Surveillance for Unexplained Deaths of Possible Infectious Etiologies During the COVID-19 Pandemic-Minnesota, 2020-2021.

OBJECTIVES: Surveillance systems for unexplained deaths that might have an infectious etiology are rare. We examined the Minnesota Department of Health Unexplained Deaths and Critical Illnesses of Possible Infectious Etiology and Medical Examiner Infectious Deaths (UNEX/MED-X) surveillance system,-a system that expanded postmortem surveillance for infectious diseases during the COVID-19 pandemic by leveraging standard (medical examiner [ME]) and expanded (mortuary) surveillance to identify COVID-19-related deaths. METHODS: MEs, coroners, or morticians collected postmortem swabs from decedents with an infectious prodrome or with SARS-CoV-2 exposure before death but with no known recent infectious disease testing. The Minnesota Department of Health Public Health Laboratory used nucleic acid amplification, viral culture, and standard algorithms to test specimens collected postmortem for SARS-CoV-2, influenza virus, and other infectious pathogens. We reviewed UNEX/MED-X data from March 2, 2020, through December 31, 2021, and characterized decedents by location of swab collection (ie, ME or mortuary). RESULTS: From March 2, 2020, through December 31, 2021, the UNEX/MED-X surveillance system received samples from 182 decedents from mortuaries and 955 decedents from MEs. Mortuary decedents were older than ME decedents (median age, 78 vs 46 y). Seventy-three mortuary decedents (40.1%) and 197 ME decedents (20.6%) had SARS-CoV-2 detections. The UNEX/MED-X system identified 212 COVID-19-related deaths, representing 2.0% of total COVID-19-related deaths in Minnesota. Eighty-nine decedents (42.0%) were from racial and ethnic minority populations, representing 6.1% more COVID-19-related deaths among people from racial and ethnic minority populations than would have been detected without this surveillance system. PRACTICE IMPLICATIONS: Expanded and standard UNEX/MED-X surveillance builds capacity and flexibility for responding to emerging public health threats. Similar programs should be considered elsewhere as resources allow.

A research and development (R&D) roadmap for broadly protective coronavirus vaccines: A pandemic preparedness strategy.

Broadly protective coronavirus vaccines are an important tool for protecting against future SARS-CoV-2 variants and could play a critical role in mitigating the impact of future outbreaks or pandemics caused by novel coronaviruses. The Coronavirus Vaccines Research and Development (R&D) Roadmap (CVR) is aimed at promoting the development of such vaccines. The CVR, funded by the Bill & Melinda Gates Foundation and The Rockefeller Foundation, was generated through a collaborative and iterative process, which was led by the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota and involved 50 international subject matter experts and recognized leaders in the field. This report summarizes the major issues and areas of research outlined in the CVR and identifies high-priority milestones. The CVR covers a 6-year timeframe and is organized into five topic areas: virology, immunology, vaccinology, animal and human infection models, and policy and finance. Included in each topic area are key barriers, gaps, strategic goals, milestones, and additional R&D priorities. The roadmap includes 20 goals and 86 R&D milestones, 26 of which are ranked as high priority. By identifying key issues, and milestones for addressing them, the CVR provides a framework to guide funding and research campaigns that promote the development of broadly protective coronavirus vaccines.

Transmission of and Infection With COVID-19 Among Vaccinated and Unvaccinated Attendees of an Indoor Wedding Reception in Minnesota.

Importance: Characterizing rates of SARS-CoV-2 infection among vaccinated and unvaccinated persons with the same exposure is critical to understanding the association of vaccination with the risk of infection with the Delta variant. Additionally, evidence of Delta variant transmission by children to vaccinated adults has important public health implications. Objective: To characterize transmission and infection of SARS-CoV-2 among vaccinated and unvaccinated attendees of an indoor wedding reception. Design, Setting, and Participants: This cohort study included attendees at an indoor wedding reception in Minnesota in July 2021. Data were collected from REDCap surveys and routine surveillance interviews. The full list of attendees and a partial list of emails were obtained. Fifty-seven attendees completed the emailed survey. Eighteen additional attendees were identified from the state health department COVID-19 surveillance database. Exposures: Attendance at an indoor event. Main Outcomes and Measures: Risk of SARS-CoV-2 infection among vaccinated and unvaccinated attendees, identification of an index case, whole genome sequencing (WGS) to identify the COVID-19 variant, understanding of transmission patterns, and assessment of secondary transmission. The primary case definition was an individual with a positive SARS-CoV-2 test who attended the wedding in the 14 days prior to their illness. Results: Data were gathered for 75 attendees (mean [SE] age, 37.5 [13.7] years; 57 [76%] female individuals), of whom 56 (75%) were fully vaccinated, 4 (5%) were partially vaccinated, and 15 (20%) were unvaccinated. Of 62 attendees who were tested, 29 (47%) tested positive, including 16 of 46 fully vaccinated attendees (35%), 2 of 4 partially vaccinated attendees (50%), and 11 of 12 unvaccinated attendees (92%). Being unvaccinated was associated with a higher risk of infection compared with being vaccinated (risk ratio, 2.64; 95% CI, 1.71-4.06; P = .001). One unvaccinated adult required hospitalization. An unvaccinated child who was symptomatic on the event date was identified as the index case. Eleven specimens were available for WGS. All sequenced specimens were closely related and were identified as the Delta variant. WGS supported secondary transmission from a vaccinated individual with SARS-CoV-2. Conclusions and Relevance: This cohort study identified a COVID-19 Delta variant outbreak at an indoor event despite a high proportion of vaccinated attendees. It found that vaccination was associated with a reduced risk of infection.

COVID-19 Outbreak Associated With a Fitness Center-Minnesota, September-November 2020.

The Minnesota Department of Health investigated a coronavirus disease 2019 (COVID-19) outbreak at a fitness center in Olmsted County, Minnesota. Twenty-three severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections (5 employees and 18 members) were identified. An epidemiological investigation supported by whole genome sequencing demonstrated that transmission of SARS-CoV-2 occurred at the fitness center despite following recommended prevention strategies.

Rapid onset of functional tic-like behaviors among adolescent girls-Minnesota, September-November 2021.

Background: On October 15, 2021, the Minnesota Department of Health began investigating a school cluster of students experiencing tic-like behaviors thought to be related to recent COVID-19. The objective of this report is to describe the investigation, key findings, and public health recommendations. Methods: Affected students and proxies were interviewed with a standardized questionnaire including validated depression and anxiety screens. Results: Eight students had tic-like behaviors lasting >24 h after initial report with onset during September 26-October 30, 2021. All eight students were females aged 15-17 years. All students either had a history of depression or anxiety or scored as having more than minimal anxiety or depression on validated screens. Four students previously had confirmed COVID-19: the interval between prior COVID-19 and tic symptom onset varied from more than a year prior to tic symptom onset to at the time of tic symptom onset. Conclusion: The onset of tic-like behaviors at one school in Minnesota appeared to be related more to underlying mental health conditions than recent COVID-19. These findings highlight the need to better understand functional tic-like behaviors and adolescent mental health.

Vaping, lung injury, and mental health Minnesota 2018-2019.

This report describes and contextualizes the high prevalence of mental health conditions (MHC) among Minnesota 2019 EVALI patients by examining the prevalence of MHC and associations between MHC and e-cigarette or vaping product (EVP) use in Minnesota population surveys. Investigators reviewed medical records for 140 EVALI patients to determine history of MHC. History of MHC and EVP use in the general population was estimated using self-reported measures and screening tools from two population-based surveys, the 2019 Minnesota Student Survey (MSS) and the 2018 Minnesota Behavioral Risk Factor Surveillance Survey (MN-BRFSS). Some 64.3% of EVALI patients had an MHC. In both Minnesota population surveys, MHCs were common among people who used EVP. The odds of MHC among youth aged <18 were higher among those who reported current EVP use compared with those did not report EVP use. Similarly, the odds of depression were higher among adults who reported current EVP use compared with those who did not. Clinicians treating patients with EVALI should consider evaluating the need for, and providing indicated referrals to, post-discharge mental health services for their patients.

Transmission Dynamics of Severe Acute Respiratory Syndrome Coronavirus 2 in High-Density Settings, Minnesota, USA, March-June 2020.

Coronavirus disease has disproportionately affected persons in congregate settings and high-density workplaces. To determine more about the transmission patterns of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in these settings, we performed whole-genome sequencing and phylogenetic analysis on 319 (14.4%) samples from 2,222 SARS-CoV-2-positive persons associated with 8 outbreaks in Minnesota, USA, during March-June 2020. Sequencing indicated that virus spread in 3 long-term care facilities and 2 correctional facilities was associated with a single genetic sequence and that in a fourth long-term care facility, outbreak cases were associated with 2 distinct sequences. In contrast, cases associated with outbreaks in 2 meat-processing plants were associated with multiple SARS-CoV-2 sequences. These results suggest that a single introduction of SARS-CoV-2 into a facility can result in a widespread outbreak. Early identification and cohorting (segregating) of virus-positive persons in these settings, along with continued vigilance with infection prevention and control measures, is imperative.

First Identified Cases of SARS-CoV-2 Variant P.1 in the United States - Minnesota, January 2021.

Since December 2020, the Minnesota Department of Health (MDH) Public Health Laboratory has been receiving 100 specimens per week (50 from each of two clinical partners) with low cycle threshold (Ct) values for routine surveillance for SARS-CoV-2, the virus that causes COVID-19. On January 25, 2021, MDH identified the SARS-CoV-2 variant P.1 in one specimen through this surveillance system using whole genome sequencing, representing the first identified case of this variant in the United States. The P.1 variant was first identified in travelers from Brazil during routine airport screening in Tokyo, Japan, in early January 2021 (1). This variant has been associated with increased transmissibility (2), and there are concerns that mutations in the spike protein receptor-binding domain might disrupt both vaccine-induced and natural immunity (3,4). As of February 28, 2021, a total of 10 P.1 cases had been identified in the United States, including the two cases described in this report, followed by one case each in Alaska, Florida, Maryland, and Oklahoma (5).

First Identified Cases of SARS-CoV-2 Variant B.1.1.7 in Minnesota - December 2020-January 2021.

On January 9, 2021, the Minnesota Department of Health (MDH) announced the identification of the SARS-CoV-2 variant of concern (VOC) B.1.1.7, also referred to as 20I/501Y.V1 and VOC 202012/01, in specimens from five persons; on January 25, MDH announced the identification of this variant in specimens from three additional persons. The B.1.1.7 variant, which is reported to be more transmissible than certain other SARS-CoV-2 lineages*,† (1), was first reported in the United Kingdom in December 2020 (1). As of February 14, 2021, a total of 1,173 COVID-19 cases of the B.1.1.7 variant had been identified in 39 U.S. states and the District of Columbia (2). Modeling data suggest that B.1.1.7 could become the predominant variant in the United States in March 2021 (3).

COVID-19 Outbreak Associated with a 10-Day Motorcycle Rally in a Neighboring State - Minnesota, August-September 2020.

During August 7-16, 2020, a motorcycle rally was held in western South Dakota that attracted approximately 460,000 persons from across the United States to numerous indoor and outdoor events over a 10-day period. During August-September 2020, the Minnesota Department of Health (MDH) investigated a coronavirus disease 2019 (COVID-19) outbreak associated with the rally in Minnesota residents. Fifty-one primary event-associated cases were identified, and 35 secondary or tertiary cases occurred among household, social, and workplace contacts, for a total of 86 cases; four patients were hospitalized, and one died. Approximately one third (34%) of 87 counties in Minnesota had at least one primary, secondary, or tertiary case associated with this rally. Genomic sequencing supported the associations with the motorcycle rally. These findings support current recommendations for mask use, physical distancing, reducing the number of attendees at gatherings, isolation for patients with COVID-19, and quarantine for close contacts to slow the spread of SARS-CoV-2 (1). Furthermore, although these findings did not capture the impact of the motorcycle rally on residents of other states, they demonstrate the rationale for consistent mitigation measures across states.

COVID-19-Associated Hospitalizations Among Health Care Personnel - COVID-NET, 13 States, March 1-May 31, 2020.

Health care personnel (HCP) can be exposed to SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), both within and outside the workplace, increasing their risk for infection. Among 6,760 adults hospitalized during March 1-May 31, 2020, for whom HCP status was determined by the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), 5.9% were HCP. Nursing-related occupations (36.3%) represented the largest proportion of HCP hospitalized with COVID-19. Median age of hospitalized HCP was 49 years, and 89.8% had at least one underlying medical condition, of which obesity was most commonly reported (72.5%). A substantial proportion of HCP with COVID-19 had indicators of severe disease: 27.5% were admitted to an intensive care unit (ICU), 15.8% required invasive mechanical ventilation, and 4.2% died during hospitalization. HCP can have severe COVID-19-associated illness, highlighting the need for continued infection prevention and control in health care settings as well as community mitigation efforts to reduce transmission.

Characteristics of E-cigarette, or Vaping, Products Used by Patients with Associated Lung Injury and Products Seized by Law Enforcement - Minnesota, 2018 and 2019.

During August 9-October 31, 2019, 96 patients were classified as having e-cigarette, or vaping, product use-associated lung injury (EVALI) by the Minnesota Department of Health (MDH); other patients are being investigated for case classification and exposures. Among 58 patients interviewed, 53 (91%) reported obtaining tetrahydrocannabinol (THC)-containing products from informal sources such as friends, family members, or in-person or online dealers. Using gas chromatography-mass spectrometry (GCMS), the MDH Public Health Laboratory (PHL) analyzed 46 THC-containing e-cigarette, or vaping, products obtained from 12 EVALI patients for various potential toxicants, including vitamin E acetate, which has recently been detected in some THC-containing products and in samples of lung fluid from EVALI patients (1-4). To explore whether vitamin E acetate is a recently added component in THC-containing products, MDH tested ten products seized by law enforcement in 2018, before the EVALI outbreak, and 20 products seized in 2019, during the outbreak. Twenty-four products obtained from 11 EVALI patients from 2019 contained vitamin E acetate. Among the seized products tested by MDH, none seized in 2018 contained vitamin E acetate, although all tested THC-containing products seized in 2019 tested positive for vitamin E acetate. These chemical analyses of products obtained from EVALI patients and of products intended for the illicit market both before and during the outbreak support a potential role for vitamin E acetate in the EVALI outbreak; however, the number of products tested was small, and further research is needed to establish a causal link between exposure to inhaled vitamin E acetate and EVALI. Collaboration between public health jurisdictions and law enforcement to characterize THC-containing products circulating before the recognition of the EVALI outbreak and during the outbreak might provide valuable information about a dynamic market. These Minnesota findings highlight concerns about e-cigarette, or vaping, products that contain THC acquired from informal sources. Because local supply chains and policy environments vary, CDC continues to recommend not using e-cigarette, or vaping, products that contain THC or any e-cigarette, or vaping, products obtained from informal sources. E-cigarette, or vaping, products should never be used by youths, young adults, or pregnant women.* Until the relationship between inhaled vitamin E acetate and lung health is better characterized, vitamin E acetate should not be added to e-cigarette, or vaping, products.

Multistate analysis of prospective Legionnaires' disease cluster detection using SaTScan, 2011-2015.

Detection of clusters of Legionnaires' disease, a leading waterborne cause of pneumonia, is challenging. Clusters vary in size and scope, are associated with a diverse range of aerosol-producing devices, including exposures such as whirlpool spas and hotel water systems typically associated with travel, and can occur without an easily identified exposure source. Recently, jurisdictions have begun to use SaTScan spatio-temporal analysis software prospectively as part of routine cluster surveillance. We used data collected by the Active Bacterial Core surveillance platform to assess the ability of SaTScan to detect Legionnaires' disease clusters. We found that SaTScan analysis using traditional surveillance data and geocoded residential addresses was unable to detect many common Legionnaires' disease cluster types, such as those associated with travel or a prolonged time between cases. Additionally, signals from an analysis designed to simulate a real-time search for clusters did not align with clusters identified by traditional surveillance methods or a retrospective SaTScan analysis. A geospatial analysis platform better tailored to the unique characteristics of Legionnaires' disease epidemiology would improve cluster detection and decrease time to public health action.

Hospital Water Management Programs for Legionella Prevention, Minnesota, 2017.

Infection preventionists at Minnesota hospitals were surveyed to determine whether they had Legionella water management plans. Of 137 hospitals, 84 (61%) responded. Among them, 27% hospitals had a water management plan, 21% regularly sampled for Legionella, and 51% had knowledge of ASHRAE Legionella prevention standards. Significant changes are needed to protect patients from nosocomial infection. Infect Control Hosp Epidemiol 2018;39:336-338.

Public Health and Law Enforcement Joint Investigation of Unknown Suspicious Substances and Potential Threat Evaluations, Minnesota, 2007-2016.

From the Field is a semi-regular column that explores what it means to be a local health professional on the front lines of an emergency. Typically, National Association of County and City Health Officials (NACCHO) members share their stories of preparing for and responding to disasters, epidemics, and other major health issues. This month's column features a submission from a state health department that describes their experience in investigating white powder incidents. Through exploring the analysis of the challenges faced and the solutions developed, readers can learn how these public health champions keep their communities safe even in extreme situations. Readers may submit topics of interest to the column's editor, Meghan McGinty, PhD, MPH, MBA, at mmcginty@naccho.org.

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.

Recent Outbreaks of Meningococcal Disease among Men Who Have Sex with Men.

Meningococcal disease outbreaks recently have occurred in several U.S. cities among men who are HIV-infected and who have had sex with other men. This article describes the first similar case of meningococcal meningitis serogroup C in Minnesota, which was confirmed this summer. It also offers vaccination guidance for physicians who care for patients who may be at high risk for the disease.

Emerging Infections Program--State Health Department Perspective.

The Emerging Infections Program (EIP) is a collaboration between the Centers for Disease Control and Prevention and 10 state health departments working with academic partners to conduct active population-based surveillance and special studies for several emerging infectious disease issues determined to need special attention. The Centers for Disease Control and Prevention funds the 10 EIP sites through cooperative agreements. Our objective was to highlight 1) what being an EIP site has meant for participating health departments and associated academic centers, including accomplishments and challenges, and 2) the synergy between the state and federal levels that has resulted from the collaborative relationship. Sharing these experiences should provide constructive insight to other public health programs and other countries contemplating a collaborative federal-local approach to collective public health challenges.

Training in Infectious Disease Epidemiology through the Emerging Infections Program Sites.

One objective of the Emerging Infections Program (EIP) of the US Centers for Disease Control and Prevention is to provide training opportunities in infectious disease epidemiology. To determine the extent of training performed since the program's inception in 1995, we reviewed training efforts at the 10 EIP sites. By 2015, all sites hosted trainees (most were graduate public health students and physicians) who worked on a variety of infectious disease surveillance and epidemiologic projects. Trainee projects at all sites were used for graduate student theses or practicums. Numerous projects resulted in conference presentations and publications in peer-reviewed journals. Local public health and health care partners have also benefitted from EIP presentations and training. Consideration should be given to standardizing and documenting EIP training and to sharing useful training initiatives with other state and local health departments and academic institutions.

Legal Authority for Infectious Disease Reporting in the United States: Case Study of the 2009 H1N1 Influenza Pandemic.

Tracking of infectious diseases is a public health core function essential to disease prevention and control. Each state mandates reporting of certain infectious diseases to public health authorities. These laws vary by state, and the variation could affect the ability to collect critical information. The 2009 H1N1 influenza pandemic served as a case study to examine the legal authority in the 50 states; Washington, DC; and New York City for mandatory infectious disease reporting, particularly for influenza and new or emerging infectious diseases. Our study showed reporting laws to be generally present and functioning well; nevertheless, jurisdictions should be mindful of their mandated parameters and review the robustness of their laws before they face a new or emerging disease outbreak.