Heatwave Events and Mortality Outcomes in Memphis, Tennessee: Testing Effect Modification by Socioeconomic Status and Urbanicity.

Heatwave studies typically estimate heat-related mortality and morbidity risks at the city level; few have addressed the heterogeneous risks by socioeconomic status (SES) and location within a city. This study aimed to examine the impacts of heatwaves on mortality outcomes in Memphis, Tennessee, a Mid-South metropolitan area top-ranked in morbidity and poverty rates, and to investigate the effects of SES and urbanicity. Mortality data were retrieved from the death records in 2008-2017, and temperature data from the Applied Climate Information System. Heatwave days were defined based on four temperature metrics. Heatwave effects on daily total-cause, cardiovascular, and respiratory mortality were evaluated using Poisson regression, accounting for temporal trends, sociodemographic factors, urbanicity, and air pollution. We found higher cardiovascular mortality risk (cumulative RR (relative risk) = 1.25, 95% CI (confidence interval): 1.01-1.55) in heatwave days defined as those with maximum daily temperature >95th percentile for more than two consecutive days. The effects of heatwaves on mortality did not differ by SES, race, or urbanicity. The findings of this study provided evidence to support future heatwave planning and studies of heatwave and health impacts at a coarser geographic resolution.

Subsequent HIV Diagnosis Risk After Syphilis in a Southern Black Population.

BACKGROUND: Southern non-Hispanic black persons are disproportionately represented in the HIV epidemic. Those previously diagnosed as having syphilis are at significant risk to become HIV infected within 36 months. Effective prevention strategies such as preexposure prophylaxis should be offered to those at highest risk to maximize prevention efforts. METHODS: HIV-negative persons diagnosed as having primary or secondary (P&S) syphilis during 1998-2014 were matched with incident HIV cases diagnosed during 1998-2016 in Shelby County Tennessee. Person-year HIV incidence rate, Kaplan-Meier survival estimates, and Cox proportional regression model analyses were performed to explore predicting risk factors and quantifying risk factors associated with HIV-free survival time frames. RESULTS: Among 2032 HIV-negative non-Hispanic black Shelby County residents diagnosed as having P&S syphilis, 139 (6.8%) were subsequently diagnosed as having HIV infection. Men who have sex with men (MSM) experienced the highest incidence of HIV diagnosis rate (4.98 per 100 person-years, 95% confidence interval, 4.76-5.2). Being male, MSM, younger than 30 years, or coinfected with gonorrhea increased risk of HIV acquisition 2.32, 11.80, 1.67, and 2.44 times, respectively, compared with being female, heterosexual men, 30+ years old, or not infected with other sexually transmitted infections. CONCLUSIONS: Among our population diagnosed as having P&S syphilis, 1 in 6 MSM and 1 in 16 persons coinfected with gonorrhea were subsequently diagnosed as having HIV during 36 months of follow-up. These findings have implications for HIV screening and recruitment as priority preexposure prophylaxis candidates.

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.

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).

A Community Health Record: Improving Health Through Multisector Collaboration, Information Sharing, and Technology.

We present a framework for developing a community health record to bring stakeholders, information, and technology together to collectively improve the health of a community. It is both social and technical in nature and presents an iterative and participatory process for achieving multisector collaboration and information sharing. It proposes a methodology and infrastructure for bringing multisector stakeholders and their information together to inform, target, monitor, and evaluate community health initiatives. The community health record is defined as both the proposed framework and a tool or system for integrating and transforming multisector data into actionable information. It is informed by the electronic health record, personal health record, and County Health Ranking systems but differs in its social complexity, communal ownership, and provision of information to multisector partners at scales ranging from address to zip code.

Gastroenteritis outbreak associated with unpasteurized tempeh, North Carolina, USA.

During an investigation of an outbreak of gastroenteritis caused by Salmonella enterica serovar Paratyphi B variant L(+) tartrate(+), we identified unpasteurized tempeh as a novel food vehicle and Rhizopus spp. starter culture as the source of the contamination. Safe handling of uncooked, unpasteurized tempeh should be emphasized for prevention of foodborne illnesses.

Clostridium perfringens infections initially attributed to norovirus, North Carolina, 2010.

We investigated an outbreak initially attributed to norovirus; however, Clostridium perfringens toxicoinfection was subsequently confirmed. C. perfringens is an underrecognized but frequently observed cause of food-borne disease outbreaks. This investigation illustrates the importance of considering epidemiologic and laboratory data together when evaluating potential etiologic agents that might require unique control measures.

Cholera in United States associated with epidemic in Hispaniola.

Cholera is rare in the United States (annual average 6 cases). Since epidemic cholera began in Hispaniola in 2010, a total of 23 cholera cases caused by toxigenic Vibrio cholerae O1 have been confirmed in the United States. Twenty-two case-patients reported travel to Hispaniola and 1 reported consumption of seafood from Haiti.

Salmonella typhimurium infections associated with peanut products.

BACKGROUND: Contaminated food ingredients can affect multiple products, each distributed through various channels and consumed in multiple settings. Beginning in November 2008, we investigated a nationwide outbreak of salmonella infections. METHODS: A case was defined as laboratory-confirmed infection with the outbreak strain of Salmonella Typhimurium occurring between September 1, 2008, and April 20, 2009. We conducted two case-control studies, product "trace-back," and environmental investigations. RESULTS: Among 714 case patients identified in 46 states, 166 (23%) were hospitalized and 9 (1%) died. In study 1, illness was associated with eating any peanut butter (matched odds ratio, 2.5; 95% confidence interval [CI], 1.3 to 5.3), peanut butter-containing products (matched odds ratio, 2.2; 95% CI, 1.1 to 4.7), and frozen chicken products (matched odds ratio, 4.6; 95% CI, 1.7 to 14.7). Investigations of focal clusters and single cases associated with nine institutions identified a single institutional brand of peanut butter (here called brand X) distributed to all facilities. In study 2, illness was associated with eating peanut butter outside the home (matched odds ratio, 3.9; 95% CI, 1.6 to 10.0) and two brands of peanut butter crackers (brand A: matched odds ratio, 17.2; 95% CI, 6.9 to 51.5; brand B: matched odds ratio, 3.6; 95% CI, 1.3 to 9.8). Both cracker brands were made from brand X peanut paste. The outbreak strain was isolated from brand X peanut butter, brand A crackers, and 15 other products. A total of 3918 peanut butter-containing products were recalled between January 10 and April 29, 2009. CONCLUSIONS: Contaminated peanut butter and peanut products caused a nationwide salmonellosis outbreak. Ingredient-driven outbreaks are challenging to detect and may lead to widespread contamination of numerous food products.

2008 outbreak of Salmonella Saintpaul infections associated with raw produce.

BACKGROUND: Raw produce is an increasingly recognized vehicle for salmonellosis. We investigated a nationwide outbreak that occurred in the United States in 2008. METHODS: We defined a case as diarrhea in a person with laboratory-confirmed infection with the outbreak strain of Salmonella enterica serotype Saintpaul. Epidemiologic, traceback, and environmental studies were conducted. RESULTS: Among the 1500 case subjects, 21% were hospitalized, and 2 died. In three case-control studies of cases not linked to restaurant clusters, illness was significantly associated with eating raw tomatoes (matched odds ratio, 5.6; 95% confidence interval [CI], 1.6 to 30.3); eating at a Mexican-style restaurant (matched odds ratio, 4.6; 95% CI, 2.1 to ∞) and eating pico de gallo salsa (matched odds ratio, 4.0; 95% CI, 1.5 to 17.8), corn tortillas (matched odds ratio, 2.3; 95% CI, 1.2 to 5.0), or salsa (matched odds ratio, 2.1; 95% CI, 1.1 to 3.9); and having a raw jalapeño pepper in the household (matched odds ratio, 2.9; 95% CI, 1.2 to 7.6). In nine analyses of clusters associated with restaurants or events, jalapeño peppers were implicated in all three clusters with implicated ingredients, and jalapeño or serrano peppers were an ingredient in an implicated item in the other three clusters. Raw tomatoes were an ingredient in an implicated item in three clusters. The outbreak strain was identified in jalapeño peppers collected in Texas and in agricultural water and serrano peppers on a Mexican farm. Tomato tracebacks did not converge on a source. CONCLUSIONS: Although an epidemiologic association with raw tomatoes was identified early in this investigation, subsequent epidemiologic and microbiologic evidence implicated jalapeño and serrano peppers. This outbreak highlights the importance of preventing raw-produce contamination.

Multistate outbreak of Salmonella infections associated with small turtle exposure, 2007-2008.

OBJECTIVE: Turtle-associated salmonellosis was increasingly recognized in the United States during the 1960s, leading to a federal ban in 1975 on the sale of turtles <4 inches in carapace length (small turtles). Although sporadic reports of turtle-associated Salmonella are frequent, outbreaks are rare. In September 2007, several patients with Salmonella enterica serotype Paratyphi B var Java infections reported recent turtle exposure. We conducted an investigation to determine the source and extent of the infections. PATIENTS AND METHODS: Patients with Salmonella Paratyphi B var Java infections with a specific pulsed-field gel electrophoresis pattern (outbreak strain) and illness onset between May 2007 and January 2008, were compared with healthy controls. Reptile exposure and awareness of a Salmonella-reptile link were assessed. Turtle size and purchase information were collected. RESULTS: We identified 107 patients with outbreak-strain infections. The median patient age was 7 years; 33% were hospitalized. Forty-seven (60%) of 78 patients interviewed reported exposure to turtles during the week before illness; 41 (87%) were small turtles, and 16 (34%) were purchased in a retail pet store. In the case-control study, 72% of 25 patients reported turtle exposure during the week before illness compared with 4% of 45 controls (matched odds ratio [mOR]: 40.9 [95% confidence interval (CI): 6.9-unbounded]). Seven (32%) of 22 patients versus 11 (28%) of 39 controls reported knowledge of a link between reptile exposure and Salmonella infection (mOR: 1.3 [95% CI: 0.4-4.6]). CONCLUSIONS: We observed a strong association between turtle exposure and Salmonella infections in this outbreak. Small turtles continue to be sold and pose a health risk, especially to children; many people remain unaware of the link between Salmonella infection and reptile contact.

Integrating hepatitis B prevention into sexually transmitted disease services: U.S. sexually transmitted disease program and clinic trends--1997 and 2001.

OBJECTIVE: The objective of this study was to measure the progress since 1997 of implementing sexually transmitted disease (STD) clinic-based recommendations for hepatitis B prevention. GOAL: The goal of this study was to assess improvements since 1997 in hepatitis B prevention integration in STD services. STUDY: Repeating a 1997 survey, in 2001, a survey was sent to state, municipal, and territorial STD program managers, previously surveyed clinic managers, and a national sample of 500 STD clinics. RESULTS: Large increases were found in the percentage of clinics offering hepatitis B vaccine (from 61% to 82%), providing education (49% to 84%), and accessing federal vaccine programs (48% to 84%). Twice as many program managers considered all patients with STDs eligible for hepatitis B vaccination. Lack of resources and patient noncompliance with vaccine series completion were program barriers. CONCLUSIONS: Hepatitis B policies and vaccination and education efforts in STD clinics have improved; however, many barriers reported in 1997 remained in 2001.

Outbreak of Shiga toxin-producing Escherichia coli O111:H8 infections among attendees of a high school cheerleading camp.

Few US clinical laboratories screen stool specimens for Shiga toxin-producing Escherichia coli (STEC) other than E. coli O157. An outbreak of STEC O111:H8 infections indistinguishable from E. coli O157:H7 at a youth camp highlights the need to improve non-O157 STEC surveillance. Interviews of 521 (80%) of 650 attendees revealed 55 (11%) were ill; 2 developed hemolytic-uremic syndrome. Illness was associated with consuming salad during the camp's first lunch meal (hazard ratio [HR], 4.68; P<.01), consuming ice provided in barrels on the camp's final day (HR, 3.41; P<.01), eating cob corn (HR, 3.22; P<.01), and eating a dinner roll (HR, 2.82; P<.01). Cultures of 2 of 11 stools yielded E. coli O111:H8. Results of serologic testing and additional stool cultures demonstrated no evidence of infection with other bacterial pathogens, including E. coli O157, and supported infection with E. coli O111. Clinical laboratories should routinely screen suspect specimens for non-O157 STEC and should serotype and report Shiga-positive isolates.