Stephanie Griese

Fungal Infections Associated with Contaminated Methylprednisolone Injections

BACKGROUND Fungal infections are rare complications of injections for treatment of chronic pain. In September 2012, we initiated an investigation into fungal infections associated with injections of preservative-free methylprednisolone acetate that was purchased from a single compounding pharmacy. METHODS Three lots of methylprednisolone acetate were recalled by the pharmacy; examination of unopened vials later revealed fungus. Notification of all persons potentially exposed to implicated methylprednisolone acetate was conducted by federal, state, and local public health officials and by staff at clinical facilities that administered the drug. We collected clinical data on standardized case-report forms, and we tested for the presence of fungi in isolates and specimens by examining cultures and performing polymerase-chain-reaction assays and histopathological and immunohistochemical testing. RESULTS By October 19, 2012, more than 99% of 13,534 potentially exposed persons had been contacted. As of July 1, 2013, there were 749 reported cases of infection in 20 states, with 61 deaths (8%). Laboratory evidence of Exserohilum rostratum was present in specimens from 153 case patients (20%). Additional data were available for 728 case patients (97%); 229 of these patients (31%) had meningitis with no other documented infection. Case patients had received a median of 1 injection (range, 1 to 6) of implicated methylprednisolone acetate. The median age of the patients was 64 years (range, 15 to 97), and the median incubation period (the number of days from the last injection to the date of the first diagnosis) was 47 days (range, 0 to 249); 40 patients (5%) had a stroke. CONCLUSIONS Analysis of data from a large, multistate outbreak of fungal infections showed substantial morbidity and mortality. The infections were associated with injection of a contaminated glucocorticoid medication from a single compounding pharmacy. Rapid public health actions included prompt recall of the implicated product, notification of exposed persons, and early outreach to clinicians.

Raccoon Rabies Virus Variant Transmission Through Solid Organ Transplantation

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.

Public Health Emergency Planning for Children in Chemical, Biological, Radiological, and Nuclear (CBRN) Disasters

Children represent nearly a quarter of the US population, but their unique needs in chemical, biological, radiological, and nuclear (CBRN) emergencies may not be well understood by public health and emergency management personnel or even clinicians. Children are different from adults physically, developmentally, and socially. These characteristics have implications for providing care in CBRN disasters, making resulting illness in children challenging to prevent, identify, and treat. This article discusses these distinct physical, developmental, and social traits and characteristics of children in the context of the science behind exposure to, health effects from, and treatment for the threat agents potentially present in CBRN incidents.

CDC Grand Rounds: Addressing Preparedness Challenges for Children in Public Health Emergencies.

Recent public health emergencies including Hurricane Katrina (2005), the influenza H1N1 pandemic (2009), and the Ebola virus disease outbreak in West Africa (2014–2015) have demonstrated the importance of multiple-level emergency planning and response. An effective response requires integrating coordinated contributions from community-based health care providers, regional health care coalitions, state and local health departments, and federal agency initiatives. This is especially important when planning for the needs of children, who make up 23% of the U.S. population (1) and have unique needs that require unique planning strategies.

Clinical Inquiries Received by CDC Regarding Suspected Ebola Virus Disease in Children--United States, July 9, 2014-January 4, 2015.

The 2014–2015 Ebola virus disease (Ebola) epidemic is the largest in history and represents the first time Ebola has been diagnosed in the United States. On July 9, 2014, CDC activated its Emergency Operations Center and established an Ebola clinical consultation service to assist U.S. state and local public health officials and health care providers with the evaluation of suspected cases. CDC reviewed all 89 inquiries received by the consultation service during July 9, 2014– January 4, 2015, about children (persons aged ≤18 years). Most (56 [63%]) children had no identifiable epidemiologic risk factors for Ebola; among the 33 (37%) who did have an epidemiologic risk factor, in every case this was travel from an Ebola-affected country. Thirty-two of these children met criteria for a person under investigation (PUI) because of clinical signs or symptoms. Fifteen PUIs had blood samples tested for Ebola virus RNA by reverse transcription–polymerase chain reaction; all tested negative. Febrile children who have recently traveled from an Ebola-affected country can be expected to have other common diagnoses, such as malaria and influenza, and in the absence of epidemiologic risk factors for Ebola, the likelihood of Ebola is extremely low. Delaying evaluation and treatment for these other more common illnesses might lead to poorer clinical outcomes. Additionally, many health care providers expressed concerns about whether and how parents should be allowed in the isolation room. While maintaining an appropriate level of vigilance for Ebola, public health officials and health care providers should ensure that pediatric PUIs receive timely triage, diagnosis, and treatment of other more common illnesses, and care reflecting best practices in supporting children’s psychosocial needs.

Pediatric Botulism and Use of Equine Botulinum Antitoxin in Children: A Systematic Review

Background Botulism manifests with cranial nerve palsies and flaccid paralysis in children and adults. Botulism must be rapidly identified and treated; however, clinical presentation and treatment outcomes of noninfant botulism in children are not well described. Methods We searched 12 databases for peer-reviewed and non-peer-reviewed reports with primary data on botulism in children (persons <18 years of age) or botulinum antitoxin administration to children. Reports underwent title and abstract screening and full text review. For each case, patient demographic, clinical, and outcome data were abstracted. Results Of 7065 reports identified, 184 met inclusion criteria and described 360 pediatric botulism cases (79% confirmed, 21% probable) that occurred during 1929-2015 in 34 countries. Fifty-three percent were male; age ranged from 4 months to 17 years (median, 10 years). The most commonly reported signs and symptoms were dysphagia (53%), dysarthria (39%), and generalized weakness (37%). Inpatient length of stay ranged from 1 to 425 days (median, 24 days); 14% of cases required intensive care unit admission; 25% reported mechanical ventilation. Eighty-three (23%) children died. Median interval from illness onset to death was 1 day (range, 0-260 days). Among patients who received antitoxin (n = 193), 23 (12%) reported an adverse event, including rash, fever, serum sickness, and anaphylaxis. Relative risk of death among patients treated with antitoxin compared with patients not treated with antitoxin was 0.24 (95% confidence interval, .14-.40; P < .0001). Conclusions Dysphagia and dysarthria were the most commonly reported cranial nerve symptoms in children with botulism; generalized weakness was described more than paralysis. Children who received antitoxin had better survival; serious adverse events were rare. Most deaths occurred early in the clinical course; therefore, botulism in children should be identified and treated rapidly.

Clinical Criteria to Trigger Suspicion for Botulism: An Evidence-Based Tool to Facilitate Timely Recognition of Suspected Cases During Sporadic Events and Outbreaks

Effective treatment for botulism requires early clinical recognition. Diagnosis of botulism, including during outbreaks, can be challenging. We assessed combinations of signs and symptoms among confirmed cases and identified sensitive clinical criteria to trigger suspicion. We produced a tool that may facilitate rapid identification of sporadic and outbreak-associated cases.

Establishing a Hospital Response Network Among Children’s Hospitals

A timely and effective response to public health threats requires a broad-reaching infrastructure. Childrens hospitals are focused on evaluating and managing some of the most vulnerable patients and thus have unique preparedness and response planning needs. A virtual forum was established specifically for childrens hospitals during the 2014-15 Ebola outbreak, and it demonstrated the importance and utility of connecting these specialty hospitals to discuss their shared concerns. Developing a successful childrens hospital response network could build the national infrastructure for addressing childrens needs in preparedness and response and for enhancing preparedness and response to high-consequence pathogens. Using the Laboratory Response Network and tiered-hospital network as models, a network of childrens hospitals could work together, and with government and nongovernment partners, to establish and refine best practices for treating children with pathogens of public health concern. This network could more evenly distribute hospital readiness and tertiary pediatric patient care capabilities for highly infectious diseases across the country, thus reducing the need to transport pediatric patients across the country and increasing the national capacity to care for children infected with high-consequence pathogens.

Middle East Respiratory Syndrome Coronavirus and Children: What Pediatric Health Care Professionals Need to Know.

As of December 31, 2015, 1621 laboratory-confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) had been reported to the World Health Organization (WHO), with 584 deaths in 26 countries (http://www.who.int/emergencies/mers-cov/en/). Two imported MERS-CoV cases were identified in the United States in May 2014. WHO has not declared this disease to constitute a Public Health Emergency of International Concern. However, sporadic MERS-CoV cases could continue to be imported into the United States. This article provides background information on MERS-CoV and MERS-CoV infections in children for pediatric health care providers in the United States. MERS-CoV infections among children have been reported, and severe respiratory illnesses have been documented in children with underlying conditions. United States health care providers should be vigilant in assessing children with severe respiratory illnesses and history of recent travel in or near the Arabian Peninsula for MERS-CoV infections.

Disaster Planning and Response with and for People with Disabilities

Individuals with disabilities require special planning for, and support during, disasters, but that planning and support cannot occur in isolation. Emergency management policy regarding individuals with disabilities has evolved into the concept of “whole community.” Whole community informs how families, clinicians, and public health can play a vital role in disaster planning for individuals with disabilities. This planning includes special considerations for communication and notification, evacuation and emergency transportation, sheltering, medication supplies and equipment, and service animals.