Anil Suryaprasad

Emerging Epidemic of Hepatitis C Virus Infections Among Young Nonurban Persons Who Inject Drugs in the United States, 2006–2012

BACKGROUND Reports of acute hepatitis C in young persons in the United States have increased. We examined data from national surveillance and supplemental case follow-up at selected jurisdictions to describe the US epidemiology of hepatitis C virus (HCV) infection among young persons (aged ≤30 years). METHODS We examined trends in incidence of acute hepatitis C among young persons reported to the Centers for Disease Control and Prevention (CDC) during 2006-2012 by state, county, and urbanicity. Sociodemographic and behavioral characteristics of HCV-infected young persons newly reported from 2011 to 2012 were analyzed from case interviews and provider follow-up at 6 jurisdictions. RESULTS From 2006 to 2012, reported incidence of acute hepatitis C increased significantly in young persons-13% annually in nonurban counties (P = .003) vs 5% annually in urban counties (P = .028). Thirty (88%) of 34 reporting states observed higher incidence in 2012 than 2006, most noticeably in nonurban counties east of the Mississippi River. Of 1202 newly reported HCV-infected young persons, 52% were female and 85% were white. In 635 interviews, 75% of respondents reported injection drug use. Of respondents reporting drug use, 75% had abused prescription opioids, with first use on average 2.0 years before heroin. CONCLUSIONS These data indicate an emerging US epidemic of HCV infection among young nonurban persons of predominantly white race. Reported incidence was higher in 2012 than 2006 in at least 30 states, with largest increases in nonurban counties east of the Mississippi River. Prescription opioid abuse at an early age was commonly reported and should be a focus for medical and public health intervention.

A Large Outbreak of Hepatitis C Virus Infections in a Hemodialysis Clinic

BACKGROUND In November and December 2012, 6 patients at a hemodialysis clinic were given a diagnosis of new hepatitis C virus (HCV) infection. OBJECTIVE To investigate the outbreak to identify risk factors for transmission. METHODS A case patient was defined as a patient who was HCV-antibody negative on clinic admission but subsequently was found to be HCV-antibody positive from January 1, 2008, through April 30, 2013. Patient charts were reviewed to identify and describe case patients. The hypervariable region 1 of HCV from infected patients was tested to assess viral genetic relatedness. Infection control practices were evaluated via observations. A forensic chemiluminescent agent was used to identify blood contamination on environmental surfaces after cleaning. RESULTS Eighteen case patients were identified at the clinic from January 1, 2008, through April 30, 2013, resulting in an estimated 16.7% attack rate. Analysis of HCV quasispecies identified 4 separate clusters of transmission involving 11 case patients. The case patients and previously infected patients in each cluster were treated in neighboring dialysis stations during the same shift, or at the same dialysis station on 2 consecutive shifts. Lapses in infection control were identified. Visible and invisible blood was identified on multiple surfaces at the clinic. CONCLUSIONS Epidemiologic and laboratory data confirmed transmission of HCV among numerous patients at the dialysis clinic over 6 years. Infection control breaches were likely responsible. This outbreak highlights the importance of rigorous adherence to recommended infection control practices in dialysis settings.

Impact of hysterectomy and bilateral oophorectomy prevalence on rates of cervical, uterine, and ovarian cancer among American Indian and Alaska Native women, 1999–2004

ObjectiveTo present more accurate incidence rates of cervical, uterine, and ovarian cancer by geographic region in American Indian/Alaska Native (AI/AN) women.MethodsThe authors used data from central cancer registries linked to Indian Health Service (IHS) patient registration database, the Behavioral Risk Factor Surveillance System, IHS National Data Warehouse, and the National Hospital Discharge Survey. Cancer incidence rates were adjusted for hysterectomy and oophorectomy prevalence and presented by region for non-Hispanic White (NHW) and AI/AN women.ResultsAI/AN women had a higher prevalence of hysterectomy (23.1%) compared with NHW women (20.9%). Correcting cancer rates for population-at-risk significantly increased the cancer incidence rates among AI/AN women: 43% for cervical cancer, 67% for uterine cancer, and 37% for ovarian cancer. Risk-correction led to increased differences in cervical cancer incidence between AI/AN and NHW women in certain regions.ConclusionsCurrent reporting of cervical, uterine, and ovarian cancer underestimates the incidence in women at risk and can affect the measure of cancer disparities. Improved cancer surveillance using methodology to correct for population-at-risk may better inform disease control priorities for AI/AN populations.

Influenza surveillance using electronic health records in the American Indian and Alaska Native population

OBJECTIVE Increasing use of electronic health records (EHRs) provides new opportunities for public health surveillance. During the 2009 influenza A (H1N1) virus pandemic, we developed a new EHR-based influenza-like illness (ILI) surveillance system designed to be resource sparing, rapidly scalable, and flexible. 4 weeks after the first pandemic case, ILI data from Indian Health Service (IHS) facilities were being analyzed. MATERIALS AND METHODS The system defines ILI as a patient visit containing either an influenza-specific International Classification of Disease, V.9 (ICD-9) code or one or more of 24 ILI-related ICD-9 codes plus a documented temperature ≥100°F. EHR-based data are uploaded nightly. To validate results, ILI visits identified by the new system were compared to ILI visits found by medical record review, and the new systems results were compared with those of the traditional US ILI Surveillance Network. RESULTS The system monitored ILI activity at an average of 60% of the 269 IHS electronic health databases. EHR-based surveillance detected ILI visits with a sensitivity of 96.4% and a specificity of 97.8% based on chart review (N=2375) of visits at two facilities in September 2009. At the peak of the pandemic (week 41, October 17, 2009), the median time from an ILI visit to data transmission was 6 days, with a mode of 1 day. DISCUSSION EHR-based ILI surveillance was accurate, timely, occurred at the majority of IHS facilities nationwide, and provided useful information for decision makers. EHRs thus offer the opportunity to transform public health surveillance.

Severe acute respiratory infections caused by 2009 pandemic influenza A (H1N1) among American Indians—southwestern United States, May 1–July 21, 2009

During April–July 2009, U.S. hospitalization rates for 2009 pandemic influenza A (H1N1) virus (H1N1pdm09) infection were estimated at 4·5/100 000 persons. We describe rates and risk factors for H1N1pdm09 infection among American Indians (AIs) in four isolated southwestern U.S. communities served by the Indian Health Service (IHS).

Effect of rapid influenza diagnostic testing on antiviral treatment decisions for patients with influenza-like illness: southwestern U.S., May-December 2009.

Rapid influenza diagnostic tests (RIDTs) had low test sensitivity for detecting 2009 pandemic influenza A (H1N1pdm09) infection, causing public health authorities to recommend that treatment decisions be based primarily upon risk for influenza complications. We used multivariate Poisson regression analysis to estimate the contribution of RIDT results and risk for H1N1pdm09 complications to receipt of early antiviral (AV) treatment among 290 people with influenza-like illness (ILI) who received an RIDT ≤48 hours after symptom onset from May to December 2009 at four southwestern U.S. facilities. RIDT results had a stronger association with receipt of early AVs (rate ratio [RR] = 3.3, 95% confidence interval [CI] 2.4, 4.6) than did the presence of risk factors for H1N1pdm09 complications (age <5 years or high-risk medical conditions) (RR=1.9, 95% CI 1.3, 2.7). Few at-risk people (28/126, 22%) who had a negative RIDT received early AVs, suggesting the need for sustained efforts by public health to influence clinician practices.

Incident hepatitis among repeat blood donors: A sentinel event signaling possible health care-associated infection and need for reporting to public health authorities.

I dentification of a recently acquired viral hepatitis infection among repeat blood donors can be a sentinel event signaling a possible health care–associated infection (HAI) in the donor, especially in individuals who did not disclose self-reported behavioral risk factors and were test negative at prior successful donations. With the 2012 update to the Council of State and Territorial Epidemiologists (CSTE) acute hepatitis B and hepatitis C surveillance case definitions, asymptomatic individuals who meet the laboratory criteria for these case definitions should be included among the cases reportable to public health authorities. This report serves as a reminder of the importance of recognizing incident hepatitis infections in blood donors as a possible sentinel event to uncover previous health care–associated transmission clusters and that identification of a hepatitis B virus (HBV) or hepatitis C virus (HCV) nucleic acid test (NAT) confirmed positive result within 6 months of a NATnegative result (as may be identified in a repeat blood donor) is reportable to public health authorities. Recent data suggest consideration that this 6-month period be extended to 1 year. Because of extensive behavioral (risk factor assessment) and laboratory (NAT) screening of blood donors, which occur with each donation, repeat donors are considered to be at low risk for hepatitis infection. Thus, an incident infection in these donors is particularly concerning for possible HAI and can serve as a sentinel event indicative of infection control problems at a health care facility where the donor previously received health care, possibly signaling a larger outbreak. Health care–associated transmission resulting from unsafe medical practices has been recognized as an important source of new HBV and HCV infections, particularly among older adults. At least four HAI outbreaks or transmissions (Table S1, available as supporting information in the online version of this paper; South Carolina Department of Public Health, unpublished data, 2013; California Department of Public Health, unpublished data, 2012) have been detected since 2008 after public health investigations were initiated after the detection of an incident HBV or HCV infection identified in a repeat blood donor. None of these transmissions were related to donation or receipt of blood products. The cases provided in Table S1 were either identified through routine tracking by the American Red Cross (ARC) of donors who converted their NAT results from negative to positive or identified to public health by the donor or donor’s clinician after donor notification. In three of these investigations, recognition of these infections served to identify inadequate infection control practices at a health care facility, like syringe reuse, and to

603Transmission of Hepatitis C Virus (HCV) from a Deceased Organ Donor at Increased Risk of HCV infection with Negative Nucleic Acid Test Screening at the Time of Organ Donation

603. Transmission of Hepatitis C Virus (HCV) from a Deceased Organ Donor at Increased Risk of HCV infection with Negative Nucleic Acid Test Screening at the Time of Organ Donation Nicole Theodoropoulos, MD; Sridhar Basavaraju, MD, FACEP; Elmahdi Elkhammas, MD; Joseph Forbi, PhD; Tonya Hayden, PhD; Stanley Martin, MD; Amy Pope-Harman, MD; Pali Shah,; Bryan Whitson, MD, PhD; Anil Suryaprasad, MD; Division of Infectious Diseases, The Ohio State University, Columbus, OH; FACEP, CDC/ Division of Healthcare Quality Promotion, Atlanta, GA; Dorrie Dils, Lifeline of Ohio, Columbus, OH; Division of Transplant Surgery, The Ohio State University, Columbus, OH; Division of Viral Hepatitis, Centers for Disease Control & Prevention, Atlanta, GA; Centers for Disease Control and Prevention, Atlanta, GA; Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, OH; Division of Pulmonary, The Ohio State University, Columbus, OH; Division of Pulmonary & Critical Care, Johns Hopkins University, Baltimore, MD; Division of Cardiac Surgery, The Ohio State University, Columbus, OH; Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA