Gayle Langley

Active Bacterial Core Surveillance for Legionellosis - United States, 2011-2013.

During 2000–2011, passive surveillance for legionellosis in the United States demonstrated a 249% increase in crude incidence, although little was known about the clinical course and method of diagnosis. In 2011, a system of active, population-based surveillance for legionellosis was instituted through CDC’s Active Bacterial Core surveillance (ABCs) program. Overall disease rates were similar in both the passive and active systems, but more complete demographic information and additional clinical and laboratory data were only available from ABCs. ABCs data during 2011–2013 showed that approximately 44% of patients with legionellosis required intensive care, and 9% died. Disease incidence was higher among blacks than whites and was 10 times higher in New York than California. Laboratory data indicated a reliance on urinary antigen testing, which only detects Legionella pneumophila serogroup 1 (Lp1). ABCs data highlight the severity of the disease, the need to better understand racial and regional differences, and the need for better diagnostic testing to detect infections.

Twenty Years of Active Bacterial Core Surveillance.

This program has directly affected public health policies and practices.

Effect of Culture-Independent Diagnostic Tests on Future Emerging Infections Program Surveillance

Use of such tests in clinical settings presents opportunities and challenges.

The Impact of Obesity and Diabetes on the Risk of Disease and Death due to Invasive Group A Streptococcus Infections in Adults

BACKGROUND Invasive group A Streptococcus (iGAS) infections cause significant morbidity and mortality worldwide. We analyzed whether obesity and diabetes were associated with iGAS infections and worse outcomes among an adult US population. METHODS We determined the incidence of iGAS infections using 2010-2012 cases in adults aged ≥ 18 years from Active Bacterial Core surveillance (ABCs), a population-based surveillance system, as the numerator. For the denominator, we used ABCs catchment area population estimates from the 2011 to 2012 Behavioral Risk Factor Surveillance System (BRFSS) survey. The relative risk (RR) of iGAS was determined by obesity and diabetes status after adjusting for age group, gender, race, and other underlying conditions through binomial logistic regression. Multivariable logistic regression was used to determine whether obesity or diabetes was associated with increased odds of death due to iGAS compared to normal weight and nondiabetic patients, respectively. RESULTS Between 2010 and 2012, 2927 iGAS cases were identified. Diabetes was associated with an increased risk of iGAS in all racial groups (adjusted risk ratio [aRR] ranged from 2.71 to 5.08). Grade 3 obesity (body mass index [BMI] ≥ 40) was associated with an increased risk of iGAS for whites (aRR = 3.47; 95% confidence interval [CI], 3.00-4.01). Grades 1-2 (BMI = 30.0-<40.0) and grade 3 obesity were associated with an increased odds of death (odds ratio [OR] = 1.55, [95% CI, 1.05, 2.29] and OR = 1.62 [95% CI, 1.01, 2.61], respectively) when compared to normal weight patients. CONCLUSIONS These results may help target vaccines against GAS that are currently under development. Efforts to develop enhanced treatment regimens for iGAS may improve prognoses for obese patients.

On-Site Availability of Legionella Testing in Acute Care Hospitals, United States

We surveyed 399 US acute care hospitals regarding availability of on-site Legionella testing; 300 (75.2%) did not offer Legionella testing on site. Availability varied according to hospital size and geographic location. On-site access to testing may improve detection of Legionnaires disease and inform patient management and prevention efforts.

Community-Acquired Invasive GAS Disease among Native Americans, Arizona, USA, Winter 2013

To the Editor: Group A streptococci (GAS) can cause severe invasive diseases, such as necrotizing fasciitis, streptococcal toxic shock syndrome, and sepsis. In 2012, ≈11,000 cases of invasive GAS (iGAS) disease and 1,100 associated deaths occurred in the United States (1,2). The risk for iGAS infection is 10 times higher among Native Americans than among the general population (3). Other predisposing factors for iGAS infection include skin wounds and underlying diseases, such as diabetes (1,3,4). Household risk factors include exposure to children with pharyngitis and crowding (4). Most iGAS infections occur sporadically within the community. Postpartum and postsurgical clusters arising from a common nosocomial source occur but are rare (5). During the winter of 2012–13, a 3-fold increase in necrotizing fasciitis was observed at an Arizona hospital (hospital X) that predominantly treats Native Americans. Tribal leadership initiated a collaborative investigation with state and federal officials to characterize the outbreak and implement appropriate control measures. A confirmed case of iGAS was defined as isolation of GAS from normally sterile sites (i.e., blood) or isolation of GAS from nonsterile sites (i.e., wound) in the presence of necrotizing fasciitis or streptococcal toxic shock syndrome among patients who sought care at hospital X during August 2012–March 2013. Hospital X serves ≈45,000 persons in a rural community. Eleven confirmed iGAS cases were identified (Figure), of which 8 (73%) occurred in women and 3 (27%) occurred in men. The case-patients had a mean age of 63 years (range 32–92 years). All cases were community-onset illnesses; none of the case-patients had recent exposures to health care settings, and all were of Native American ancestry. Of the 11 case-patients, 8 required critical care treatment and 3 died. Nine (82%) case-patients had open wounds or skin breakdown (e.g., skin abrasion, burns), and 9 had underlying medical conditions that are known risk factors for iGAS (e.g., obesity, diabetes, chronic kidney or heart disease, alcoholism). Figure Week of symptom onset and principal clinical syndrome of patients with confirmed invasive group A streptococcus infections at hospital X, Arizona, August 2012–March 2013. STSS, streptococcal toxic shock syndrome. Five GAS isolates were available. Two of the isolates were emm type 11; antimicrobial drug–susceptibility profiles for the 2 were identical (i.e., tetracycline resistant). The 2 patients reported no close contact with each other, but they had the same home health aide. The other 3 isolates had different emm types (1, 12, and 82) and were antimicrobial drug pansensitive. We interviewed 58 household contacts of the case-patients (35 adults, 23 children) regarding symptoms and risks for secondary GAS infection. Among these contacts, 2 adults reported a sore throat and 6 children reported fever (without sore throat), but no confirmed secondary GAS infections were identified. Because of the known increased risk for iGAS among Native Americans and the level of crowding (average of 2–3 persons/bedroom) and the high proportion of adult household contacts with predisposing underlying conditions (29%) in this population, azithromycin prophylaxis was offered to household contacts who spent >24 hours with a case-patient during the 7 days preceding the onset of illness. With the exception of the 2 case-patients with a common health aide, we found no common epidemiologic links or common behaviors among patients that suggested a single-source outbreak. This was further supported by the finding of multiple emm types among the isolates. These are not unusual findings in community outbreaks of iGAS; clusters of iGAS cases have often been observed without a common source (6–8). Localized and transient increases in sporadic GAS infections may occur because of an influx of a new emm type into a population with low levels of community immunity to that specific emm type; an increase in the detection and reporting of iGAS without a true increase in infection; or an increase in conditions that predispose persons to iGAS, such as GAS pharyngitis among children or concurrent influenza or other virus outbreaks in the community. Past studies have shown that the risk of secondary iGAS infection among household contacts of patients with iGAS disease is higher than that among the general population but still low (5). Although Centers for Disease Control and Prevention guidelines do not recommend routine chemoprophylaxis for household contacts of patients with iGAS infection, the guidelines state that providers may choose to offer antimicrobial drug prophylaxis to those household contacts at increased risk for iGAS infection (5). Because Native Americans have increased rates of iGAS disease, compared with those of the general population, and because households in this investigation were crowded and many contacts had predisposing underlying conditions, we recommended that household contacts receive prophylaxis if given within 30 days of the index case-patient’s illness (5). No additional cases were reported at least 3 months after the investigation and intervention.

Respiratory Syncytial Virus Seasonality — United States, 2014–2017

Respiratory syncytial virus (RSV) is a leading cause of lower respiratory tract infection in young children worldwide (1-3). In the United States, RSV infection results in >57,000 hospitalizations and 2 million outpatient visits each year among children aged <5 years (3). Recent studies have highlighted the importance of RSV in adults as well as children (4). CDC reported RSV seasonality nationally, by U.S. Department of Health and Human Services (HHS) regions* and for the state of Florida, using a new statistical method that analyzes polymerase chain reaction (PCR) laboratory detections reported to the National Respiratory and Enteric Virus Surveillance System (NREVSS) (https://www.cdc.gov/surveillance/nrevss/index.html). Nationally, across three RSV seasons, lasting from the week ending July 5, 2014 through July 1, 2017, the median RSV onset occurred at week 41 (mid-October), and lasted 31 weeks until week 18 (early May). The median national peak occurred at week 5 (early February). Using these new methods, RSV season circulation patterns differed from those reported from previous seasons (5). Health care providers and public health officials use RSV circulation data to guide diagnostic testing and to time the administration of RSV immunoprophylaxis for populations at high risk for severe respiratory illness (6). With several vaccines and other immunoprophlyaxis products in development, estimates of RSV circulation are also important to the design of clinical trials and future vaccine effectiveness studies.

Obesity, Diabetes, and the Risk of Invasive Group B Streptococcal Disease in Nonpregnant Adults in the United States

Abstract Background Rates of invasive group B Streptococcus (GBS) disease, obesity, and diabetes have increased in US adults. We hypothesized that obesity would be independently associated with an increased risk of invasive GBS disease. Methods We identified adults with invasive GBS disease within Active Bacterial Core surveillance during 2010–2012 and used population estimates from the Behavioral Risk Factor Surveillance System to calculate invasive GBS incidence rates. We estimated relative risks (RRs) of invasive GBS using Poisson analysis with offset denominators, with obesity categorized as class I/II (body mass index [BMI] = 30–39.9 kg/m2) and class III (BMI ≥ 40.0 kg/m2). Results In multivariable analysis of 4281 cases, the adjusted RRs of invasive GBS disease were increased for obesity (class I/II: RR, 1.52; 95% confidence interval [CI], 1.14–2.02; and class III: RR, 4.87; 95% CI, 3.50–6.77; reference overweight) and diabetes (RR, 6.04; 95% CI, 4.77–7.65). The adjusted RR associated with class III obesity was 3-fold among persons with diabetes (95% CI, 1.38–6.61) and nearly 9-fold among persons without diabetes (95% CI, 6.41–12.46), compared with overweight. The adjusted RRs associated with diabetes varied by age and BMI, with the highest RR in young populations without obesity. Population attributable risks of invasive GBS disease were 27.2% for obesity and 40.1% for diabetes. Conclusions Obesity and diabetes were associated with substantially increased risk of infection from invasive GBS. Given the population attributable risks of obesity and diabetes, interventions that reduce the prevalence of these conditions would likely reduce the burden of invasive GBS infection.

Respiratory Syncytial Virus Hospitalization During Pregnancy in 4 High-income Countries, 2010–2016

Few studies have addressed respiratory syncytial virus (RSV) infection during pregnancy. Among 846 pregnant women hospitalized with respiratory illness and tested for RSV, 21 (2%) were RSV positive, of whom 8 (38%) were diagnosed with pneumonia. Despite study limitations, these data can help inform decisions about RSV prevention strategies.

A Cluster of Group A Streptococcal Infections in a Skilled Nursing Facility—the Potential Role of Healthcare Worker Presenteeism

To determine the extent of a group A streptococcus (GAS) cluster (2 residents with invasive GAS (invasive case‐patients), 2 carriers) caused by a single strain (T antigen type 2 and M protein gene subtype 2.0 (T2, emm 2.0)), evaluate factors contributing to transmission, and provide recommendations for disease control.