Pamela Talley

Travel-Associated Zika Virus Disease Cases Among U.S. Residents — United States, January 2015–February 2016

Zika virus is an emerging mosquito-borne flavivirus. Recent outbreaks of Zika virus disease in the Pacific Islands and the Region of the Americas have identified new modes of transmission and clinical manifestations, including adverse pregnancy outcomes. However, data on the epidemiology and clinical findings of laboratory-confirmed Zika virus disease remain limited. During January 1, 2015-February 26, 2016, a total of 116 residents of 33 U.S. states and the District of Columbia had laboratory evidence of recent Zika virus infection based on testing performed at CDC. Cases include one congenital infection and 115 persons who reported recent travel to areas with active Zika virus transmission (n = 110) or sexual contact with such a traveler (n = 5). All 115 patients had clinical illness, with the most common signs and symptoms being rash (98%; n = 113), fever (82%; 94), and arthralgia (66%; 76). Health care providers should educate patients, particularly pregnant women, about the risks for, and measures to prevent, infection with Zika virus and other mosquito-borne viruses. Zika virus disease should be considered in patients with acute onset of fever, rash, arthralgia, or conjunctivitis, who traveled to areas with ongoing Zika virus transmission (http://www.cdc.gov/zika/geo/index.html) or who had unprotected sex with a person who traveled to one of those areas and developed compatible symptoms within 2 weeks of returning.

Non-mumps Viral Parotitis During the 2014–2015 Influenza Season in the United States

Background During the 2014-2015 US influenza season, 320 cases of non-mumps parotitis (NMP) among residents of 21 states were reported to the Centers for Disease Control and Prevention (CDC). We conducted an epidemiologic and laboratory investigation to determine viral etiologies and clinical features of NMP during this unusually large occurrence. Methods NMP was defined as acute parotitis or other salivary gland swelling of >2 days duration in a person with a mumps- negative laboratory result. Using a standardized questionnaire, we collected demographic and clinical information. Buccal samples were tested at the CDC for selected viruses, including mumps, influenza, human parainfluenza viruses (HPIVs) 1-4, adenoviruses, cytomegalovirus, Epstein-Barr virus (EBV), herpes simplex viruses (HSVs) 1 and 2, and human herpes viruses (HHVs) 6A and 6B. Results Among the 320 patients, 65% were male, median age was 14.5 years (range, 0-90), and 67% reported unilateral parotitis. Commonly reported symptoms included sore throat (55%) and fever (48%). Viruses were detected in 210 (71%) of 294 NMP patients with adequate samples for testing, ≥2 viruses were detected in 37 samples, and 248 total virus detections were made among all samples. These included 156 influenza A(H3N2), 42 HHV6B, 32 EBV, 8 HPIV2, 2 HPIV3, 3 adenovirus, 4 HSV-1, and 1 HSV-2. Influenza A(H3N2), HHV6B, and EBV were the most frequently codetected viruses. Conclusions Our findings suggest that, in addition to mumps, clinicians should consider respiratory viral (influenza) and herpes viral etiologies for parotitis, particularly among patients without epidemiologic links to mumps cases or outbreaks.

Lymphocytic Choriomeningitis Virus Meningoencephalitis from a Household Rodent Infestation — Minnesota, 2015

On April 20, 2015, a female aged 15 years sought care at her pediatricians office after 5 days of fever, myalgia, left parietal headache, and photophobia. A rapid influenza assay was negative, and erythrocyte sedimentation rate and total white blood cell count were normal. She improved with symptomatic care at home, but returned to her pediatricians office on April 28, reporting recurrence of her headache and photophobia and new onset of a stiff neck. She was admitted to the hospital, where she was febrile to 102.9°F (39.4°C) and had meningismus. Computed tomography scan of her head was normal, and a cerebrospinal fluid (CSF) analysis showed a markedly elevated white blood cell count with 68% lymphocytes, low glucose, and a negative Gram stain. She was treated empirically for both bacterial and herpes simplex virus meningitis. The patients hospital course was notable for hypotension (blood pressure 81/50), irritability, and pancreatitis with a peak lipase of 8,627 U/L. CSF cultures yielded no growth, and CSF polymerase chain reaction (PCR) testing for herpes simplex virus was negative. Nucleic acid amplification testing, acid-fast bacilli stain, and acid-fast bacilli cultures of CSF were negative for Mycobacterium tuberculosis. Results of investigations for human immunodeficiency virus, syphilis, Lyme disease, human herpesvirus 6 and 7, and species of Babesia, Toxoplasma, Histoplasma, Cryptococcus, Blastomyces, and Brucella were negative. She recovered and was discharged on hospital day 11 with no apparent sequelae.

Influenza-Associated Parotitis During the 2014–2015 Influenza Season in the United States

Background During the 2014-2015 influenza season in the United States, 256 cases of influenza-associated parotitis were reported from 27 states. We conducted a case-control study and laboratory investigation to further describe this rare clinical manifestation of influenza. Methods During February 2015-April 2015, we interviewed 50 cases (with parotitis) and 124 ill controls (without parotitis) with laboratory-confirmed influenza; participants resided in 11 states and were matched by age, state, hospital admission status, and specimen collection date. Influenza viruses were characterized using real-time polymerase chain reaction and next-generation sequencing. We compared cases and controls using conditional logistic regression. Specimens from additional reported cases were also analyzed. Results Cases, 73% of whom were aged <20 years, experienced painful (86%), unilateral (68%) parotitis a median of 4 (range, 0-16) days after onset of systemic or respiratory symptoms. Cases were more likely than controls to be male (76% vs 51%; P = .005). We detected influenza A(H3N2) viruses, genetic group 3C.2a, in 100% (32/32) of case and 92% (105/108) of control specimens sequenced (P = .22). Influenza B and A(H3N2) 3C.3 and 3C.3b genetic group virus infections were detected in specimens from additional cases. Conclusions Influenza-associated parotitis, as reported here and in prior sporadic case reports, seems to occur primarily with influenza A(H3N2) virus infection. Because of the different clinical and infection control considerations for mumps and influenza virus infections, we recommend clinicians consider influenza in the differential diagnoses among patients with acute parotitis during the influenza season.

Correlation between Tennessee Antibiotic Use Point Prevalence Survey and NHSN AUR Module in four acute care hospitals

Abstract Background The CDC’s Core Elements of Hospital Antibiotic Stewardship Programs includes tracking and reporting of antibiotic use (AU). In 2014, the Tennessee Department of Health (TDH) developed a voluntary point prevalence survey for hospitals to report AU, as an interim measure to reporting days of therapy (DOT) data into the AU Option of the National Healthcare Safety Network (NHSN). The objective of this analysis is to correlate AU data obtained from the TDH AU Survey to NHSN AU data from those institutions who concurrently reported. Methods The TDH AU Survey is a quarterly assessment of the number of patients who received antibiotics during a 24-hour period, as a percent of daily hospital census. The metric used for NHSN is monthly DOT/days present. All available DOT from institutions reporting into the NHSN AU Option from October 2015-December 2016 was pulled and aggregated by quarter. TDH AU data reported during the same time period was also pulled. A matched data point was usable when data existed from both the TDH Survey and NHSN. Trend lines and coefficients of determination were created using Excel 2010 and SAS 9.4. Results Four Tennessee hospitals reported into both the NHSN AU Option and the TDH AU survey during the study period. From those institutions, there were 117 matched data points for nine antibiotics or groups of antibiotics. A positive correlation was observed in the primary analysis of all institutions’ reported antibiotic agents – r2=0.7947; P < 0.0001. Variation existed among the nine different drug/classes, with the strongest correlation existing for anti-pseudomonal carbapenems (r2=0.8402, P < 0.0001) and the weakest with respiratory fluoroquinolones (r2=0.0449; P = 0.487). No strong influences were observed when data were analyzed by subgroups of quarters or institutions. Conclusion A positive correlation was found between the two AU metrics, indicating that the TDH AU Survey is a reasonable interim proxy of the NHSN AU data. It is frequently used by TN hospitals for evaluating individual institutional trends, but benchmarking institutions with it is not ideal. This illustrates the need for more hospitals in our state and nationwide to report into the NHSN AU Option. Disclosures All authors: No reported disclosures.

Development and Implementation of the Ebola Traveler Monitoring Program and Clinical Outcomes of Monitored Travelers during October – May 2015, Minnesota

Background In October 2014, the United States began actively monitoring all persons who had traveled from Guinea, Liberia, and Sierra Leone in the previous 21 days. State public health departments were responsible for monitoring all travelers; Minnesota has the largest Liberian population in the United States. The MDH Ebola Clinical Team (ECT) was established to assess travelers with symptoms of concern for Ebola virus disease (EVD), coordinate access to healthcare at appropriate facilities including Ebola Assessment and Treatment Units (EATU), and provide guidance to clinicians. Methods Minnesota Department of Health (MDH) began receiving traveler information collected by U.S. Customs and Border Control and Centers for Disease Control and Prevention staff on October 21, 2014 via encrypted electronic communication. All travelers returning from Liberia, Sierra Leone, and Guinea during 10/21/14–5/15/15 were monitored by MDH staff in the manner recommended by CDC based on the traveler’s risk categorization as “low (but not zero)”, “some” and “high” risk. When a traveler reported symptoms or a temperature ≥100.4° F at any time during their 21-day monitoring period, an ECT member would speak to the traveler and perform a clinical assessment by telephone or via video-chat. Based on the assessment the ECT member would recommend 1) continued clinical monitoring while at home with frequent telephone follow-up by the ECT member, 2) outpatient clinical evaluation at an outpatient site agreed upon by all parties, or 3) inpatient clinical evaluation at one of four Minnesota EATUs. ECT members assessed and approved testing for Ebola virus infection at MDH. Traveler data, calls to the ECT and clinical outcomes were logged on a secure server at MDH. Results During 10/21/14–5/15/15, a total of 783 travelers were monitored; 729 (93%) traveled from Liberia, 30 (4%) Sierra Leone, and 24 (3%) Guinea. The median number monitored per week was 59 (range 45–143). The median age was 35 years; 136 (17%) were aged <18 years. Thirteen of 256 women of reproductive age (5%) were pregnant. The country of passport issuance was known for 720 of the travelers. The majority of monitored travelers (478 [66%]) used a non-U.S. passport including 442 (61%) Liberian nationals. A total of 772 (99%) travelers were “low (but not zero)” risk; 11 (1%) were “some” risk. Among monitored travelers, 43 (5%) experienced illness symptoms; 29 (67%) had a symptom consistent with EVD. Two were tested for Ebola virus disease and had negative results. Most frequently reported symptoms were fever (20/43, 47%) and abdominal pain (12/43, 28%). During evaluation, 16 (37%) of 43 travelers reported their symptoms began prior to travel; chronic health conditions in 24 travelers including tumors/cancer, pregnancy, and orthopedic conditions were most common. Infectious causes in 19 travelers included upper respiratory infection, malaria, and gastrointestinal infections. Discussion Prior to 2014, no similar active monitoring program for travelers had been performed in Minnesota; assessment and management of symptomatic travelers was a new activity for MDH. Ensuring safe entrance into healthcare was particularly challenging for children, and pregnant women, as well as those without an established connection to healthcare. Unnecessary inpatient evaluations were successfully avoided by close clinical follow-up by phone. Before similar monitoring programs are considered in the future, careful thought must be given to necessary resources and the impact on affected populations, public health, and the healthcare system.