A Cluster of Group A Streptococcal Infections in a Skilled Nursing Facility-the Potential Role of Healthcare Worker Presenteeism.

OBJECTIVES: To determine the extent of a group A streptococcus (GAS) cluster (2 residents with invasive GAS (invasive case-patients), 2 carriers) caused by a single strain (T antigen type 2 and M protein gene subtype 2.0 (T2, emm 2.0)), evaluate factors contributing to transmission, and provide recommendations for disease control. DESIGN: Cross-sectional analysis and retrospective review. SETTING: Skilled nursing facility (SNF). PARTICIPANTS: SNF residents and staff. MEASUREMENTS: The initial cluster was identified through laboratory notification and screening of SNF residents with wounds. Laboratory and SNF administrative records were subsequently reviewed to identify additional residents with GAS, oropharyngeal and wound (if present) swabs were collected from SNF staff and residents to examine GAS colonization, staff were surveyed to assess infection control practices and risk factors for GAS colonization, epidemiologic links between case-patients and persons colonized with GAS were determined, and facility infection control practices were assessed. RESULTS: No additional invasive case-patients were identified. Oropharyngeal swabs obtained from all 167 SNF residents were negative; one wound swab grew GAS that was the same as the outbreak strain (T2, emm 2.0). The outbreak strain was not identified in any of the 162 staff members. One of six staff members diagnosed with GAS pharyngitis worked while ill and had direct contact with invasive case-patients within a few weeks before their onset of symptoms. Additional minor breaches in infection control were noted. CONCLUSION: Sick healthcare workers may have introduced GAS into the SNF, with propagation by infection control lapses. "Presenteeism," or working while ill, may introduce and transmit GAS to vulnerable in SNF populations. Identification of an invasive GAS case-patient should trigger a prompt response by facilities to prevent further transmission and workplace culture, and policies should be in place to discourage presenteeism in healthcare settings.

Serologic response in eight alpacas vaccinated by extralabel use of a large animal rabies vaccine during a public health response to a rabid alpaca in South Carolina.

CASE DESCRIPTION A female alpaca, kept at pasture with 12 other female alpacas, 2 crias, and 5 goats, was evaluated because of clinical signs of aggression. CLINICAL FINDINGS The clinical signs of aggression progressed to include biting at other animals as well as disorientation. Three days later, the alpaca was euthanized because of suspicion of rabies virus infection. TREATMENT AND OUTCOME No physical injuries were found at necropsy. Brain tissue specimens were confirmed positive for rabies on the basis of direct fluorescent antibody test results. Molecular typing identified the rabies virus variant as one that is enzootic in raccoons. The farm was placed under quarantine, restricting movement of animals on and off the property for 6 months. To prevent further rabies cases, 14 alpacas (12 adults and 2 crias) were vaccinated by extralabel use of a large animal rabies vaccine. Of the 14 vaccinated alpacas, 8 had paired serum samples obtained immediately before and 21 days after vaccination; all 8 alpacas had adequate serum antirabies antibody production in response to rabies vaccination. As a result of an adequate serologic response, the quarantine was reduced to 3 months. In the year after the index rabies case, no other animals on the farm developed rabies. CLINICAL RELEVANCE Extralabel use of rabies vaccines in camelids was used in the face of a public health investigation. This report provides an example of handling of a rabies case for future public health investigations, which will undoubtedly need to develop ad-hoc rabies vaccination recommendations on the basis of the unique characteristics of the event.

Hepatitis B virus transmissions associated with a portable dental clinic, West Virginia, 2009.

BACKGROUND: Although hepatitis B virus (HBV) transmission in dental settings is rare, in 2009 a cluster of acute HBV infections was reported among attendees of a two-day portable dental clinic in West Virginia. METHODS: The authors conducted a retrospective investigation by using treatment records and volunteer logs, interviews of patients and volunteers with acute HBV infection as well as of other clinic volunteers, and molecular sequencing of the virus from those acutely infected. RESULTS: The clinic was held under the auspices of a charitable organization in a gymnasium staffed by 750 volunteers, including dental care providers who treated 1,137 adults. Five acute HBV infections-involving three patients and two volunteers-were identified by the local and state health departments. Of four viral isolates available for testing, all were genotype D. Three case patients underwent extractions; one received restorations and one a dental prophylaxis. None shared a treatment provider with any of the others. One case volunteer worked in maintenance; the other directed patients from triage to the treatment waiting area. Case patients reported no behavioral risk factors for HBV infection. The investigation revealed numerous infection control breaches. CONCLUSIONS: Transmission of HBV to three patients and two volunteers is likely to have occurred at a portable dental clinic. Specific breaches in infection control could not be linked to these HBV transmissions. PRACTICAL IMPLICATIONS: All dental settings should adhere to recommended infection control practices, including oversight; training in prevention of bloodborne pathogens transmission; receipt of HBV vaccination for staff who may come into contact with blood or body fluids; use of appropriate personal protective equipment, sterilization and disinfection procedures; and use of measures, such as high-volume suction, to minimize the spread of blood.

Knowledge, attitudes, and practices of veterinary facility owners regarding rabies preexposure prophylaxis--West Virginia, 2011.

OBJECTIVE: To assess the knowledge, attitudes, and practices regarding rabies preexposure prophylaxis among veterinary facility owners in West Virginia and to compare facilities in counties where raccoon rabies virus variant (RRVV) is or is not enzootic. DESIGN: Cross-sectional telephone survey. SAMPLE: 124 owners of facilities licensed by the West Virginia Board of Veterinary Medicine. PROCEDURES: In 2011, an owner of each licensed facility in West Virginia was contacted by telephone to complete a questionnaire regarding practice demographics, knowledge of rabies epidemiology, and preexposure prophylaxis policies. Data from facilities in counties where RRVV is enzootic were compared with data from facilities in counties where RRVV is not enzootic. Prevalence ratios and 95% confidence intervals were calculated to quantify the strength of associations. RESULTS: Owners of 124 of the 162 (77%) veterinary facilities participated in the survey. West Virginia veterinarians were knowledgeable of rabies epidemiology in the state. Respondents agreed that veterinarians (122/124 [98%]) and technicians and assistants (111/124 [90%]) should receive preexposure prophylaxis. Fifty-six (45%) respondents required that veterinarians receive preexposure prophylaxis, whereas 19 (15%) respondents required that technicians and assistants receive preexposure prophylaxis. A preexposure prophylaxis policy was in effect at 20 of 64 (31%) facilities in counties where RRVV is enzootic and 6 of 60 (10%) facilities in counties where RRVV is not enzootic. Concerns related to cost of preexposure prophylaxis were reported. CONCLUSIONS AND CLINICAL RELEVANCE: Except for veterinarians, veterinary staff in West Virginia did not commonly receive preexposure prophylaxis or regular assessments of serum rabies virus neutralizing antibody titers. All veterinary practices are encouraged to consider revising or implementing a preexposure prophylaxis policy based on the Advisory Committee on Immunization Practices' recommendations.