Neil M. Vora

Burden of encephalitis-associated hospitalizations in the United States, 1998–2010

Objective: To estimate the burden of encephalitis-associated hospitalizations in the United States for 1998–2010. Methods: Using the Nationwide Inpatient Sample, a nationally representative database of hospitalizations, estimated numbers and rates of encephalitis-associated hospitalizations for 1998–2010 were calculated. Etiology and outcome of encephalitis-associated hospitalizations were examined, as well as accompanying diagnoses listed along with encephalitis on the discharge records. Total hospital charges (in 2010 US dollars) were assessed. Results: An estimated 263,352 (standard error: 3,017) encephalitis-associated hospitalizations occurred in the United States during 1998–2010, which corresponds to an average of 20,258 (standard error: 232) encephalitis-associated hospitalizations per year. A fatal outcome occurred in 5.8% (95% confidence interval [CI]: 5.6%–6.0%) of all encephalitis-associated hospitalizations and in 10.1% (95% CI: 9.2%–11.2%) and 17.1% (95% CI: 14.6%–20.0%) of encephalitis-associated hospitalizations in which a code for HIV or a tissue or organ transplant was listed, respectively. The proportion of encephalitis-associated hospitalizations in which an etiology for encephalitis was specified was 50.3% (95% CI: 49.6%–51.0%) and that for which the etiology was unspecified was 49.7% (95% CI: 49.0%–50.4%). Total charges for encephalitis-associated hospitalizations in 2010 were an estimated

Raccoon Rabies Virus Variant Transmission Through Solid Organ Transplantation

2.0 billion. Conclusions: Encephalitis remains a major public health concern in the United States. Among the large number of encephalitis-associated hospitalizations for which an etiology is not reported may be novel infectious and noninfectious forms of encephalitis. Associated conditions such as HIV or transplantation increase the risk of a fatal outcome from an encephalitis-associated hospitalization and should be monitored.

Zika Virus Knowledge among Pregnant Women Who Were in Areas with Active Transmission.

IMPORTANCE The rabies virus causes a fatal encephalitis and can be transmitted through tissue or organ transplantation. In February 2013, a kidney recipient with no reported exposures to potentially rabid animals died from rabies 18 months after transplantation. OBJECTIVES To investigate whether organ transplantation was the source of rabies virus exposure in the kidney recipient, and to evaluate for and prevent rabies in other transplant recipients from the same donor. DESIGN Organ donor and all transplant recipient medical records were reviewed. Laboratory tests to detect rabies virus-specific binding antibodies, rabies virus neutralizing antibodies, and rabies virus antigens were conducted on available specimens, including serum, cerebrospinal fluid, and tissues from the donor and the recipients. Viral ribonucleic acid was extracted from tissues and amplified for nucleoprotein gene sequencing for phylogenetic comparisons. MAIN OUTCOMES AND MEASURES Determination of whether the donor died from undiagnosed rabies and whether other organ recipients developed rabies. RESULTS In retrospect, the donors clinical presentation (which began with vomiting and upper extremity paresthesias and progressed to fever, seizures, dysphagia, autonomic dysfunction, and brain death) was consistent with rabies. Rabies virus antigen was detected in archived autopsy brain tissue collected from the donor. The rabies viruses infecting the donor and the deceased kidney recipient were consistent with the raccoon rabies virus variant and were more than 99.9% identical across the entire N gene (1349/1350 nucleotides), thus confirming organ transplantation as the route of transmission. The 3 other organ recipients remained asymptomatic, with rabies virus neutralizing antibodies detected in their serum after completion of postexposure prophylaxis (range, 0.3-40.8 IU/mL). CONCLUSIONS AND RELEVANCE Unlike the 2 previous clusters of rabies virus transmission through solid organ transplantation, there was a long incubation period in the recipient who developed rabies, and survival of 3 other recipients without pretransplant rabies vaccination. Rabies should be considered in patients with acute progressive encephalitis of unexplained etiology, especially for potential organ donors. A standard evaluation of potential donors who meet screening criteria for infectious encephalitis should be considered, and risks and benefits for recipients of organs from these donors should be evaluated.

Clinical management and humoral immune responses to rabies post-exposure prophylaxis among three patients who received solid organs from a donor with rabies

We surveyed women in New York, New York, USA, who were in areas with active Zika virus transmission while pregnant. Of 99 women who were US residents, 30 were unaware of the government travel advisory to areas with active Zika virus transmission while pregnant, and 37 were unaware of their pregnancies during travel.

Burden of Adult Community-acquired, Health-care-Associated, Hospital-Acquired, and Ventilator-Associated Pneumonia: New York City, 2010 to 2014

The rabies virus causes a fatal encephalitis and can be transmitted through organ transplantation. In 2013, a man developed rabies 18 months after receiving a kidney from a donor with rabies, who was not known to have been infected when the organs were procured. Three additional persons who received organs from the same donor (liver, kidney, heart), all of whom were not vaccinated for rabies before transplantation, received rabies post‐exposure prophylaxis (PEP) with rabies immune globulin and 5 doses of rabies vaccine as soon as the diagnosis of rabies was made in the donor (18 months after their transplant surgeries). We describe their clinical management.

Prevalence and Clinical Attributes of Congenital Microcephaly - New York, 2013-2015.

BACKGROUND: Although pneumonia is a leading cause of death in New York City (NYC), limited data exist about the settings in which pneumonia is acquired across NYC. Cases of pneumonia acquired in community settings are more likely to be preventable with vaccines and treatable with first‐line antibiotics than those acquired in noncommunity settings. The objective of this study was to estimate the burden of hospitalizations associated with community‐acquired (CAP), health‐care‐associated (HCAP), hospital‐acquired (HAP), and ventilator‐associated (VAP) pneumonia from 2010 to 2014. METHODS: This retrospective analysis was performed by using an all‐payer reporting system of hospital discharges that included NYC residents aged ≥ 18 years. Pneumonia‐associated hospitalizations were defined as any hospitalization that included a diagnostic code for pneumonia among any of the discharge diagnoses. Using published clinical guidelines, we classified hospitalizations into mutually exclusive categories of CAP, HCAP, HAP, and VAP and defined pneumonia acquired in the community setting as the combination of CAP and HCAP. RESULTS: Of 4,614,108 hospitalizations during the reporting period, 283,927 (6.2%) involved pneumonia. Among pneumonia‐associated hospitalizations, 154,158 (54.3%) were CAP, 85,656 (30.2%) were HCAP, 39,712 (14.0%) were HAP, and 4,401 (1.6%) were VAP. Death during hospitalization occurred in 7.9% of CAP‐associated hospitalizations, compared with 15.6% of HCAP‐associated hospitalizations, 20.7% of HAP‐associated hospitalizations, and 21.6% of VAP‐associated hospitalizations. CONCLUSIONS: Most pneumonia‐associated hospitalizations in NYC involve pneumonias acquired in the community setting. Although 15.6% of pneumonia‐associated hospitalizations were categorized as HAP or VAP, these pneumonias accounted for > 25% of deaths from pneumonia‐associated hospitalizations. Public health pneumonia prevention efforts need to target both community and hospital settings.

Burden of Pneumonia-Associated Hospitalizations: United States, 2001-2014

Congenital Zika virus infection can cause microcephaly and other severe fetal neurological anomalies (1). To inform microcephaly surveillance efforts and assess ascertainment sources, the New York State Department of Health and the New York City Department of Health and Mental Hygiene sought to determine the prevalence of microcephaly in New York during 2013-2015, before known importation of Zika virus infections. Suspected newborn microcephaly diagnoses were identified from 1) reports submitted by birth hospitals in response to a request and 2) queries of a hospital administrative discharge database for newborn microcephaly diagnoses. Anthropometric measurements, maternal demographics, and pregnancy characteristics were abstracted from newborn records from both sources. Diagnoses were classified using microcephaly case definitions developed by CDC and the National Birth Defects Prevention Network (NBDPN) (2). During 2013-2015, 284 newborns in New York met the case definition for severe congenital microcephaly (prevalence = 4.2 per 10,000 live births). Most newborns with severe congenital microcephaly were identified by both sources; 263 (93%) were identified through hospital requests and 256 (90%) were identified through administrative discharge data. The proportions of newborns with severe congenital microcephaly who were black (30%) or Hispanic (31%) were higher than the observed proportions of black (15%) or Hispanic (23%) infants among New York live births. Fifty-eight percent of newborns with severe congenital microcephaly were born to mothers with pregnancy complications or who had in utero or perinatal infections or teratogenic exposures, genetic disorders, or family histories of birth defects.

Encephalitis-Associated Hospitalizations among American Indians and Alaska Natives

Background The epidemiology of pneumonia has likely evolved in recent years, reflecting an aging population, changes in population immunity, and socioeconomic disparities. Methods Using the National (Nationwide) Inpatient Sample, estimated numbers and rates of pneumonia‐associated hospitalizations for 2001‐2014 were calculated. A pneumonia‐associated hospitalization was defined as one in which the discharge record listed a principal diagnosis of pneumonia or a secondary diagnosis of pneumonia if the principal diagnosis was respiratory failure or sepsis. Results There were an estimated 20,361,181 (SE, 95,601) pneumonia‐associated hospitalizations in the United States during 2001‐2014 (average annual age‐adjusted pneumonia‐associated hospitalization rate of 464.8 per 100,000 population [95% CI, 462.5‐467.1]). The average annual age‐adjusted pneumonia‐associated hospitalization rate decreased over the study period (P < .0001). In‐hospital death occurred in 7.4% (SE, 0.03) of pneumonia‐associated hospitalizations. Non‐Hispanic American Indian/Alaskan Natives and non‐Hispanic blacks had the highest average annual age‐adjusted rates of pneumonia‐associated hospitalization of all race/ethnicities at 439.2 (95% CI, 415.9‐462.5) and 438.6 (95% CI, 432.5‐444.7) per 100,000 population, respectively. During 2001‐2014, the proportion of pneumonia‐associated hospitalizations colisting an immunocompromising condition increased from 18.7% (SE, 0.2) in 2001 to 29.9% (SE, 0.2) in 2014. Total charges for pneumonia‐associated hospitalizations in 2014 were over

Health Precautions Taken by Travelers to Countries with Ebola Virus Disease.

84 billion. Conclusions Pneumonia is a major cause of morbidity and mortality in the United States. Differences in rates and outcomes of pneumonia‐associated hospitalizations between sociodemographic groups warrant further investigation. The immunocompromised population has emerged as a group experiencing a disproportionate burden of pneumonia‐associated hospitalizations.

Deaths From Pneumonia—New York City, 1999–2015

Encephalitis produces considerable morbidity in the United States, but morbidity rates among American Indian/Alaska Native (AI/AN) people have not been described. Hospitalization records listing an encephalitis diagnosis were analyzed by using Indian Health Service direct/contract inpatient data. For 1998-2010, there were 436 encephalitis-associated hospitalizations among AI/AN people, an average annual age-adjusted hospitalization rate of 3.1/100,000 population. The rate for infants (11.9) was more than double that for any other age group. Death occurred for 4.1% of hospitalizations. Consistent with reports for the general U.S. population, the rate was high among infants and most (53.9%) hospitalizations were of unexplained etiology. The average annual rate during the study period appeared lower than for the general U.S. population, due particularly to lower rates in the elderly. Future community-based surveillance and mortality studies are needed to confirm these findings and examine reasons underlying the low rates of encephalitis in AI/AN people.