The true burden of reactivation of remote latent tuberculosis infection (reactivation TB) among foreign-born persons with tuberculosis (TB) within the United States is not known. Our study objectives ...were to estimate the proportion of foreign-born persons with TB due reactivation TB and to describe characteristics of foreign-born persons with reactivation TB.
We conducted a cross-sectional study of patients with an M. tuberculosis isolate genotyped by the U.S. National TB Genotyping Service, 2005-2009. TB cases were attributed to reactivation TB if they were not a member of a localized cluster of cases. Localized clusters were determined by a spatial scan statistic of cases with isolates with matching TB genotype results. Crude odds ratios and 95% confidence intervals were used to assess relations between reactivation TB and select factors among foreign-born persons.
Among the 36,860 cases with genotyping and surveillance data reported, 22,151 (60%) were foreign-born. Among foreign-born persons with TB, 18,540 (83.7%) were attributed to reactivation TB. Reactivation TB among foreign-born persons was associated with increasing age at arrival, incidence of TB in the country of origin, and decreased time in the U.S. at the time of TB diagnosis.
Four out of five TB cases among foreign-born persons can be attributed to reactivation TB and present the largest challenge to TB elimination in the U.S. TB control strategies among foreign-born persons should focus on finding and treating latent tuberculosis infection prior to or shortly after arrival to the United States and on reducing the burden of LTBI through improvements in global TB control.
Early warning and response surveillance (EWARS) systems were widely used during the early COVID-19 response. Evaluating the effectiveness of EWARS systems is critical to ensuring global health ...security. We describe the Centers for Disease Control and Prevention (CDC) global COVID-19 EWARS (CDC EWARS) system and the resources CDC used to gather, manage, and analyze publicly available data during the prepandemic period. We evaluated data quality and validity by measuring reporting completeness and compared these with data from Johns Hopkins University, the European Centre for Disease Prevention and Control, and indicator-based data from the World Health Organization. CDC EWARS was integral in guiding CDC's early COVID-19 response but was labor-intensive and became less informative as case-level data decreased and the pandemic evolved. However, CDC EWARS data were similar to those reported by other organizations, confirming the validity of each system and suggesting collaboration could improve EWARS systems during future pandemics.
To describe the epidemiology and possible risk factors for the development of multidrug-resistant tuberculosis (MDR-TB) in Namibia.
Using medical records and patient questionnaires, we conducted a ...case-control study among patients diagnosed with TB between January 2007 and March 2009. Cases were defined as patients with laboratory-confirmed MDR-TB; controls had laboratory-confirmed drug-susceptible TB or were being treated with WHO Category I or Category II treatment regimens.
We enrolled 117 MDR-TB cases and 251 TB controls, of which 100% and 2% were laboratory-confirmed, respectively. Among cases, 97% (113/117) had been treated for TB before the current episode compared with 46% (115/251) of controls (odds ratio OR 28.7, 95% confidence interval CI 10.3-80.5). Cases were significantly more likely to have been previously hospitalized (OR 1.9, 95% CI 1.1-3.5) and to have had a household member with MDR-TB (OR 5.1, 95% CI 2.1-12.5). These associations remained significant when separately controlled for being currently hospitalized or HIV-infection.
MDR-TB was associated with previous treatment for TB, previous hospitalization, and having had a household member with MDR-TB, suggesting that TB control practices have been inadequate. Strengthening basic TB control practices, including expanding laboratory confirmation, directly observed therapy, and infection control, are critical to the prevention of MDR-TB.
DISCLOSURE The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Agency ...for Toxic Substances and Diseases Registry. OBJECTIVE Describe the impact of standardizing state-specific summary measures of antibiotic resistance that inform regional interventions to reduce transmission of resistant pathogens in healthcare settings. DESIGN Analysis of public health surveillance data. METHODS Central line-associated bloodstream infection (CLABSI) data from intensive care units (ICUs) of facilities reporting to the National Healthcare Safety Network in 2011 were analyzed. For CLABSI due to methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum cephalosporin (ESC)-nonsusceptible Klebsiella species, and carbapenem-nonsusceptible Klebsiella species, we computed 3 state-level summary measures of nonsusceptibility: crude percent nonsusceptible, model-based adjusted percent nonsusceptible, and crude infection incidence rate. RESULTS Overall, 1,791 facilities reported CLABSIs from ICU patients. Of 1,618 S. aureus CLABSIs with methicillin-susceptibility test results, 791 (48.9%) were due to MRSA. Of 756 Klebsiella CLABSIs with ESC-susceptibility test results, 209 (27.7%) were due to ESC-nonsusceptible Klebsiella, and among 661 Klebsiella CLABSI with carbapenem susceptibility test results, 70 (10.6%) were due to carbapenem-nonsusceptible Klebsiella. All 3 state-specific measures demonstrated variability in magnitude by state. Adjusted measures, with few exceptions, were not appreciably different from crude values for any phenotypes. When linking values of crude and adjusted percent nonsusceptible by state, a state's absolute rank shifted slightly for MRSA in 5 instances and only once each for ESC-nonsusceptible and carbapenem-nonsusceptible Klebsiella species. Infection incidence measures correlated strongly with both percent nonsusceptibility measures. CONCLUSIONS Crude state-level summary measures, based on existing NHSN CLABSI data, may suffice to assess geographic variability in antibiotic resistance. As additional variables related to antibiotic resistance become available, risk-adjusted summary measures are preferable.
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.
Background Neuroendocrine tumors (NETs) are rare neoplasms. Our group has treated more than 2,000 NET patients and has performed more than 1,000 surgical cytoreductive procedures. Study Design ...Records of 834 NET patients who underwent surgical cytoreduction at our institution were reviewed. Demographic information, intraoperative findings, extent of disease, complications, and survival rates were calculated. Results Eight hundred patients underwent 1,001 cytoreductive operations. Sixty-five percent had small bowel primaries. One hundred and thirty-eight patients presented with an unknown primary site, which was localized intraoperatively in 89% of these cases. The intraoperative complication rate was 9%. The incidence of intraoperative carcinoid crisis was 1%. Mean ± SD operative time was 368 ± 146 minutes. Mean ± SD hospital stay was 9 ± 10 days. Minor postoperative complications occurred after 43% of procedures and major postoperative complications were noted after 19% of procedures. The 30-day postoperative mortality rate was 2%. Median overall survival (OS) for patients with pancreatic NETs was 124 months. The 5-, 10-, and 20-year OS rates for patients with pancreatic NETs were 67%, 51%, and 36%, respectively. The life expectancy difference (between OS and actuarial survival) after surgical cytoreduction for patients with pancreatic NETs was 16.6 years. Median OS for patients with small bowel NETs was 161 months. The 5-, 10-, and 20-year OS rates for patients with small bowel NETs were 84%, 67% and 31%, respectively. The life expectancy difference after surgical cytoreduction for patients with small bowel NETs was 11.7 years. Conclusions Surgical cytoreduction in NET patients has low morbidity and mortality rates and results in prolonged survival. We believe that surgical cytoreduction should play a major role in the care of patients with NETs.
Background Neuroendocrine tumors (NETs) of the duodenum are rare, heterogeneous, and often indolent neoplasms. We hypothesized that elevated pancreastatin levels are an indicator of a poor prognosis ...in well-differentiated duodenal NETs. Study Design Data from patients diagnosed with a primary duodenal NET were analyzed. Patients that underwent esophogogastroduodenoscopy, endoscopic ultrasound, or exploratory surgery to localize their neoplasm and whose tumors were confirmed histologically were included. Results Eighty-four patients were diagnosed with duodenal NETs from January 1991 to January 2014. Seventy-five percent and 21% of patients had their tumor localized by esophogogastroduodenoscopy and endoscopic ultrasound, respectively. The remaining 4% were localized during exploratory surgery. The 5-year Kaplan-Meier survival rate for the entire cohort (N = 84) was 80%. Survival sorted by normal vs abnormal pancreastatin level was statistically significant (p < 0.0001). Five-year survival rates were 94% and 37% for normal and abnormal pancreastatin, respectively. In contrast, survival sorted by normal vs abnormal plasma chromogranin A level was not statistically significant (p = 0.24). Conclusions Patients with primary duodenal NETs have high 5-year survival rates. Serial monitoring of plasma pancreastatin levels can identify patients who have a poor prognosis.
Despite the decrease in Tuberculosis (TB) in Chicago over the past ten years, substance users remain at an increased risk for TB and failing TB treatment. The goals of this study are to investigate ...the effectiveness of using former substance users (enhanced arm) vs. Chicago Department of Pubic Health (CDPH) workers (standard arm) in performing Directly Observed Therapy and TB contact tracing for substance users with TB. The study compares the two arms in terms of (1) TB treatment completion and treatment compliance, (2) TB contact tracing, and (3) lifestyle changes among adult substance users with TB in Chicago. This study was a randomized trial, in which participants were extensively interviewed at baseline and 6-9 month follow-up. Contact tracing was also performed on the participants' contacts. Forty-six participants were randomized to standard arm and 48 to enhanced arm. Participants in the standard arm had a 2.7 greater risk for failing to complete treatment, 39% vs. 15%, (95% CI 1.24-5.82). Likewise, they had a higher risk of not being compliant while on treatment (RR=2.5, 95% CI 1.15-5.48) and of missing a DOT appointment (OR=2.91, 95% CI 1.46-5.81). Seventy-five percent of cases in the enhanced arm identified contacts, compared to only 47% in the standard arm (p=0.003). Otherwise, the success of contact tracing in the two arms was not significantly different for following proper screening procedures or identifying high risk contacts. In comparing the two treatment arms there were no significant differences for lifestyle changes. However when looking at the study population as a whole, participants were significantly more likely to report that they were not using drugs at follow-up as compared to baseline (p<0.0001), and not using substances with people they did not know. Participants also had a decrease in the number of sexual partners (p=0.017) and increased condom usage (p=.031). Participants also reported decreased stigmatization (p=0.0008). This study demonstrates that using former substance users to deliver DOT to current substance users with TB gives higher rates of completing treatment and complying with the treatment regimen. For contact tracing, former substance users were only more successful in getting cases to name their contacts. Lastly, this study demonstrates that having TB and receiving DOT causes a reduction in risk behaviors and decreased stigma.
Objective. To describe antimicrobial resistance patterns for healthcare-associated infections (HAIs) reported to the National Healthcare Safety Network (NHSN) during 2009–2010.
Methods. Central ...line–associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, and surgical site infections were included. Pooled mean proportions of isolates interpreted as resistant (or, in some cases, nonsusceptible) to selected antimicrobial agents were calculated by type of HAI and compared to historical data.
Results. Overall, 2,039 hospitals reported 1 or more HAIs; 1,749 (86%) were general acute care hospitals, and 1,143 (56%) had fewer than 200 beds. There were 69,475 HAIs and 81,139 pathogens reported. Eight pathogen groups accounted for about 80% of reported pathogens: Staphylococcus aureus (16%), Enterococcus spp. (14%), Escherichia coli (12%), coagulase-negative staphylococci (11%), Candida spp. (9%), Klebsiella pneumoniae (and Klebsiella oxytoca; 8%), Pseudomonas aeruginosa (8%), and Enterobacter spp. (5%). The percentage of resistance was similar to that reported in the previous 2-year period, with a slight decrease in the percentage of S. aureus resistant to oxacillins (MRSA). Nearly 20% of pathogens reported from all HAIs were the following multidrug-resistant phenotypes: MRSA (8.5%); vancomycin-resistant Enterococcus (3%); extended-spectrum cephalosporin–resistant K. pneumoniae and K. oxytoca (2%), E. coli (2%), and Enterobacter spp. (2%); and carbapenem-resistant P. aeruginosa (2%), K. pneumoniae/oxytoca (<1%), E. coli (<1%), and Enterobacter spp. (<1%). Among facilities reporting HAIs with 1 of the above gram-negative bacteria, 20%–40% reported at least 1 with the resistant phenotype.
Conclusion. While the proportion of resistant isolates did not substantially change from that in the previous 2 years, multidrug-resistant gram-negative phenotypes were reported from a moderate proportion of facilities.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of the worldwide COVID-19 pandemic. Animal models are extremely helpful for testing vaccines and therapeutics and ...for dissecting the viral and host factors that contribute to disease severity and transmissibility. Here, we report the assessment and comparison of intranasal and small particle (~3 µm) aerosol SARS-CoV-2 exposure in ferrets. The primary endpoints for analysis were clinical signs of disease, recovery of the virus in the upper respiratory tract, and the severity of damage within the respiratory tract. This work demonstrated that ferrets were productively infected with SARS-CoV-2 following either intranasal or small particle aerosol exposure. SARS-CoV-2 infection of ferrets resulted in an asymptomatic disease course following either intranasal or small particle aerosol exposure, with no clinical signs, significant weight loss, or fever. In both aerosol and intranasal ferret models, SARS-CoV-2 replication, viral genomes, and viral antigens were detected within the upper respiratory tract, with little to no viral material detected in the lungs. The ferrets exhibited a specific IgG immune response to the SARS-CoV-2 full spike protein. Mild pathological findings included inflammation, necrosis, and edema within nasal turbinates, which correlated to positive immunohistochemical staining for the SARS-CoV-2 virus. Environmental sampling was performed following intranasal exposure of ferrets, and SARS-CoV-2 genomic material was detected on the feeders and nesting areas from days 2-10 post-exposure. We conclude that both intranasal and small particle aerosol ferret models displayed measurable parameters that could be utilized for future studies, including transmission studies and testing SARS-CoV-2 vaccines and therapeutics.
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