Notes from the Field: Verona Integron-Encoded Metallo-Beta-Lactamase-Producing Carbapenem-Resistant Enterobacteriaceae in a Neonatal and Adult Intensive Care Unit--Kentucky, 2015.

During August 4-September 1, 2015, eight cases of Verona integron-encoded metallo-beta-lactamase (VIM)-producing Carbapenem-resistant Enterobacteriaceae (CRE) colonization were identified in six patients, using weekly active surveillance perirectal cultures in a Kentucky tertiary care hospital. No cases of clinical infection or complications attributable to colonization were reported. Four of the eight isolates were identified as Enterobacter cloacae; other organisms included Raoultella species (one), Escherichia coli (one), and Klebsiella pneumoniae (two). Six isolates were reported in a neonatal intensive care unit (ICU), and two isolates in an adult trauma and surgical ICU. Patient ages at isolate culture date ranged from 21 days to 68 years. Fifty percent of the patients were male. Previously, only one VIM-producing CRE-colonized patient (an adult, in 2013) had been reported by the same hospital. The six cases are the largest occurrence of VIM-producing CRE colonization reported in the United States and the only recognized cluster of VIM-producing CRE colonization in the United States reported to include a neonatal population. Despite environmental sampling over the same period, surveying patients for exposure to health care outside the United States, surveying health care providers for risk factors, and surveillance culturing of health care provider nares and axillae, a source of VIM-producing CRE has not been identified for this cluster. Prevention measures throughout the ICUs have been enhanced in response to this cluster, as detailed in CDC's 2015 CRE toolkit update.

Lymphocytic choriomeningitis virus in employees and mice at multipremises feeder-rodent operation, United States, 2012.

We investigated the extent of lymphocytic choriomeningitis virus (LCMV) infection in employees and rodents at 3 commercial breeding facilities. Of 97 employees tested, 31 (32%) had IgM and/or IgG to LCMV, and aseptic meningitis was diagnosed in 4 employees. Of 1,820 rodents tested in 1 facility, 382 (21%) mice (Mus musculus) had detectable IgG, and 13 (0.7%) were positive by reverse transcription PCR; LCMV was isolated from 8. Rats (Rattus norvegicus) were not found to be infected. S-segment RNA sequence was similar to strains previously isolated in North America. Contact by wild mice with colony mice was the likely source for LCMV, and shipments of infected mice among facilities spread the infection. The breeding colonies were depopulated to prevent further human infections. Future outbreaks can be prevented with monitoring and management, and employees should be made aware of LCMV risks and prevention.

Direct costs of a single case of refugee-imported measles in Kentucky.

BACKGROUND: Refugees are highly vulnerable populations with limited access to health care services. The United States accepts 50,000-75,000 refugees for resettlement annually. Despite residing in camps and other locations where vaccine-preventable disease outbreaks, such as measles, occur frequently, refugees are not required to have any vaccinations before they arrive in the United States. PURPOSE: We estimated the medical and public-health response costs of a case of measles imported into Kentucky by a refugee. METHODS: The Kentucky Refugee Health Coordinator recorded the time and labor of local, state, and some federal personnel involved in caring for the refugee and implementing the public health response activities. Secondary sources were used to estimate the labor and medical care costs of the event. RESULTS: The total costs to conduct the response to the disease event were approximately $25,000. All costs were incurred by government, either public health department or federal, because refugee health costs are paid by the federal government and the event response costs are covered by the public health department. CONCLUSION: A potentially preventable case of measles that was imported into the United States cost approximately $25,000 for the public health response. RECOMMENDATION: To maintain the elimination of measles transmission in the United States, U.S.-bound refugees should be vaccinated overseas. A refugee vaccination program administered during the overseas health assessment has the potential to reduce the risk of importation of measles and other vaccine-preventable disease and would eliminate costs associated with public health response to imported cases and outbreaks.

Carbon monoxide poisoning after an ice storm in Kentucky, 2009.

OBJECTIVES: Carbon monoxide (CO) poisoning is a leading cause of morbidity and mortality during natural disasters. On January 26-27, 2009, a severe ice storm occurred in Kentucky, causing widespread, extended power outages and disrupting transportation and communications. After the storm, CO poisonings were reported throughout the state. The objectives of this investigation were to determine the extent of the problem, identify sources of CO poisoning, characterize cases, make recommendations to reduce morbidity and mortality, and develop prevention strategies. METHODS: We obtained data from the Kentucky Regional Poison Center (KRPC), hyperbaric oxygen treatment (HBOT) facilities, and coroners. Additionally, the Kentucky Department for Public Health provided statewide emergency department (ED) and hospitalization data. RESULTS: During the two weeks after the storm, KRPC identified 144 cases of CO poisoning; exposure sources included kerosene heaters, generators, and propane heaters. Hospitals reported 202 ED visits and 26 admissions. Twenty-eight people received HBOT. Ten deaths were attributed to CO poisoning, eight of which were related to inappropriate generator location. Higher rates of CO poisoning were reported in areas with the most ice accumulation. CONCLUSIONS: Although CO poisonings are preventable, they continue to occur in postdisaster situations. Recommendations include encouraging use of CO alarms, exploring use of engineering controls on generators to decrease CO exposure, providing specific information regarding safe use and placement of CO-producing devices, and using multiple communication methods to reach people without electricity.

Measures to control an outbreak of pertussis in a neonatal intermediate care nursery after exposure to a healthcare worker.

BACKGROUND: Hospitalized premature infants are particularly vulnerable to morbidity and mortality from pertussis. Effective prevention and investigative and control measures are not well described. OBJECTIVE: To identify the source of nosocomial pertussis in a 2-month-old premature infant in a neonatal intermediate care nursery (ICN) and to critically review the investigation and outbreak control measures. SETTING: An ICN and a neonatal intensive care unit. METHODS: We queried healthcare workers (HCWs) and family members about cough illness and contacted potentially exposed patients to determine whether they had symptoms of pertussis. Culture and polymerase chain reaction (PCR) testing for Bordetella pertussis were performed by the hospital laboratory with specimens collected from symptomatic patients and HCWs. Levels of pertussis toxin immunoglobulin G antibodies were measured in HCWs with cough of at least 14 days' duration at a public health laboratory. Extensive control measures were instituted. RESULTS: Four ICN HCWs met the clinical case definition for presence of pertussis. Serologic test results were positive for 3 of the HCWs. The primary case patient was a 36-year-old HCW with a cough illness of 3-weeks' duration that was accompanied by paroxysms, whoop, posttussive emesis, and pneumothorax. Among the 4 affected HCWs, the duration of cough illness prior to identification of the infant index patient ranged from 11 to 25 days. Outbreak control measures included isolation of the infant case patient, furlough and treatment of symptomatic HCWs, administration of chemoprophylaxis to contacts, and surveillance for additional cases. Seventy-two infant patients and 72 HCWs were exposed and were given antibiotic prophylaxis. One additional case of pertussis, confirmed by PCR and culture, occurred in a resident physician who declined prophylaxis; she had cared for the index patient but had no contact with symptomatic HCWs. CONCLUSION: HCWs or patients may serve as the source of pertussis in nosocomial outbreaks, which can result in substantial morbidity and outlay of resources for control measures. Our review suggested that a diagnosis of pertussis should be an early consideration for HCWs with cough illness. Targeted pertussis immunization of HCWs, employee health policies that provide for testing and furlough of HCWs with prolonged cough, and monitoring of HCWs for compliance with infection control measures could reduce the morbidity and costs associated with pertussis outbreaks. These measures will require evaluation of their effectiveness.

Maternal colonization and neonatal sepsis caused by Edwardsiella tarda.

A case of neonatal sepsis caused by Edwardsiella tarda, a bacterium usually associated with freshwater ecosystems, is described. The infant's mother was immersed in lake water during the sixth month of pregnancy and had vaginal and gastrointestinal colonization with the same strain of E tarda as the infant at the time of delivery. This case suggests that maternal exposures to contaminated bodies of water during pregnancy may represent a risk to newborns.