Shiga toxin-producing Escherichia coli O157:H7 outbreak associated with school field trips at a farm animal exhibit-Tennessee, September-October 2023.

AIMS: In October 2023, the Tennessee Department of Health identified an outbreak of Shiga toxin-producing Escherichia coli (STEC) O157:H7 infections among elementary school students who attended school field trips to the same farm animal exhibit. Our aim was to determine STEC source and prevent additional illnesses by initiating epidemiologic, laboratory and environmental investigations. METHODS AND RESULTS: We identified cases using laboratory-based surveillance and by surveying caregivers of children who attended the exhibit. Probable cases were defined as illness with abdominal cramps or diarrhoea after attendance; confirmed cases were laboratory-confirmed STEC infection in an attendee or household contact. A site visit was conducted, and event organizers were interviewed. Human stool, animal faeces and environmental samples were tested for STEC O157:H7 by real-time polymerase chain reaction (PCR), culture and whole-genome sequencing (WGS). Approximately 2300 elementary school students attended the animal exhibit during 2 days. Field trip activities included contact with different farm animal species, drinking pasteurized milk outside animal enclosures and eating lunch in a separate building onsite. We received survey responses from 399 caregivers for 443 (19%) animal exhibit attendees. We identified 9 confirmed and 55 probable cases with illness onset dates during 26 September to 12 October. Seven children aged 1-7 years were hospitalized. Four children aged 1-6 years experienced haemolytic uraemic syndrome; none died. Laboratory testing identified STEC O157:H7 by culture from eight human stool samples with 0-1 allele difference by WGS. Three environmental samples had Shiga toxin (stx 2) genes detected by PCR, but no STEC isolates were recovered by culture. CONCLUSIONS: This is the largest reported STEC O157:H7 outbreak associated with an animal exhibit in Tennessee. We identified opportunities for educating school staff, event organizers and families about zoonotic disease risks associated with animal contact and published prevention measures.

Respiratory Syncytial Virus Hospitalizations Associated With Social Vulnerability by Census Tract: An Opportunity for Intervention?

Background: Respiratory syncytial virus (RSV) can cause hospitalization in young children and older adults. With vaccines and monoclonal antibody prophylaxis increasingly available, identifying social factors associated with severe illnesses can guide mitigation efforts. Methods: Using data collected by the RSV Hospitalization Surveillance Network from 2016 to 2023, we identified RSV hospitalizations in Tennessee. We linked hospitalization information (eg, patient demographic characteristics and outcome) with population-level variables (eg, social vulnerability and health care insurance coverage) from publicly available data sets using census tract of residence. Hospitalization incidence was calculated and stratified by period (2016-2020 and 2020-2023). We modeled social vulnerability effect on hospitalization incidence using Poisson regression. Results: Among 2687 RSV hospitalizations, there were 677 (25.2%) intensive care unit admissions and 38 (1.4%) deaths. The highest RSV hospitalization incidences occurred among children aged <5 years and adults aged ≥65 years: 272.8 per 100 000 person-years (95% CI, 258.6-287.0) and 60.6 (95% CI, 56.0-65.2), respectively. Having public health insurance was associated with higher hospitalization incidence as compared with not having public insurance: 60.5 per 100 000 person-years (95% CI, 57.6-63.4) vs 14.3 (95% CI, 13.4-15.2). Higher hospitalization incidence was associated with residing in a census tract in the most socially vulnerable quartile vs the least vulnerable quartile after adjusting for age, sex, and period (incidence rate ratio, 1.4; 95% CI, 1.3-1.6). Conclusions: RSV hospitalization was associated with living in more socially vulnerable census tracts. Population measures of social vulnerability might help guide mitigation strategies, including vaccine and monoclonal antibody promotion and provision to reduce RSV hospitalization.

Implications of Measles Inclusion by Commercial Syndromic Polymerase Chain Reaction Panels - United States, May 2022-April 2023.

Syndromic polymerase chain reaction (PCR) panels are used to test for pathogens that can cause rash illnesses, including measles. Rash illnesses have infectious and noninfectious causes, and approximately 5% of persons experience a rash 7-10 days after receipt of a measles, mumps, and rubella (MMR) vaccine. MMR vaccine includes live attenuated measles virus, which is detectable by PCR tests. No evidence exists of person-to-person transmission of measles vaccine virus, and illness does not typically result among immunocompetent persons. During September 2022-January 2023, the Tennessee Department of Health received two reports of measles detected by syndromic PCR panels. Both reports involved children (aged 1 and 6 years) without known risk factors for measles, who were evaluated for rash that occurred 11-13 days after routine MMR vaccination. After public health responses in Tennessee determined that both PCR panels had detected measles vaccine virus, six state health departments collaborated to assess the frequency and characteristics of persons receiving a positive measles PCR panel test result in the United States. Information was retrospectively collected from a commercial laboratory testing for measles in syndromic multiplex PCR panels. During May 2022-April 2023, among 1,548 syndromic PCR panels, 17 (1.1%) returned positive test results for measles virus. Among 14 persons who received a positive test result and for whom vaccination and case investigation information were available, all had received MMR vaccine a median of 12 days before specimen collection, and none had known risk factors for acquiring measles. All positive PCR results were attributed to detection of measles vaccine virus. Increased awareness among health care providers about potential measles detection by PCR after vaccination is needed. Any detection of measles virus by syndromic PCR testing should be immediately reported to public health agencies, which can use measles vaccination history and assessment of risk factors to determine the appropriate public health response. If a person recently received MMR vaccine and has no risk factors for acquiring measles, additional public health response is likely unnecessary.

Lessons Learned From Implementation of Mpox Surveillance During an Outbreak Response in Tennessee, 2022.

OBJECTIVES: Mpox surveillance was integral during the 2022 outbreak response. We evaluated implementation of mpox surveillance in Tennessee during an outbreak response and made recommendations for surveillance during emerging infectious disease outbreaks. METHODS: To understand surveillance implementation, system processes, and areas for improvement, we conducted 8 semistructured focus groups and 7 interviews with 36 health care, laboratory, and health department representatives during September 9-20, 2022. We categorized and analyzed session transcription and notes. We analyzed completeness and timeliness of surveillance data, including 349 orthopoxvirus-positive laboratory reports from commercial, public health, and health system laboratories during July 1-August 31, 2022. RESULTS: Participants described an evolving system and noted that existing informatics platforms inefficiently supported iterations of reporting requirements. Clear communication, standardization of terminology, and shared, adaptable, and user-friendly informatics platforms were prioritized for future emerging infectious disease surveillance systems. Laboratory-reported epidemiologic information was often incomplete; only 55% (191 of 349) of reports included patient address and telephone number. The median time from symptom onset to specimen collection was 5 days (IQR, 3-6 d), from specimen collection to laboratory reporting was 3 days (IQR, 1-4 d), from laboratory reporting to patient interview was 1 day (IQR, 1-3 d), and from symptom onset to patient interview was 9 days (IQR, 7-12 d). CONCLUSIONS: Future emerging infectious disease responses would benefit from standardized surveillance approaches that facilitate rapid implementation. Closer collaboration among informatics, laboratory, and clinical partners across jurisdictions and agencies in determining system priorities and designing workflow processes could improve flexibility of the surveillance platform and completeness and timeliness of laboratory reporting. Improved timeliness will facilitate public health response and intervention, thereby mitigating morbidity.

Early and Increased Influenza Activity Among Children - Tennessee, 2022-23 Influenza Season.

Influenza seasons typically begin in October and peak between December and February (1); however, the 2022-23 influenza season in Tennessee began in late September and was characterized by high pediatric hospitalization rates during November. This report describes a field investigation conducted in Tennessee during November 2022, following reports of increasing influenza hospitalizations. Data from surveillance networks, patient surveys, and whole genome sequencing of influenza virus specimens were analyzed to assess influenza activity and secondary illness risk. Influenza activity increased earlier than usual among all age groups, and rates of influenza-associated hospitalization among children were high in November, reaching 12.6 per 100,000 in children aged <5 years, comparable to peak levels typically seen in high-severity seasons. Circulating influenza viruses were genetically similar to vaccine components. Among persons who received testing for influenza at outpatient clinics, children were twice as likely to receive a positive influenza test result as were adults. Among household contacts exposed to someone with influenza, children were more than twice as likely to become ill compared with adults. As the influenza season continues, it is important for all persons, especially those at higher risk for severe disease, to protect themselves from influenza. To prevent influenza and severe influenza complications, all persons aged ≥6 months should get vaccinated, avoid contact with ill persons, and take influenza antivirals if recommended and prescribed.

Epidemiologic and Clinical Characteristics of Monkeypox Cases - United States, May 17-July 22, 2022.

Monkeypox, a zoonotic infection caused by an orthopoxvirus, is endemic in parts of Africa. On August 4, 2022, the U.S. Department of Health and Human Services declared the U.S. monkeypox outbreak, which began on May 17, to be a public health emergency (1,2). After detection of the first U.S. monkeypox case), CDC and health departments implemented enhanced monkeypox case detection and reporting. Among 2,891 cases reported in the United States through July 22 by 43 states, Puerto Rico, and the District of Columbia (DC), CDC received case report forms for 1,195 (41%) cases by July 27. Among these, 99% of cases were among men; among men with available information, 94% reported male-to-male sexual or close intimate contact during the 3 weeks before symptom onset. Among the 88% of cases with available data, 41% were among non-Hispanic White (White) persons, 28% among Hispanic or Latino (Hispanic) persons, and 26% among non-Hispanic Black or African American (Black) persons. Forty-two percent of persons with monkeypox with available data did not report the typical prodrome as their first symptom, and 46% reported one or more genital lesions during their illness; 41% had HIV infection. Data suggest that widespread community transmission of monkeypox has disproportionately affected gay, bisexual, and other men who have sex with men and racial and ethnic minority groups. Compared with historical reports of monkeypox in areas with endemic disease, currently reported outbreak-associated cases are less likely to have a prodrome and more likely to have genital involvement. CDC and other federal, state, and local agencies have implemented response efforts to expand testing, treatment, and vaccination. Public health efforts should prioritize gay, bisexual, and other men who have sex with men, who are currently disproportionately affected, for prevention and testing, while addressing equity, minimizing stigma, and maintaining vigilance for transmission in other populations. Clinicians should test patients with rash consistent with monkeypox,† regardless of whether the rash is disseminated or was preceded by prodrome. Likewise, although most cases to date have occurred among gay, bisexual, and other men who have sex with men, any patient with rash consistent with monkeypox should be considered for testing. CDC is continually evaluating new evidence and tailoring response strategies as information on changing case demographics, clinical characteristics, transmission, and vaccine effectiveness become available.§.

Characteristics, Comorbidities, and Data Gaps for Coronavirus Disease Deaths, Tennessee, USA.

As of March 2021, coronavirus disease (COVID-19) had led to >500,000 deaths in the United States, and the state of Tennessee had the fifth highest number of cases per capita. We reviewed the Tennessee Department of Health COVID-19 surveillance and chart-abstraction data during March 15‒August 15, 2020. Patients who died from COVID-19 were more likely to be older, male, and Black and to have underlying conditions (hereafter comorbidities) than case-patients who survived. We found 30.4% of surviving case-patients and 20.3% of deceased patients had no comorbidity information recorded. Chart-abstraction captured a higher proportion of deceased case-patients with >1 comorbidity (96.3%) compared with standard surveillance deaths (79.0%). Chart-abstraction detected higher rates of each comorbidity except for diabetes, which had similar rates among standard surveillance and chart-abstraction. Investing in public health data collection infrastructure will be beneficial for the COVID-19 pandemic and future disease outbreaks.

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.

Educational Disabilities Among Children Born With Neonatal Abstinence Syndrome.

BACKGROUND: Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome that can occur after intrauterine opioid exposure. Adverse neurobehavioral outcomes have been documented in infants with NAS; however, educational outcomes have not been thoroughly examined. We analyzed Tennessee data to understand the need for special educational services among infants who are born with NAS. METHODS: By using Tennessee Medicaid and birth certificate data, infants who were born in Tennessee between 2008 and 2011 with a history of NAS were matched (1:3) to infants who were born during the same period without a history of NAS. Groups were matched on the basis of sex, race and/or ethnicity, age, birth region of residence, and Medicaid enrollment status. Data were linked to Tennessee Department of Education special education data during early childhood (3-8 years of age). Conditional multivariable logistic regression was used to assess associations between NAS and selected special education outcomes. RESULTS: A total of 1815 children with a history of NAS and 5441 children without NAS were assessed. Children with NAS were significantly more likely to be referred for a disability evaluation (351 of 1815 [19.3%] vs 745 of 5441 [13.7%]; P < .0001), to meet criteria for a disability (284 of 1815 [15.6%] vs 634 of 5441 [11.7%]; P < .0001), and to require classroom therapies or services (278 of 1815 [15.3%] vs 620 of 5441 [11.4%]; P < .0001). These findings were sustained in a multivariable analysis, with multiple models controlling for maternal tobacco use, maternal education status, birth weight, gestational age, and/or NICU admission. CONCLUSIONS: Results of this novel analysis linking health and education data revealed that children with a history of NAS were significantly more likely to have a subsequent educational disability.

Predictors of Intravenous Immunoglobulin Nonresponse and Racial Disparities in Kawasaki Disease.

BACKGROUND: Kawasaki disease (KD) is the most common cause of acquired heart disease in American children. Intravenous immunoglobulin (IVIG) nonresponse is a known risk factor for cardiac sequelae. Previously reported risk factors for nonresponse include age, male sex and laboratory abnormalities. We set out to identify additional risk factors for IVIG nonresponse in a racially diverse KD population. METHODS: We conducted a retrospective chart review at a referral center in the Southeastern United States of children meeting ICD-9 (International Statistical Classification of Disease and Related Health Problems) criteria for KD and being treated with IVIG. RESULTS: Four-hundred and fifty-nine children met inclusion criteria, 67 were excluded for subsequent rheumatologic diagnosis, unknown race, or failure to meet the American Heart Association guideline criteria. Our final cohort consisted of 392 subjects, with median age of 2.7 years, 65.1% male, 66.1% White, 24.2% Black, 4.9% Asian and 82.9% responded to a single dose of IVIG. Coronary ectasia or aneurysm developed in 27%; 7.4% developed aneurysms and 2.3% giant coronary aneurysms. Nonresponders were more likely to be Black, have higher white blood cell, erythrocyte sedimentation rate and C-reactive protein, lower hemoglobin, develop ectasia or aneurysm and require critical care and hospital readmission. Responders achieved echocardiographic normalization more often compared with nonresponders (81.3% vs. 60.9%, P = 0.002) and coronary artery pseudonormalization (87.2% vs. 69.7%, P = 0.03) at 1 year. Black nonresponders had the slowest normalization at 1 year (52.9%, P = 0.02). CONCLUSIONS: Nonresponders have higher rates and greater severity of coronary involvement than responders. Our study uniquely demonstrates Black race as a risk factor for nonresponse and for delayed normalization of cardiac involvement at 1-year follow-up.

Cryptosporidiosis Outbreak Associated With a Single Hotel.

We investigated a gastrointestinal illness cluster among persons who attended a baseball tournament (>200 teams) during July 2015. We interviewed representatives of 19 teams; illness was reported among only the 9 (47%) teams that stayed at Hotel A (p < .01). We identified 55 primary cases. A case-control study demonstrated that pool exposure at Hotel A was significantly associated with illness (odds ratio: 7.3; 95% confidence interval: 3.6, 15.2). Eight out of nine (89%) stool specimens tested were positive for Cryptosporidium, with C. hominis IfA12G1 subtype identified in two specimens. The environmental health assessment detected a low free available chlorine level, and pool water tested positive for E. coli and total coliforms. A possible diarrheal contamination event, substantial hotel pool use, and use of cyanuric acid might have contributed to this outbreak and magnitude. Aquatic facilities practicing proper operation and maintenance (e.g., following the Centers for Disease Control and Prevention's Model Aquatic Health Code) can protect the public's health.

Evaluation of a Spotted Fever Group Rickettsia Public Health Surveillance System in Tennessee.

Spotted fever group (SFG) rickettsioses are endemic in Tennessee, with ∼2,500 cases reported during 2000-2012. Because of this substantial burden of disease, we performed a three-part evaluation of Tennessee's routine surveillance for SFG rickettsioses cases and deaths to assess the system's effectiveness. Tennessee Department of Health (TDH) SFG rickettsioses surveillance records were matched to three patient series: 1) patients with positive serologic specimens from a commercial reference laboratory during 2010-2011, 2) tertiary medical center patients with positive serologic tests during 2007-2013, and 3) patients identified from death certificates issued during 1995-2014 with SFG rickettsiosis-related causes of death. Chart reviews were performed and patients were classified according to the Council of State and Territorial Epidemiologists' case definition. Of 254 SFG Rickettsia-positive serologic specimens from the reference laboratory, 129 (51%) met the case definition for confirmed or probable cases of rickettsial disease after chart review. The sensitivity of the TDH surveillance system to detect cases was 45%. Of the 98 confirmed or probable cases identified from the medical center, the sensitivity of the TDH surveillance system to detect cases was 34%. Of 27 patients identified by death certificates, 12 (44%) were classified as confirmed or probable cases; four (33%) were reported to TDH, but none were correctly identified as deceased. Cases of SFG rickettsioses were underreported and fatalities not correctly identified. Efforts are needed to improve SFG rickettsiosis surveillance in Tennessee.

Health Care Provider Knowledge and Attitudes Regarding Reporting Diseases and Events to Public Health Authorities in Tennessee.

CONTEXT: In the United States, state laws require health care providers to report specific diseases and events to public health authorities, a fundamental facet of disease surveillance. However, reporting by providers is often inconsistent, infrequent, and delayed. OBJECTIVE: To examine knowledge, attitudes, and practices regarding provider disease reporting and to understand current barriers to provider disease reporting. DESIGN: A cross-sectional study was conducted via an anonymous, standardized electronic survey. SETTING: The survey was conducted at Vanderbilt University Medical Center, a large, tertiary academic medical center in Nashville, Tennessee. PARTICIPANTS: Health care providers in 4 specialties (internal medicine, pediatrics, obstetrics-gynecology, and emergency medicine). MAIN OUTCOME MEASURE(S): Knowledge of and attitudes regarding provider reporting of diseases to public health authorities in Tennessee. RESULTS: The majority of providers acknowledged they cared for patients with reportable diseases (362/435, 83.2%) and believed that it was their responsibility to report to public health authorities (429/436, 98.4%); however, less than half had ever reported a case (206/436, 47.2%). The median percent correct on the knowledge assessment of Tennessee reportable diseases and conditions was 81.3% (interquartile range = 68.8-87.5). Providers cited a lack of knowledge of which diseases are reportable (186/429, 43.3%) and the logistics of reporting (153/429, 35.7%) as the primary barriers for compliance. CONCLUSION: Most providers acknowledged they cared for patients with reportable diseases and believed they had an obligation to report to public health authorities. However, a lack of knowledge about reporting was frequently described as a limitation to report effectively. Many knowledge deficits were significantly greater among residents than other providers.The policy and practice implications of these findings include a demonstrated need for education of providers about disease reporting as well as development of more convenient reporting mechanisms. Fundamental knowledge of reportable disease requirements and procedures is critical for participation in the broader public health system.

Novel Clinical and Pathologic Findings in a Heartland Virus-Associated Death.

We describe an investigation into a Heartland virus (HRTV)-associated death in Tennessee with novel clinical and pathologic findings. HRTV can cause rapidly fatal, widely disseminated infection with multisystem organ failure in patients without substantial comorbidities. We identified viral antigen in multiple organ tissues where it was not detected previously.

Notes from the Field: Measles Outbreak of Unknown Source - Shelby County, Tennessee, April-May 2016.

On April 15, 2016, local public health officials in Shelby County, Tennessee, were notified of a positive measles immunoglobulin M (IgM) test for a male aged 18 months (patient A). On April 18, 2016, a second positive measles IgM test was reported for a man aged 50 years (patient B). Both patients had rash onset on April 9, 2016. The Shelby County Health Department initiated an investigation, and confirmatory testing for measles virus on oropharyngeal swabs by polymerase chain reaction (PCR) at CDC was positive for both patients. On April 21, 2016, public health officials were notified of a third suspected measles case in a female aged 7 months (patient C) who had developed a rash on April 14; PCR testing was positive. Genotyping conducted at CDC identified genotype B3 measles virus in all three cases. Genotype B3 is known to be circulating globally and has previously been associated with imported cases in the United States (1).