Autochthonous Plasmodium vivax Infections, Florida, USA, 2023.

During May-July 2023, a cluster of 7 patients at local hospitals in Florida, USA, received a diagnosis of Plasmodium vivax malaria. Whole-genome sequencing of the organism from 4 patients and phylogenetic analysis with worldwide representative P. vivax genomes indicated probable single parasite introduction from Central/South America.

Outbreak of Locally Acquired Mosquito-Transmitted (Autochthonous) Malaria - Florida and Texas, May-July 2023.

Eight cases of locally acquired, mosquito-transmitted (i.e., autochthonous) Plasmodium vivax malaria, which has not been reported in the United States since 2003, were reported to CDC from state health departments in Florida and Texas during May 18-July 17, 2023. As of August 4, 2023, case surveillance, mosquito surveillance and control activities, and public outreach and education activities continue in both states. U.S. clinicians need to consider a malaria diagnosis in patients with unexplained fever, especially in areas where autochthonous malaria has been recently reported, although the risk for autochthonous malaria in the United States remains very low. Prompt diagnosis and treatment of malaria can prevent severe disease or death and limit ongoing transmission to local Anopheles mosquitoes and other persons. Preventing mosquito bites and controlling mosquitoes at home can prevent mosquitoborne diseases, including malaria. Before traveling internationally to areas with endemic malaria, travelers should consult with a health care provider regarding recommended malaria prevention measures, including potentially taking malaria prophylaxis. Malaria is a nationally notifiable disease; continued reporting of malaria cases to jurisdictional health departments and CDC will also help ensure robust surveillance to detect and prevent autochthonous malaria in the United States.

Monkeypox Virus Infection Resulting from an Occupational Needlestick - Florida, 2022.

In August 2022, the Florida Department of Health notified CDC of a nurse who acquired monkeypox through an occupational exposure while providing care to a patient with monkeypox. To date, occupationally acquired Monkeypox virus (MPXV) infections in health care personnel (HCP) have been rarely reported during the 2022 multinational outbreak (1,2). This report describes the first reported U.S. case and recommends approaches for preventing occupationally acquired MPXV infections in HCP.

Community Assessment for Mental and Physical Health Effects After Hurricane Irma - Florida Keys, May 2019.

Disasters can adversely affect population health, resulting in increased need for health services. Hurricane Irma made landfall in the Florida Keys (Monroe County) as a Category 4 hurricane on September 10, 2017. The hurricane caused substantial damage to 65% of homes and resulted in 40 persons injured and 17 deaths from hurricane-related causes.* During 2018, the county suicide rate increased to 34.9 per 100,000 population from the 5-year (2013-2017) average of 25.2 per 100,000 population (1). In May 2019, 20 months after the hurricane, the Florida Department of Health (FDOH) conducted a modified Community Assessment for Public Health Emergency Response (CASPER) to assess the community's mental, physical, and economic health and develop public health interventions to decrease the suicide rate. A consenting adult member from 231 households was interviewed, and a weighted cluster analysis was conducted to estimate the number and percentage of households throughout the Florida Keys with a particular response, as well as the number and percentage of persons at risk for suicide. During the 20 months since Hurricane Irma, 17% of households reported a need for a mental health care provider; 37.9% of these did not receive those services. A modified CASPER was used to calculate population estimates of suicide risk in an area of high landfall for hurricanes; estimated population suicide risk was 7.3%. Respondents reported worsening of respiratory conditions (17.7%), anxiety (17.0%), and depression (11.3%). Emergency preparedness plans should consider strengthening mental health service delivery after a hurricane, particularly during the long-term recovery phase.

SARS-COV-2 ANTIBODY PREVALENCE AMONG HEALTHCARE WORKERS AND FIRST RESPONDERS, FLORIDA, MAY-JUNE 2020.

BACKGROUND: The SARS-CoV-2 virus responsible for severe respiratory infection associated with coronavirus disease 2019 (COVID-19) was first confirmed in Florida on March 1, 2020. Responding to the pandemic, multi-agency collaborative partnerships put in place actions integrating point-of-care antibody testing at established large-scale COVID-19 testing sites where the baseline seropositivity of COVID-19 in health care workers and first responders in Florida at the start of the pandemic was established. PURPOSE: Determine the seropositivity of healthcare workers and first responders at five drive thru testing sites using a rapid SARS-CoV-2 antibody test in Florida from May 6 through June 3, 2020. METHODS: The first drive-thru SARS-CoV-2 antibody test site was opened at Miami Hard Rock Stadium, May 6, 2020. Testing expanded to three additional sites on May 9, 2020: Jacksonville, Orlando, and Palm Beach. The fifth and final site, Miami Beach, began testing on May 21, 2020. Healthcare workers and first responder's self-seeking SARS-CoV-2 testing were designated for antibody testing and completed a laboratory collection form onsite for the point-of-care test. All testing was performed on whole blood specimens (obtained by venipuncture) using the Cellex Inc. qSARS-CoV-2 IgG/IgM Rapid Test. Seropositivity was assessed by univariate analysis and by logistic regression including the covariates age, sex, race/ethnicity, and testing location. RESULTS AND DISCUSSION: As of June 3, 2020, of 5,779 healthcare workers and first responders tested, 4.1% were seropositive (range 2.6-8.2%). SARS-COV-2 antibody tests had higher odds of being positive for persons testing at the Miami Hard Rock Stadium (aOR 2.24 [95% C.I. 1.48-3.39]), persons of Haitian/Creole ethnicity (aOR 3.28 [95% C.I. 1.23-8.72]), Hispanic/Latino(a) ethnicity (aOR 2.17 [95% C.I. 1.50-3.13], and Black non-Hispanic persons (aOR 1.63 [95% C.I. 1.08-2.46]). SARS-COV-2 antibody prevalence among first responders and healthcare workers in five sites in Florida varied by race and ethnicity and by testing location.

COVID-19 in Primary and Secondary School Settings During the First Semester of School Reopening - Florida, August-December 2020.

After detection of cases of COVID-19 in Florida in March 2020, the governor declared a state of emergency on March 9,* and all school districts in the state suspended in-person instruction by March 20. Most kindergarten through grade 12 (K-12) public and private schools in Florida reopened for in-person learning during August 2020, with varying options for remote learning offered by school districts. During August 10-December 21, 2020, a total of 63,654 COVID-19 cases were reported in school-aged children; an estimated 60% of these cases were not school-related. Fewer than 1% of registered students were identified as having school-related COVID-19 and <11% of K-12 schools reported outbreaks. District incidences among students correlated with the background disease incidence in the county; resumption of in-person education was not associated with a proportionate increase in COVID-19 among school-aged children. Higher rates among students were observed in smaller districts, districts without mandatory mask-use policies, and districts with a lower proportion of students participating in remote learning. These findings highlight the importance of implementing both community-level and school-based strategies to reduce the spread of COVID-19 and suggest that school reopening can be achieved without resulting in widespread illness among students in K-12 school settings.

SARS-CoV-2 Transmission Associated with High School Wrestling Tournaments - Florida, December 2020-January 2021.

On December 7, 2020, local public health officials in Florida county A were notified of a person with an antigen-positive SARS-CoV-2 test* result who had attended two high school wrestling tournaments held in the county on December 4 and 5. The tournaments included 10 participating high schools from three counties. The host school (school A in county A) participated in the tournaments on both days; five high school teams from two counties participated the first day only; four additional high school teams from the three counties participated the second day. A total of 130 wrestlers, coaches, and referees attended the tournaments (Table). During December 8-9, 13 wrestlers from school A received positive SARS-CoV-2 test results (Figure), including nine who were symptomatic, two who were asymptomatic, and two for whom symptom status at time of specimen collection was unknown. Local public health officials in the three counties initiated an investigation† and tested specimens from an additional 40 attendees from nine of the 10 participating schools. A total of 54 (41.5%) of the 130 tournament attendees received testing, and 38 cases of SARS-CoV-2 infection were identified; the minimum attack rate was 30.2% (38 of 126§), and 70.4% (38 of 54) of tests had a positive result. Among contacts of the 38 COVID-19 patients, 446 were determined by investigators to meet the CDC definition of a close contact,¶ including 62 who were household contacts and 384 who were in-school contacts (classmates, teachers, noncompeting wrestling team members, and other school athletic team members). Among these 446 contacts, five had received a diagnosis of COVID-19 during June-November and were excluded from attack rate calculations. Among 95 (21.3%) contacts who received SARS-CoV-2 testing, 41 (43.2%) received a positive test result (minimum attack rate = 9.3% [41 of 441]); 21 (51.2%) persons with positive test results were symptomatic, eight (19.5%) were asymptomatic, and symptom status for 12 (29.3%) was unknown at the time of specimen collection. Among contacts, attack rates were highest among household members (30.0%) and wrestling team members who did not attend the tournament (20.3%), as were the percentages of positive test results (60.0% among household members and 54.2% among team members). Among all contacts, the odds of receiving a positive test result were highest among household contacts (odds ratio = 2.7; 95% confidence interval = 1.2-6.0). Local health authorities reported the death of one adult contact aged >50 years.

Seroprevalence of Antibodies to SARS-CoV-2 in 10 Sites in the United States, March 23-May 12, 2020.

IMPORTANCE: Reported cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection likely underestimate the prevalence of infection in affected communities. Large-scale seroprevalence studies provide better estimates of the proportion of the population previously infected. OBJECTIVE: To estimate prevalence of SARS-CoV-2 antibodies in convenience samples from several geographic sites in the US. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study performed serologic testing on a convenience sample of residual sera obtained from persons of all ages. The serum was collected from March 23 through May 12, 2020, for routine clinical testing by 2 commercial laboratory companies. Sites of collection were San Francisco Bay area, California; Connecticut; south Florida; Louisiana; Minneapolis-St Paul-St Cloud metro area, Minnesota; Missouri; New York City metro area, New York; Philadelphia metro area, Pennsylvania; Utah; and western Washington State. EXPOSURES: Infection with SARS-CoV-2. MAIN OUTCOMES AND MEASURES: The presence of antibodies to SARS-CoV-2 spike protein was estimated using an enzyme-linked immunosorbent assay, and estimates were standardized to the site populations by age and sex. Estimates were adjusted for test performance characteristics (96.0% sensitivity and 99.3% specificity). The number of infections in each site was estimated by extrapolating seroprevalence to site populations; estimated infections were compared with the number of reported coronavirus disease 2019 (COVID-19) cases as of last specimen collection date. RESULTS: Serum samples were tested from 16 025 persons, 8853 (55.2%) of whom were women; 1205 (7.5%) were 18 years or younger and 5845 (36.2%) were 65 years or older. Most specimens from each site had no evidence of antibodies to SARS-CoV-2. Adjusted estimates of the proportion of persons seroreactive to the SARS-CoV-2 spike protein antibodies ranged from 1.0% in the San Francisco Bay area (collected April 23-27) to 6.9% of persons in New York City (collected March 23-April 1). The estimated number of infections ranged from 6 to 24 times the number of reported cases; for 7 sites (Connecticut, Florida, Louisiana, Missouri, New York City metro area, Utah, and western Washington State), an estimated greater than 10 times more SARS-CoV-2 infections occurred than the number of reported cases. CONCLUSIONS AND RELEVANCE: During March to early May 2020, most persons in 10 diverse geographic sites in the US had not been infected with SARS-CoV-2 virus. The estimated number of infections, however, was much greater than the number of reported cases in all sites. The findings may reflect the number of persons who had mild or no illness or who did not seek medical care or undergo testing but who still may have contributed to ongoing virus transmission in the population.

Rapid Identification and Investigation of an HIV Risk Network Among People Who Inject Drugs -Miami, FL, 2018.

Prevention of HIV outbreaks among people who inject drugs remains a challenge to ending the HIV epidemic in the United States. The first legal syringe services program (SSP) in Florida implemented routine screening in 2018 leading to the identification of ten anonymous HIV seroconversions. The SSP collaborated with the Department of Health to conduct an epidemiologic investigation. All seven acute HIV seroconversions were linked to care (86% within 30 days) and achieved viral suppression (mean 70 days). Six of the seven individuals are epidemiologically and/or socially linked to at least two other seroconversions. Analysis of the HIV genotypes revealed that two individuals are connected molecularly at 0.5% genetic distance. We identified a risk network with complex transmission dynamics that could not be explained by epidemiological methods or molecular analyses alone. Providing wrap-around services through the SSP, including routine screening, intensive linkage and patient navigation, could be an effective model for achieving viral suppression for people who inject drugs.

Zika Virus IgM 25 Months after Symptom Onset, Miami-Dade County, Florida, USA.

We assessed IgM detection in Zika patients from the 2016 outbreak in Miami-Dade County, Florida, USA. Of those with positive or equivocal IgM after 12-19 months, 87% (26/30) had IgM 6 months later. In a survival analysis, ≈76% had IgM at 25 months. Zika virus IgM persists for years, complicating serologic diagnosis.

Zika Virus IgM Detection and Neutralizing Antibody Profiles 12-19 Months after Illness Onset.

Data on the duration of detectable Zika virus-specific IgM in infected persons are limited. Neutralizing antibody cross-reactivity occurs between Zika virus and related flaviviruses, but the degree to which this confounds diagnosis is uncertain. We tested serum specimens collected 12-19 months after illness onset from patients with confirmed Zika virus disease for Zika virus IgM and Zika virus and dengue virus neutralizing antibodies. Among 62 participants, 45 (73%) had detectable Zika virus IgM and 12 (19%) had an equivocal result. Although all patients tested had Zika virus neutralizing antibodies, 39 (63%) also had neutralizing antibodies against dengue virus; of those, 12 (19%) had <4-fold difference between Zika virus and dengue virus titers, and 5 (8%) had dengue virus titer >4-fold higher than Zika virus titer. Prolonged detection of IgM and neutralizing antibody cross-reactivity make it difficult to determine the timing of Zika virus infection and differentiate between related flaviviruses.

Deaths Related to Hurricane Irma - Florida, Georgia, and North Carolina, September 4-October 10, 2017.

Three powerful and devastating hurricanes from the 2017 Atlantic hurricane season (Harvey [August 17-September 1], Irma [August 30-September 13], and Maria [September 16-October 2]) resulted in the deaths of hundreds of persons. Disaster-related mortality surveillance is critical to an emergency response because it provides government and public health officials with information about the scope of the disaster and topics for prevention messaging. CDC's Emergency Operations Center collaborated with state health departments in Florida, Georgia, and North Carolina to collect and analyze Hurricane Irma-related mortality data to understand the main circumstances of death. The most common circumstance-of-death categories were exacerbation of existing medical conditions and power outage. Further analysis revealed two unique subcategories of heat-related and oxygen-dependent deaths in which power outage contributed to exacerbation of an existing medical condition. Understanding the need for subcategorization of disaster-related circumstances of death and the possibility of overlapping categories can help public health practitioners derive more effective public health interventions to prevent deaths in future disasters.

Local Mosquito-Borne Transmission of Zika Virus - Miami-Dade and Broward Counties, Florida, June-August 2016.

During the first 6 months of 2016, large outbreaks of Zika virus disease caused by local mosquito-borne transmission occurred in Puerto Rico and other U.S. territories, but local mosquito-borne transmission was not identified in the continental United States (1,2). As of July 22, 2016, the Florida Department of Health had identified 321 Zika virus disease cases among Florida residents and visitors, all occurring in either travelers from other countries or territories with ongoing Zika virus transmission or sexual contacts of recent travelers.* During standard case investigation of persons with compatible illness and laboratory evidence of recent Zika virus infection (i.e., a specimen positive by real-time reverse transcription-polymerase chain reaction [rRT-PCR], or positive Zika immunoglobulin M [IgM] with supporting dengue serology [negative for dengue IgM antibodies and positive for dengue IgG antibodies], or confirmation of Zika virus neutralizing antibodies by plaque reduction neutralization testing [PRNT]) (3), four persons were identified in Broward and Miami-Dade counties whose infections were attributed to likely local mosquito-borne transmission. Two of these persons worked within 120 meters (131 yards) of each other but had no other epidemiologic connections, suggesting the possibility of a local community-based outbreak. Further epidemiologic and laboratory investigations of the worksites and surrounding neighborhood identified a total of 29 persons with laboratory evidence of recent Zika virus infection and likely exposure during late June to early August, most within an approximate 6-block area. In response to limited impact on the population of Aedes aegypti mosquito vectors from initial ground-based mosquito control efforts, aerial ultralow volume spraying with the organophosphate insecticide naled was applied over a 10 square-mile area beginning in early August and alternated with aerial larviciding with Bacillus thuringiensis subspecies israelensis (Bti), a group biologic control agent, in a central 2 square-mile area. No additional cases were identified after implementation of this mosquito control strategy. No increases in emergency department (ED) patient visits associated with aerial spraying were reported, including visits for asthma, reactive airway disease, wheezing, shortness of breath, nausea, vomiting, or diarrhea. Local and state health departments serving communities where Ae. aegypti, the primary vector of Zika virus, is found should continue to actively monitor for local transmission of the virus.(†).

Full House: A Retrospective Analysis of High Sexually Transmitted Infection Prevalence among Adult Film Actors at a Singular Residence.

BACKGROUND: During a routine human immunodeficiency virus (HIV) investigation, Florida Department of Health staff identified a house (house A) in which over 150 individuals had resided at least briefly. Further investigation revealed that house A is used by the producer of a small adult film production company to board his actors. This report describes sexually transmitted infection (STI) prevalence among male actors in gay adult films residing in a common Florida residence. METHODS: LexisNexis Accurint was used to identify house A residents since October 2002 when the producer arrived. Information on STIs and interview data were obtained from Florida's STI surveillance system. An infection was considered to be associated with residence in house A if the date of diagnosis occurred 6 months before an individual's residence start date through 6 months after his residence end date. RESULTS: Excluding the producer, 150 men resided in house A starting from September 2003 to July 2015. Forty-six individuals had a reported case of HIV, syphilis, gonorrhea, and/or chlamydia with 92 infections total. Forty-two (46%) infections among 24 men were considered associated with residence in house A. CONCLUSIONS: LexisNexis Accurint was a useful tool for identifying house A residents, a highly mobile and highly sexually active population. There is a high prevalence of STIs among residents, but it is unclear where transmission is occurring. Settings like house A are good candidates for HIV pre-exposure prophylaxis and active STI screenings and may be an opportunity for public health officials to intervene in high-risk groups to reduce STI rates in the community.

Comparison of Test Results for Zika Virus RNA in Urine, Serum, and Saliva Specimens from Persons with Travel-Associated Zika Virus Disease - Florida, 2016.

In May 2015, Zika virus was reported to be circulating in Brazil. This was the first identified introduction of the virus in the Region of the Americas. Since that time, Zika virus has rapidly spread throughout the region. As of April 20, 2016, the Florida Department of Health Bureau of Public Health Laboratories (BPHL) has tested specimens from 913 persons who met state criteria for Zika virus testing. Among these 913 persons, 91 met confirmed or probable Zika virus disease case criteria and all cases were travel-associated (1). On the basis of previous small case studies reporting real time reverse-transcription polymerase chain reaction (RT-PCR) detection of Zika virus RNA in urine, saliva, and semen (2-6), the Florida Department of Health collected multiple specimen types from persons with suspected Zika virus disease. Test results were evaluated by specimen type and number of days after symptom onset to determine the most sensitive and efficient testing algorithm for acute Zika virus disease. Urine specimens were collected from 70 patients with suspected Zika virus disease from zero to 20 days after symptom onset. Of these, 65 (93%) tested positive for Zika virus RNA by RT-PCR. Results for 95% (52/55) of urine specimens collected from persons within 5 days of symptom onset tested positive by RT-PCR; only 56% (31/55) of serum specimens collected on the same date tested positive by RT-PCR. Results for 82% (9/11) of urine specimens collected >5 days after symptom onset tested positive by RT-PCR; none of the RT-PCR tests for serum specimens were positive. No cases had results that were exclusively positive by RT-PCR testing of saliva. BPHL testing results suggest urine might be the preferred specimen type to identify acute Zika virus disease.

Infant and maternal characteristics in neonatal abstinence syndrome--selected hospitals in Florida, 2010-2011.

Neonatal abstinence syndrome (NAS) is a constellation of physiologic and neurobehavioral signs exhibited by newborns exposed to addictive prescription or illicit drugs taken by a mother during pregnancy. The number of hospital discharges of newborns diagnosed with NAS has increased more than 10-fold (from 0.4 to 4.4 discharges per 1,000 live births) in Florida since 1995, far exceeding the three-fold increase observed nationally. In February 2014, the Florida Department of Health requested the assistance of CDC to 1) assess the accuracy and validity of using Florida's hospital inpatient discharge data, linked to birth and infant death certificates, as a means of NAS surveillance and 2) describe the characteristics of infants with NAS and their mothers. This report focuses only on objective two, describing maternal and infant characteristics in the 242 confirmed NAS cases identified in three Florida hospitals during a 2-year period (2010-2011). Infants with NAS experienced serious medical complications, with 97.1% being admitted to an intensive care unit, and had prolonged hospital stays, with a mean duration of 26.1 days. The findings of this investigation underscore the important public health problem of NAS and add to current knowledge on the characteristics of these mothers and infants. Effective June 2014, NAS is now a mandatory reportable condition in Florida. Interventions are also needed to 1) increase the number and use of community resources available to drug-abusing and drug-dependent women of reproductive age, 2) improve drug addiction counseling and rehabilitation referral and documentation policies, and 3) link women to these resources before or earlier in pregnancy.

Notes from the field: Transmission of chikungunya virus in the continental United States--Florida, 2014.

On June 27, 2014, the Florida Department of Health in Miami-Dade County was notified by the Florida Poison Information Center Network of a patient with travel to Southeast Asia who was suspected of having chikungunya virus infection. After further investigation and additional testing, it was determined that the patient had not recently traveled to an endemic area, and this case was confirmed as the first locally acquired chikungunya case in the continental United States. Since the first case of locally acquired chikungunya virus infection in the Americas was reported on the Caribbean island of St. Martin in December 2013, the United States has seen an increase in chikungunya cases among travelers returning from areas where chikungunya has become endemic, particularly the Caribbean and South America. Compared with other states, Florida has seen an especially large number of chikungunya fever cases. During January 1-October 14, 2014, a total of 272 imported cases were reported in Florida, compared with 1,110 reported in the other 47 contiguous states. In addition, 11 locally acquired chikungunya cases have been identified. The recent spread of the virus and the presence of competent mosquito vectors provide the conditions for transmission of chikungunya virus in Florida.

Evaluating public housing residents for knowledge, attitudes, and practices following dengue prevention outreach in Key West, Florida.

BACKGROUND: In 2009-2010, 93 cases of dengue were identified in Key West, Florida. This was the first outbreak of autochthonous transmission of dengue in Florida since 1934. In response to this outbreak, a multifaceted public education outreach campaign was launched. The aim of this study is to compare dengue prevention knowledge, attitudes, perceptions, and prevention practices among residents of subsidized public housing to the general population in Key West and to assess whether there were barriers preventing effective outreach from reaching specific vulnerable populations. METHODS: A randomized population-based evaluation of knowledge, attitudes, and behaviors toward dengue prevention consisting of 521 separate household interviews was undertaken in July of 2011. A subset analysis was performed on interviews collected from 28 public housing units within four subsidized public housing complexes. Analysis was performed to determine whether knowledge, attitudes, and behaviors exhibited by public housing residents differed from the non-public housing study population. RESULTS: Public housing residents recalled fewer outreach materials (p=0.01) and were 3.4 times (95% confidence interval [CI] 1.4-8.3) more likely not to recall any outreach materials. Public housing residents were less likely to correctly identify how dengue transmission occurs (61% vs. 89%), where mosquitoes lay their eggs (54% vs. 85%), or to identify any signs or symptoms related to dengue (36% vs. 64%). Public housing residents were less likely to perform dengue prevention practices such as removing standing water or always using air conditioning. CONCLUSIONS: Examination of public housing residents identified an at-risk population that recalled less exposure to outreach materials and had less knowledge about dengue infection and prevention than the randomized study population. This provides public health systems the opportunity to target or modify future health messages and interventions to this group. Differences identified in the demographics of this population suggest that alternative methods or non-English materials may be required to reach desired outcomes.