a vaccine-preventable infection that can spread in healthcare setting. Data on HBV infections and vaccine in African healthcare workers (HCWs) are limited. We estimated HBV infection prevalence, hepatitis B vaccination status and identified factors associated with vaccination in one Kenyan county. Methods Randomly selected HCWs completed a questionnaire about HBV exposure and self-reported immunization histories, and provided blood for testing of selected HBV biomarkers to assess HBV infection and vaccination status: HBV core antibodies (anti-HBc), HBV surface antigen (HBsAg) and HBV surface antibodies (anti-HBs). Prevalence odds ratios (OR) with 95% confidence intervals (95% CI) were calculated to identify factors associated with vaccination. Results Among 312 HCWs surveyed, median age was 31 years (range: 19–67 years). Of 295 blood samples tested, 13 (4%) were anti-HBc and HBsAg-positive evidencing chronic HBV infection; 139 (47%) had protective anti-HBs levels. Although 249 (80%) HCWs received ≥1 HBV vaccine dose, only 119 (48%) received all three recommended doses. Complete vaccination was more likely among those working in hospitals compared to those working in primary healthcare facilities (OR = 2.5; 95% CI: 1.4–4.3). Conclusion We recommend strengthening county HCW vaccination, and collecting similar data nationally to guide HBV prevention and control.

Background From December 2014 to September 2016, a cholera outbreak in Kenya, the largest since 2010, caused 16,840 reported cases and 256 deaths. The outbreak affected 30 of Kenya’s 47 counties and occurred shortly after the decentralization of many healthcare services to the county level. This mixed-methods study, conducted June–July 2015, assessed cholera preparedness in Homa Bay, Nairobi, and Mombasa counties and explored clinic- and community-based health care workers’ (HCW) experiences during outbreak response. Methods Counties were selected based on cumulative cholera burden and geographic characteristics. We conducted 44 health facility cholera preparedness checklists (according to national guidelines) and 8 focus group discussions (FGDs). Frequencies from preparedness checklists were generated. To determine key themes from FGDs, inductive and deductive codes were applied; MAX software for qualitative data analysis (MAXQDA) was used to identify patterns. Results Some facilities lacked key materials for treating cholera patients, diagnosing cases, and maintaining infection control. Overall, 82% (36/44) of health facilities had oral rehydration salts, 65% (28/43) had IV fluids, 27% (12/44) had rectal swabs, 11% (5/44) had Cary-Blair transport media, and 86% (38/44) had gloves. A considerable number of facilities lacked disease reporting forms (34%, 14/41) and cholera treatment guidelines (37%, 16/43). In FDGs, HCWs described confusion regarding roles and reporting during the outbreak, which highlighted issues in coordination and management structures within the health system. Similar to checklist findings, FGD participants described supply challenges affecting laboratory preparedness and infection prevention and control. Perceived successes included community engagement, health education, strong collaboration between clinic and community HCWs, and HCWs’ personal passion to help others. Conclusions The confusion over roles, reporting, and management found in this evaluation highlights a need to adapt, implement, and communicate health strategies at the county level, in order to inform and train HCWs during health system transformations. International, national, and county stakeholders could strengthen preparedness and response for cholera and other public health emergencies in Kenya, and thereby strengthen global health security, through further investment in the existing Integrated Disease Surveillance and Response structure and national cholera prevention and control plan, and the adoption of county-specific cholera control plans.

Background. Lead exposure is linked to intellectual disability and anemia in children. The United States Centers for Disease Control and Prevention (CDC) recommends biomonitoring of blood lead levels (BLLs) in children with BLL ≥5 μg/dL and chelation therapy for those with BLL ≥45 μg/dL.Objectives. This study aimed to determine blood and environmental lead levels and risk factors associated with elevated BLL among children from Owino Uhuru and Bangladesh settlements in Mombasa County, Kenya.Methods. The present study is a population-based, cross-sectional study of children aged 12–59 months randomly selected from households in two neighboring settlements, Owino Uhuru, which has a lead smelter, and Bangladesh settlement (no smelter). Structured questionnaires were administered to parents and 1–3 ml venous blood drawn from each child was tested for lead using a LeadCare ® II portable analyzer. Environmental samples collected from half of the sampled households were tested for lead using graphite furnace atomic absorption spectroscopy.Results: We enrolled 130 children, 65 from each settlement. Fifty-nine (45%) were males and the median age was 39 months (interquartile range (IQR): 30–52 months). BLLs ranged from 1 μg/dL to 31 μg/dL, with 45 (69%) children from Owino Uhuru and 18 (28%) children from Bangladesh settlement with BLLs >5 μg/dL. For Owino Uhuru, the geometric mean BLL in children was 7.4 μg/dL (geometric standard deviation (GSD); 1.9) compared to 3.7 μg/dL (GSD: 1.9) in Bangladesh settlement (pConclusions. Children in Owino Uhuru had significantly higher BLLs compared with children in Bangladesh settlement. Interventions to diminish continued exposure to lead in the settlement should be undertaken. Continued monitoring of levels in children with detectable levels can evaluate whether interventions to reduce exposure are effective.Participant Consent. ObtainedEthics Approval. Scientific approval for the study was obtained from the Ministry of Health, lead poisoning technical working group. Since this investigation was considered a public health response of immediate concern, expedited ethical approval was obtained from the Kenya Medical Research Institute and further approval from the Mombasa County Department of Health Services. The investigation was considered a non-research public health response activity by the CDC.Competing Interests. The authors declare no competing financial interests.

Introduction:HIV-exposed infants (HEI) lost-to-follow-up (LTFU) remains a problem in sub Saharan Africa (SSA). In 2015, SSA accounted >90% of the 150,000 new infant HIV infections, with an estimated 13,000 reported in Kenya. Despite proven and effective HIV interventions, many HEI fail to benefit because of LTFU. LTFU leads to delays or no initiation of interventions, thereby contributing to significant child morbidity and mortality. Kenya did not achieve the

Background Malaria accounts for ~21% of outpatient visits annually in Kenya; prompt and accurate malaria diagnosis is critical to ensure proper treatment. In 2013, formal malaria microscopy refresher training for microscopists and a pilot quality-assurance (QA) programme for malaria diagnostics were independently implemented to improve malaria microscopy diagnosis in malaria low-transmission areas of Kenya. A study was conducted to identify factors associated with malaria microscopy performance in the same areas. Methods From March to April 2014, a cross-sectional survey was conducted in 42 public health facilities; 21 were QA-pilot facilities. In each facility, 18 malaria thick blood slides archived during January–February 2014 were selected by simple random sampling. Each malaria slide was re-examined by two expert microscopists masked to health-facility results. Expert results were used as the reference for microscopy performance measures. Logistic regression with specific random effects modelling was performed to identify factors associated with accurate malaria microscopy diagnosis. Results Of 756 malaria slides collected, 204 (27%) were read as positive by health-facility microscopists and 103 (14%) as positive by experts. Overall, 93% of slide results from QA-pilot facilities were concordant with expert reference compared to 77% in non-QA pilot facilities (p

Dromedary camels are implicated as reservoirs for the zoonotic transmission of Middle East Respiratory Syndrome coronavirus (MERS‐CoV) with the respiratory route thought to be the main mode of transmission. Knowledge and practices regarding MERS among herders, traders and slaughterhouse workers were assessed at Athi‐River slaughterhouse, Kenya. Questionnaires were administered, and a check list was used to collect information on hygiene practices among slaughterhouse workers. Of 22 persons, all washed hands after handling camels, 82% wore gumboots, and 65% wore overalls/dustcoats. None of the workers wore gloves or facemasks during slaughter processes. Fourteen percent reported drinking raw camel milk; 90% were aware of zoonotic diseases with most reporting common ways of transmission as: eating improperly cooked meat (90%), drinking raw milk (68%) and slaughter processes (50%). Sixteen (73%) were unaware of MERS‐CoV. Use of personal protective clothing to prevent direct contact with discharges and aerosols was lacking. Although few people working with camels were interviewed, those met at this centralized slaughterhouse lacked knowledge about MERS‐CoV but were aware of zoonotic diseases and their transmission. These findings highlight need to disseminate information about MERS‐CoV and enhance hygiene and biosafety practices among camel slaughterhouse workers to reduce opportunities for potential virus transmission.

The recent Zika outbreak in the Americas, Ebola epidemic in West Africa and the increased frequency and impact of emerging and re-emerging infections of animal origin have increased the calls for greater preparedness in early detection and responses to public health events. One-Health approaches that emphasize collaborations between human health, animal health and environmental health sectors for the prevention, early detection and response to disease outbreaks have been hailed as a key strategy. Here we highlight three main efforts that have progressed the implementation of One Health in Kenya.

This article summarizes the status of environmental surveillance (ES) used by the Global Polio Eradication Initiative, provides the rationale for ES, gives examples of ES methods and findings, and summarizes how these data are used to achieve poliovirus eradication. ES complements clinical acute flaccid paralysis (AFP) surveillance for possible polio cases. ES detects poliovirus circulation in environmental sewage and is used to monitor transmission in communities. If detected, the genetic sequences of polioviruses isolated from ES are compared with those of isolates from clinical cases to evaluate the relationships among viruses. To evaluate poliovirus transmission, ES programs must be developed in a manner that is sensitive, with sufficiently frequent sampling, appropriate isolation methods, and specifically targeted sampling sites in locations at highest risk for poliovirus transmission. After poliovirus ceased to be detected in human cases, ES documented the absence of endemic WPV transmission and detected imported WPV. ES provides valuable information, particularly in high-density populations where AFP surveillance is of poor quality, persistent virus circulation is suspected, or frequent virus reintroduction is perceived. Given the benefits of ES, GPEI plans to continue and expand ES as part of its strategic plan and as a supplement to AFP surveillance.

While global polio eradication requires tremendous efforts in countries where wild polioviruses (WPVs) circulate, numerous outbreaks have occurred following WPV importation into previously polio-free countries. Countries that have interrupted endemic WPV transmission should continue to conduct routine risk assessments and implement mitigation activities to maintain their polio-free status as long as wild poliovirus circulates anywhere in the world. This article reviews the methods used by World Health Organization (WHO) regional offices to qualitatively assess risk of WPV outbreaks following an importation. We describe the strengths and weaknesses of various risk assessment approaches, and opportunities to harmonize approaches. These qualitative assessments broadly categorize risk as high, medium, or low using available national information related to susceptibility, the ability to rapidly detect WPV, and other population or program factors that influence transmission, which the regions characterize using polio vaccination coverage, surveillance data, and other indicators (e.g., sanitation), respectively. Data quality and adequacy represent a challenge in all regions. WHO regions differ with respect to the methods, processes, cut-off values, and weighting used, which limits comparisons of risk assessment results among regions. Ongoing evaluation of indicators within regions and further harmonization of methods between regions are needed to effectively plan risk mitigation activities in a setting of finite resources for funding and continued WPV circulation.

Background Globally, vaccine preventable diseases are responsible for nearly 20 % of deaths annually among children 5 km from health facility (OR 1.6, CI 1.0–2.7) were associated with higher odds of dropping out. Those who received text messages were less likely to drop out compared to controls (OR 0.2, CI 0.04–0.8). There was no statistical difference between those who received stickers and controls (OR 0.9, CI 0.5–1.6). Conclusion Text message reminders can reduce vaccination dropout rates in Kenya. We recommend the extended implementation of text message reminders in routine vaccination services.

On January 6, 2015, a man aged 40 years was admitted to Kenyatta National Hospital in Nairobi, Kenya, with acute watery diarrhea. The patient was found to be infected with toxigenic Vibrio cholerae serogroup O1, serotype Inaba. A subsequent review of surveillance reports identified four patients in Nairobi County during the preceding month who met either of the Kenya Ministry of Health suspected cholera case definitions: 1) severe dehydration or death from acute watery diarrhea (more than four episodes in 12 hours) in a patient aged ≥5 years, or 2) acute watery diarrhea in a patient aged ≥2 years in an area where there was an outbreak of cholera. An outbreak investigation was immediately initiated. A confirmed cholera case was defined as isolation of V. cholerae O1 or O139 from the stool of a patient with suspected cholera or a suspected cholera case that was epidemiologically linked to a confirmed case. By January 15, 2016, a total of 11,033 suspected or confirmed cases had been reported from 22 of Kenya's 47 counties (Table). The outbreak is ongoing.

In 2010, the requirement for human immunodeficiency virus (HIV) testing of adult refugees prior to US resettlement was removed, thus leading to a potential for missed diagnosis. We reviewed refugee health assessment data and medical charts to evaluate the health status of HIV-infected refugees who arrived in Minnesota during 2000–2007, prior to this 2010 policy change. Among 19,292 resettled adults, 174 were HIV-infected; 169 (97%) were African (median age 26.4 (range: 17–76) years). Charts were abstracted for 157 (124 (79%) with ≥1 year of follow-up). At initial presentation, two of 74 (3%) women were pregnant; 27% became pregnant during follow-up. HIV clinical stage varied (59%, asymptomatic; 11%, mild symptoms; 10%, advanced symptoms; 3%, severe symptoms; 17%, unknown); coinfections were common (51 tuberculosis, 13 hepatitis B, 13 parasites, four syphilis). Prior to arrival 4% had received antiretrovirals. Opportunistic infections were diagnosed among 13%; 2% died from AIDS-related causes. Arrival screening may be needed to identify these HIV-infected refugees and prevent HIV-related morbidity and mortality.

Background Salmonella enterica serovar Typhi causes an estimated 22 million cases of typhoid fever and 216 000 deaths annually worldwide. We investigated an outbreak of unexplained febrile illnesses with neurologic findings, determined to be typhoid fever, along the Malawi-Mozambique border. Methods The investigation included active surveillance, interviews, examinations of ill and convalescent persons, medical chart reviews, and laboratory testing. Classification as a suspected case required fever and ≥1 other finding (eg, headache or abdominal pain); a probable case required fever and a positive rapid immunoglobulin M antibody test for typhoid (TUBEX TF); a confirmed case required isolation of Salmonella Typhi from blood or stool. Isolates underwent antimicrobial susceptibility testing and subtyping by pulsed-field gel electrophoresis (PFGE). Results We identified 303 cases from 18 villages with onset during March-November 2009; 214 were suspected, 43 were probable, and 46 were confirmed cases. Forty patients presented with focal neurologic abnormalities, including a constellation of upper motor neuron signs (n = 19), ataxia (n = 22), and parkinsonism (n = 8). Eleven patients died. All 42 isolates tested were resistant to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole; 4 were also resistant to nalidixic acid. Thirty-five of 42 isolates were indistinguishable by PFGE. Conclusions The unusual neurologic manifestations posed a diagnostic challenge that was resolved through rapid typhoid antibody testing in the field and subsequent blood culture confirmation in the Malawi national reference laboratory. Extending laboratory diagnostic capacity, including blood culture, to populations at risk for typhoid fever in Africa will improve outbreak detection, response, and clinical treatment.

SUMMARYAn increase in invasiveHaemophilus influenzaetype b (Hib) cases occurred in Minnesota in 2008 after the recommended deferral of the 12–15 months Hib vaccine boosters during a US vaccine shortage. Five invasive Hib cases (one death) occurred in children; four had incomplete Hib vaccination (three refused/delayed); one was immunodeficient. Subsequently, we evaluated Hib carriage and vaccination. From 18 clinics near Hib cases, children (aged 4 weeks–60 months) were surveyed for pharyngeal Hib carriage. Records were compared for Hib, diphtheria-tetanus-acellular pertussis (DTaP), and pneumococcal (PCV-7) vaccination. Parents completed questionnaires on carriage risk factors and vaccination beliefs. In 1631 children (February–March 2009), no Hib carriage was detected; Hib vaccination was less likely to be completed than DTaP and PCV-7. Non-type bH. influenzae, detected in 245 (15%) children, was associated with: male sex, age 24–60 months, daycare attendance >15 h/week, a household smoker, and Asian/Pacific Islander race/ethnicity. In 2009, invasive Hib disease occurred in two children caused by the same strain that circulated in 2008. Hib remains a risk for vulnerable/unvaccinated children, although Hib carriage is not widespread in young children.

Approximately 1.4 million Salmonella infections and 400 deaths occur annually in the United States. Approximately 6% of human Salmonella cases are thought to be associated with reptiles; Salmonella enterica subspecies IV is primarily reptile-associated. During 1-4 December, 2009, three isolates of Salmonella IV 6,7:z4,z24:- with indistinguishable pulsed-field gel electrophoresis (PFGE) patterns were identified through Minnesota Department of Health laboratory-based surveillance. None of the three patients associated with the isolates reported reptile contact; however, all had attended the same potluck dinner. Dinner attendees were asked questions regarding illness history, foods they prepared for and consumed at the event, and pet ownership. Cases were defined as illness in a person who had eaten potluck food and subsequently experienced fever and diarrhoea (three or more loose stools in 24 h) or laboratory-confirmed infection with Salmonella IV matching the outbreak PFGE subtype. Nineteen days after the event, environmental samples were collected from a food preparer's house where two pet bearded dragons were kept. Sixty-six of 73 potluck food consumers were interviewed; 19 cases were identified; 18 persons reported illness but did not meet the case definition. Median incubation period was 19 h (range: 3-26 h). Median duration of illness was 5 days (range: 1-11 days). Consumption of gravy, prepared by the bearded dragons' asymptomatic owner, was associated with illness (16/32 exposed versus 1/12 unexposed; risk ratio: 6.0; exact P = 0.02). Salmonella Labadi was recovered from 10 samples, including from one bearded dragon, the bathroom door knob and sink drain, and the kitchen sink drain. The outbreak PFGE subtype of Salmonella subspecies IV was isolated from vacuum-cleaner bag contents. This foodborne outbreak probably resulted from environmental contamination from bearded dragons. Reptiles pose a community threat when food for public consumption is prepared in households with reptiles.

Summary Objectives To describe our experience using satellite image-based sampling to conduct a health survey of children in an urban area of Lusaka, Zambia, as an approach to sampling when the population is poorly characterized by existing census data or maps. Methods Using a publicly available Quickbird™ image of several townships, we created digital records of structures within the residential urban study area using ArcGIS 9.2. Boundaries were drawn to create geographic subdivisions based on natural and man-made barriers (e.g. roads). Survey teams of biomedical research students and local community health workers followed a standard protocol to enrol children within the selected structure, or to move to the neighbouring structure if the selected structure was ineligible or refused enrolment. Spatial clustering was assessed using the K-difference function. Results Digital records of 16 105 structures within the study area were created. Of the 750 randomly selected structures, six (1%) were not found by the survey teams. A total of 1247 structures were assessed for eligibility, of which 691 eligible households were enroled. The majority of enroled households were the initially selected structures (51%) or the first selected neighbour (42%). Households that refused enrolment tended to cluster more than those which enroled. Conclusions Sampling from a satellite image was feasible in this urban African setting. Satellite images may be useful for public health surveillance in populations with inaccurate census data or maps and allow for spatial analyses such as identification of clustering among refusing households. Objectifs: Decrire notre experience utilisant l’echantillonnage base sur des images satellites pour proceder a une enquete sur la sante des enfants dans une zone urbaine de Lusaka, en Zambie, comme une approche a l’echantillonnage lorsque la population est mal caracterisee par les donnees du recensement ou des cartes. Methodes: En utilisant des images Quickbird™publiquement disponibles de plusieurs townships, nous avons cree des donnees numeriques de structures a l’interieur de la zone urbaine etudiee en utilisant ArcGIS 9.2. Les limites ont ete dessinees afin de creer des subdivisions geographiques basees sur des barrieres naturelles ou fixees par l’homme (exemple: routes). Des equipes de surveillance constituees d’etudiants en recherche biomedicale et d’agents de sante communautaires locaux ont suivi un protocole standard pour inscrire les enfants au sein de la structure choisie ou de passer a la structure voisine si la structure selectionneetait ineligible ou avait refuse l’inscription. Le regroupement spatial a eteevaluea l’aide de la fonction de difference K. Resultats: Des donnees numeriques de 16105 structures a l’interieur de la zone d’etude ont ete creees. Sur les 750 structures choisies aleatoirement, 6 (1%) n’ont pas ete retrouvees par les equipes d’enquete. Au total, 1247 structures ont eteevaluees pour l’eligibilite, dont 691 menages eligibles ont ete inscrits. La majorite des menages inscrits etaient ceux des structures initialement selectionnees (51%) ou les premiers voisins selectionnes (42%). Les menages qui ont refuse l’inscription avaient tendance aetre plus regroupes que ceux qui ont ete inscrits. Conclusions: L’echantillonnage sur base d’image satellite a ete possible dans ce milieu urbain africain. Les images satellites peuvent etre utiles pour la surveillance de la sante publique dans les populations avec des donnees de recensement et des cartes geographiques non precises afin de permettre des analyses spatiales telles que l’identification de regroupements parmi les menages refusant l’enrolement. Objetivos: Describir nuestra experiencia utilizando un muestreo basado en imagenes satelitales, como una forma de muestrear cuando la poblacion esta mal caracterizada con los censos o mapas disponibles, durante la realizacion de un estudio sanitario con ninos en un area urbana de Lusaka, Zambia,. Metodos: Utilizando imagenes Quickbird™ publicas, se creo una base de datos digital de estructuras dentro del area urbana residencial de estudio, utilizando ArcGIS 9.2. Se trazaron los limites para crear subdivisiones geograficas basandose en barreras naturales o creadas por el hombre (por ejemplo, carreteras). Los equipos de encuestadores, compuestos por estudiantes de investigacion biomedica o trabajadores sanitarios locales (TSLs) siguieron un protocolo estandar para incluir a ninos dentro de la estructura seleccionada, o se movieron a la estructura vecina si la seleccionada no era legible o se negaban a participar en el estudio. La agrupacion espacial fue evaluada utilizando las formas diferenciales de grado K . Resultados: Se crearon datos digitales para 16,105 estructuras dentro del area de estudio. De las 750 estructuras elegidas al azar, 6 (1%) no fueron halladas por los equipos de encuestadores. Se evaluo un total de 1,247 estructuras, de las cuales se incluyeron en el estudio 691 hogares aptos. La mayoria de los hogares incluidos estaban dentro de las estructuras elegidas inicialmente (51%) o dentro de la primera seleccion de vecinos (42%). Los hogares que rehusaron participar tendian a estar mas agrupados que aquellos que aceptaron participar. Conclusiones: El muestreo mediante imagenes satelitales fue viable en esta area Africana. Las imagenes satelitales pueden ser utiles para realizar vigilancias de salud publica en poblaciones con datos censales o mapas inexactos, y permiten realizar analisis espaciales tales como la identificacion de agrupamientos entre hogares que se rehusan participar en estudios.

Background Severe acute respiratory syndrome–associated coronavirus (SARS-CoV) was introduced to the United States through air travel. Although the risk of SARS-CoV transmission within aircraft cabins has been addressed by several studies, the magnitude of the risk remains unclear. Methods We attempted to contact all persons with working US telephone numbers aboard seven US-bound flights carrying SARS patients. Consenting participants responded to a questionnaire, and a serum sample was collected at least 38 days after the flight and tested for SARS-CoV-associated antibodies. Participants reporting an illness compatible with SARS, with onset during the 2- to 10-day incubation period, were considered suspect cases; positive serology was required for confirmed cases. Results Among 1,766 passengers and crew, 339 (19%) persons were contacted. Of these, 312 (92%) completed questionnaires, and blood was collected from 127 (37%). Serology was negative for all 127 participants, including three of four who met the clinical case criteria for SARS, and the fourth had a mild illness that lasted only 5 days. Conclusions Transmission of SARS-associated CoV was not observed, suggesting that the risk of transmission is not amplified aboard aircraft.

Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract illness among infants and young children. Respiratory system diseases account for a large proportion of hospitalizations in American Indian and Alaska Native (AI/AN) children; however, aggregate estimates of RSV-associated hospitalizations among AI/AN children have not been made.We used Indian Health Service hospitalization data from 1990 through 1995 to describe hospitalizations associated with bronchiolitis, the most characteristic clinical manifestation of RSV infection, among AI/AN children5 years old.The overall bronchiolitis-associated hospitalization rate among AI/AN infants1 year old was considerably higher (61.8 per 1,000) than the 1995 estimated bronchiolitis hospitalization rate among all US infants (34.2 per 1,000). Hospitalization rates were higher among male infants (72.2 per 1,000) than among females infants (51.1 per 1,000). The highest infant hospitalization rate was noted in the Navajo Area (96.3 per 1,000). Hospitalizations peaked annually in January or February, consistent with national peaks for RSV detection. Bronchiolitis hospitalizations accounted for an increasing proportion of hospitalizations for lower respiratory tract illnesses.Bronchiolitis-associated hospitalization rates are substantially greater for AI/AN infants than those for all US infants. This difference may reflect an increased likelihood of severe RSV-associated disease or a decreased threshold for hospitalization among AI/AN infants with bronchiolitis compared with all US infants. AI/AN children would receive considerable benefit from lower respiratory tract illness prevention programs, including an RSV vaccine, if and when one becomes available.

While global polio eradication requires tremendous efforts in countries where wild polioviruses (WPVs) circulate, numerous outbreaks have occurred following WPV importation into previously polio-free countries. Countries that have interrupted endemic WPV transmission should continue to conduct routine risk assessments and implement mitigation activities to maintain their polio-free status as long as wild poliovirus circulates anywhere in the world. This article reviews the methods used by World Health Organization (WHO) regional offices to qualitatively assess risk of WPV outbreaks following an importation. We describe the strengths and weaknesses of various risk assessment approaches, and opportunities to harmonize approaches. These qualitative assessments broadly categorize risk as high, medium, or low using available national information related to susceptibility, the ability to rapidly detect WPV, and other population or program factors that influence transmission, which the regions characterize using polio vaccination coverage, surveillance data, and other indicators (e.g., sanitation), respectively. Data quality and adequacy represent a challenge in all regions. WHO regions differ with respect to the methods, processes, cut-off values, and weighting used, which limits comparisons of risk assessment results among regions. Ongoing evaluation of indicators within regions and further harmonization of methods between regions are needed to effectively plan risk mitigation activities in a setting of finite resources for funding and continued WPV circulation.

In 2010, the requirement for human immunodeficiency virus (HIV) testing of adult refugees prior to US resettlement was removed, thus leading to a potential for missed diagnosis. We reviewed refugee health assessment data and medical charts to evaluate the health status of HIV-infected refugees who arrived in Minnesota during 2000–2007, prior to this 2010 policy change. Among 19,292 resettled adults, 174 were HIV-infected, 169 (97%) were African (median age 26.4 (range: 17–76) years). Charts were abstracted for 157 (124 (79%) with ≥1 year of follow-up). At initial presentation, two of 74 (3%) women were pregnant, 27% became pregnant during follow-up. HIV clinical stage varied (59%, asymptomatic, 11%, mild symptoms, 10%, advanced symptoms, 3%, severe symptoms, 17%, unknown), coinfections were common (51 tuberculosis, 13 hepatitis B, 13 parasites, four syphilis). Prior to arrival 4% had received antiretrovirals. Opportunistic infections were diagnosed among 13%, 2% died from AIDS-related causes. Arrival screening may be needed to identify these HIV-infected refugees and prevent HIV-related morbidity and mortality.

PCR detecting the protein D ( hpd ) and fuculose kinase ( fucK ) genes showed high sensitivity and specificity for identifying Haemophilus influenzae and differentiating it from H. haemolyticus . Phylogenetic analysis using the 16S rRNA gene demonstrated two distinct groups for H. influenzae and H. haemolyticus .

Objectives. We described the outbreak investigation and control measures after the Minnesota Department of Health identified a cluster of tuberculosis (TB) cases among Guatemalan immigrants within three rural Minnesota counties in August 2008. Methods. TB cases were diagnosed by tuberculin skin test followed by chest radiography and sputum testing for Mycobacterium tuberculosis (M. tuberculosis). We reviewed medical records, interviewed patients, and completed a contact investigation for each infectious case. We used isolate genotyping to confirm epidemiologic links between cases. Results. The index case was a six-month-old U.S.-born male with Guatemalan parents. Although he experienced four months of cough and fever, TB was not considered at two medical visits but was diagnosed upon hospitalization in May 2008. The presumed source of infection was a Guatemalan male aged 25 years who sang in a band that practiced in the infant's house and whose pulmonary TB was diagnosed at hospitalization in June 2008, despite his having sought medical attention for symptoms seven months earlier. Among the 16 identified TB cases, 14 were outbreak-related. Three genetically distinct M. tuberculosis strains circulated. Of 150 contacts of the singer, 62 (41%) had latent TB infection and 13 (9%), including 10 children, had TB disease. Conclusions. In this outbreak, delayed diagnoses contributed to M. tuberculosis transmission. Isolate genotyping corroborated the social links between outbreak-related patients. More timely diagnosis of TB among immigrants and their children can prevent TB transmission among communities in rural, low-incidence areas that might have limited resources for contact investigations.

Summary Background Measles control efforts are hindered by challenges in sustaining high vaccination coverage, waning immunity in HIV-1-infected children, and clustering of susceptible individuals. Our aim was to assess population immunity to measles virus after a mass vaccination campaign in a region with high HIV prevalence. Methods 3 years after a measles supplemental immunisation activity (SIA), we undertook a cross-sectional survey in Lusaka, Zambia. Households were randomly selected from a satellite image. Children aged 9 months to 5 years from selected households were eligible for enrolment. A questionnaire was administered to the children's caregivers to obtain information about measles vaccination history and history of measles. Oral fluid samples were obtained from children and tested for antibodies to measles virus and HIV-1 by EIA. Findings 1015 children from 668 residences provided adequate specimens. 853 (84%) children had a history of measles vaccination according to either caregiver report or immunisation card. 679 children (67%) had antibodies to measles virus, and 64 (6%) children had antibodies to HIV-1. Children with antibodies to HIV-1 were as likely to have no history of measles vaccination as those without antibodies to HIV-1 (odds ratio [OR] 1·17, 95% CI 0·57–2·41). Children without measles antibodies were more likely to have never received measles vaccine than those with antibodies (adjusted OR 2·50, 1·69–3·71). In vaccinated children, 33 (61%) of 54 children with antibodies to HIV-1 also had antibodies to measles virus, compared with 568 (71%) of 796 children without antibodies to HIV-1 (p=0·1). Interpretation 3 years after an SIA, population immunity to measles was insufficient to interrupt measles virus transmission. The use of oral fluid and satellite images for sampling are potential methods to assess population immunity and the timing of SIAs. Funding Thrasher Research Fund.

Human parainfluenza viruses 1 through 3 (HPIV-1-3) are important causes of respiratory tract infections in young children. This study sought to provide current estimates of HPIV-1-3-associated hospitalizations among US children.Hospitalizations for bronchiolitis, bronchitis, croup and pneumonia among children age5 years were determined for the years 1979 through 1997 using the National Hospital Discharge Survey. Average annual hospitalizations during the last 4 years of the study for each of these four diseases were multiplied by the proportions of each disease associated with HPIV-1-3 infection (as previously reported in hospital-based studies) to estimate hospitalizations potentially associated with HPIV-1-3 infections. Seasonal trends in HPIV-1-3-associated hospitalizations were compared with HPIV detections in the National Respiratory and Enteric Virus Surveillance System, which prospectively monitors respiratory viral detections throughout the United States.The proportions of hospitalizations associated with HPIV infection for each disease varied widely in the 6 hospital-based studies we selected. Consequently our annual estimated rates of hospitalization were broad: HPIV-1, 0.32 to 1.59 per 1,000 children; HPIV-2, 0.10 to 0.86 per 1,000 children; and HPIV-3, 0.48 to 2.6 per 1,000 children. Based on these data HPIV-1 may account for 5,800 to 28,900 annual hospitalizations; HPIV-2 for 1,800 to 15,600 hospitalizations; and HPIV-3 for 8,700 to 52,000 hospitalizations.We provide broad, serotype-specific estimates of US childhood hospitalizations associated with HPIV infections. More precise estimates of HPIV-associated hospitalizations would require large prospective studies of HPIV-associated diseases by more sensitive viral testing methods, such as polymerase chain reaction techniques.

We describe the incidence of and laboratory and clinical characteristics associated with Entamoeba histolytica/Entamoeba dispar infection diagnosed in human immunodeficiency virus (HIV)-infected persons enrolled in the Adult and Adolescent Spectrum of HIV Disease Project. From 1 January 1990 to 1 January 1998 (82, 518 person-years of follow-up), 111 patients (98% men) were diagnosed with E. histolytica/E. dispar infection. Among HIV-infected patients in the United States, the incidence of diagnosed E. histolytica disease is low (13.5 cases per 10,000 person-years [95% confidence interval, 7.7-22.2], with diagnosis most common in those patients exposed to HIV through male-male sex.

To the Editor: Two of eight persons with laboratory-confirmed severe acute respiratory syndrome–associated coronavirus (SARS-CoV) infection in the United States during 2003 were pregnant women. Robertson et al. (1) reported data describing one pregnant patient who recovered and delivered a healthy infant. We report data concerning the second patient, with follow-up 1 month after the child's birth. The patient, a healthy, 38-year-old woman in the 7th week of pregnancy, traveled with her husband to Hong Kong. From March 1 to March 6, 2003, they stayed at the Hong Kong hotel where it is believed a physician from China spread SARS-CoV to several guests. These guests were the index case-patients for subsequent outbreaks in Hong Kong, Vietnam, Singapore, and Toronto, Canada (2). The woman and her husband returned to the United States on March 6; the husband had onset of SARS illness on March 13. On March 19, the patient had onset of an illness with fever (temperature 37.8–40°C), muscle aches, chills, headache, runny nose, productive cough, wheezing, and shortness of breath. A chest radiograph showed a diffuse infiltrate in the left lung. The patient was hospitalized for 9 days and given broad-spectrum antimicrobial drugs. She recovered from her illness, and enzyme immunoassay and immunofluorescent assays conducted on serum samples on days 28 and 64 after illness onset were positive for antibodies to SARS-CoV. The patient had an uneventful pregnancy until the last trimester, when her blood glucose levels were elevated. Early spontaneous rupture of membranes initiated preterm labor, and a cesarean section was performed at 36 weeks' gestation because of fetal distress. A 5-pound, 7-ounce, healthy boy was delivered without complications. Apgar scores were 7 at 1 minute and 8 at 5 minutes. The newborn had no illness, abnormalities, or congenital malformations. Serum samples from the patient at delivery were positive for antibodies to SARS-CoV, but cord blood and placenta samples were negative. Breast milk samples on postpartum days 12 and 30 were also negative for SARS-CoV antibodies. Blood, stool, and nasopharyngeal swab samples from the patient and cord-blood samples showed no viral RNA by reverse transcription–polymerase chain reaction. Stool samples from the newborn, collected on days 12 and 30 after delivery, were also negative for viral RNA. Although other countries have reported cases of severe illness and poor outcome associated with SARS-CoV infection during pregnancy (3–5), neither of the two pregnant SARS case-patients in the United States had serious adverse outcomes. The presence of antibodies to SARS-CoV in breast milk might be influenced by the time of infection in relation to gestation. Robertson et al. (1) reported that antibodies to SARS-CoV were detected in the breast milk of a patient who was infected at 19 weeks' gestation; however, the patient in this case was infected at 7 weeks' gestation, and antibodies to the virus were not detected in her breast milk. No reports have indicated vertical transmission of SARS-CoV, a finding that is supported by our data. However, too few cases have been studied to clearly define the risks and provide guidance for treating pregnant women infected with SARS CoV.

BACKGROUND: The bacterium Salmonella enterica serovar Typhi causes typhoid fever, which is typically associated with fever and abdominal pain. An outbreak of typhoid fever in Malawi-Mozambique in 2009 was notable for a high proportion of neurologic illness. OBJECTIVE: Describe neurologic features complicating typhoid fever during an outbreak in Malawi-Mozambique METHODS: Persons meeting a clinical case definition were identified through surveillance, with laboratory confirmation of typhoid by antibody testing or blood/stool culture. We gathered demographic and clinical information, examined patients, and evaluated a subset of patients 11 months after onset. A sample of persons with and without neurologic signs was tested for vitamin B6 and B12 levels and urinary thiocyanate. RESULTS: Between March - November 2009, 303 cases of typhoid fever were identified. Forty (13%) persons had objective neurologic findings, including 14 confirmed by culture/serology; 27 (68%) were hospitalized, and 5 (13%) died. Seventeen (43%) had a constellation of upper motor neuron findings, including hyperreflexia, spasticity, or sustained ankle clonus. Other neurologic features included ataxia (22, 55%), parkinsonism (8, 20%), and tremors (4, 10%). Brain MRI of 3 (ages 5, 7, and 18 years) demonstrated cerebral atrophy but no other abnormalities. Of 13 patients re-evaluated 11 months later, 11 recovered completely, and 2 had persistent hyperreflexia and ataxia. Vitamin B6 levels were markedly low in typhoid fever patients both with and without neurologic signs. CONCLUSIONS: Neurologic signs may complicate typhoid fever, and the diagnosis should be considered in persons with acute febrile neurologic illness in endemic areas.

In early April 2003, severe acute respiratory syndrome (SARS) was diagnosed in a Pennsylvania resident after his exposure to persons with SARS in Toronto, Canada. To identify contacts of the case-patient and evaluate the risk for SARS transmission, a detailed epidemiologic investigation was performed. On the basis of this investigation, 26 persons (17 healthcare workers, 4 household contacts, and 5 others) were identified as having had close contact with this case-patient before infection-control practices were implemented. Laboratory evaluation of clinical specimens showed no evidence of transmission of SARS-associated coronavirus (SARS-CoV) infection to any close contact of this patient. This investigation documents that, under certain circumstances, SARS-CoV is not readily transmitted to close contacts, despite ample unprotected exposures. Improving the understanding of risk factors for transmission will help focus public health control measures.

To better assess the risk for transmission of the severe acute respiratory syndrome–associated coronavirus (SARS-CoV), we obtained serial specimens and clinical and exposure data from seven confirmed U.S. SARS patients and their 10 household contacts. SARS-CoV was detected in a day-14 sputum specimen from one case-patient and in five stool specimens from two case-patients. In one case-patient, SARS-CoV persisted in stool for at least 26 days after symptom onset. The highest amounts of virus were in the day-14 sputum sample and a day-14 stool sample. Residual respiratory symptoms were still present in recovered SARS case-patients 2 months after illness onset. Possible transmission of SARS-CoV occurred in one household contact, but this person had also traveled to a SARS-affected area. The data suggest that SARS-CoV is not always transmitted efficiently. Laboratory diagnosis of SARS-CoV infection is difficult; thus, sputum and stool specimens should be included in the diagnostic work-up for SARS-CoV infection.