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.

Z-selective dimerization of terminal alkynes by a (PNNP)FeII complex.

A tetradentate bis(amido)bis(phosphine) FeII complex, (PNNP)Fe, is shown to activate the terminal C-H bond of aryl alkynes across its Fe-Namide bonds. (PNNP)Fe is also shown to catalytically dimerize terminal aryl alkynes to produce 1,3-enynes with Z : E ratios as high as 96 : 4 with yields up to 95% and loadings as low as 1 mol% at 30 °C in 2 h. A plausible metal-ligand cooperative mechanism invoking a vinylidene intermediate is proposed.

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.

Mobile Distribution of COVID-19 Vaccines to Migrant Farmworkers in Minnesota.

The COVID-19 pandemic has disproportionately impacted migrant farmworkers (MFWs). MFWs have experienced higher rates of infection and death than any other occupational group in the United States due to workplace exposure risks, overcrowded housing, and limited access to personal protective equipment. Barriers to accessing COVID-19 vaccines have also contributed to these disparities, especially in rural areas where the pandemic's impact has been devastating. Mobile health clinics, in partnership with community-based organizations, are an effective method for vaccine distribution to rural communities where many MFWs live and work. Between June 2021 and October 2022, the University of Minnesota's Mobile Health Initiative (MHI) organized health fairs in southern Minnesota to distribute vaccines to MFWs and their families. The success of these events can be attributed to partnering with trusted local organizations, bridging geographic barriers, ensuring language-concordant care, and offering multiple health services in one place. MHI's health fairs serve as a model for future mobile vaccination events. As the COVID-19 pandemic has ended as of this time, future pandemics may occur, and equitable vaccine access must be a priority for MFWs. Mobile health clinics are an essential tool to achieving this goal.

Synthesis, Characterization, and Reactivity of a (PPP) Pincer-Ligated Manganese Carbonyl Complex: Polarity Reversal Imparted by the Electrophilic Nature of a Planar Mn-P(NR2)2 Fragment.

The bonding interactions of a synthesized pincer-ligated manganese dicarbonyl complex featuring an N-heterocyclic phosphenium (NHP+) central moiety are explored. The pincer ligand [PPP]Cl was coordinated to a manganese center using Mn(CO)5Br and 254 nm light to afford the chlorophosphine complex (PPClP)Mn(CO)2Br (2) as a mixture of halide exchange products and stereoisomers. The target dicarbonyl species (PPP)Mn(CO)2 (3) was prepared by treatment of 2 with 2 equiv of the reductant KC8. Computational investigations and analysis of structural parameters were used to elucidate multiple bonding interactions between the Mn center and the PNHP atom in 3. The generation of a product of formal H2 addition, (PPHP)Mn(CO)2H (4), was achieved through the dehydrogenation of NH3BH3, affording a 2:1 mixture of 4syn:4anti stereoisomers. The nucleophilic nature of the Mn center and the electrophilic nature of the PNHP moiety were demonstrated through hydride addition and protonation of 3 to produce K(THF)2[(PPHP)Mn(CO)2] (6) and (PPClP)Mn(CO)2H (5), respectively. The observed reactivity suggests that 3 is best described as a Mn-I/NHP+ complex, in contrast to pincer-ligated dicarbonyl manganese analogues typically assigned as MnI species.

Experiences of American Health Departments, Health Systems, and Community Organizations in COVID-19 Vaccine Provision for Refugee, Immigrant, and Migrant Communities.

Effective provision of COVID-19 vaccines could mitigate the disproportionate impact of the COVID-19 pandemic experienced by many immigrant communities. To describe organizational experiences in using COVID-19 vaccination programs, qualitative interviews were conducted from September 2020 to April 2021 with representatives from public health, health system, and community organizations responding to the COVID-19 pandemic among immigrant communities across the United States. Interviews followed a semistructured interview guide and were audio recorded, transcribed, and coded. A latent thematic analysis was facilitated by Dedoose software. Interviews representative of 18 public health departments, 20 healthcare systems, and 18 community organizations were included in the analysis. Five identified themes referenced the importance of 1) appreciating community and individual heterogeneity in health priorities and attitudes; 2) addressing vaccine fears with trustworthy messages; 3) ensuring equitable access to vaccine opportunities; 4) making substantive investments in community partnerships and outreach; and 5) adapting to meet new needs. It is essential that vaccine efforts consider community heterogeneity, communicate in a trustworthy and culturally and linguistically appropriate manner, strive for equitable provision of care, build partnerships, and learn from prior experiences.

Si-H Bond Activation and Dehydrogenative Coupling of Silanes across the Iron-Amide Bond of a Bis(amido)bis(phosphine) Iron(II) Complex.

Despite the utility of Si-Si bonds, there are relatively few examples of Si-Si bond formation by base metals. In this work, a four-coordinate iron complex, (PNNP)FeII, is shown to strongly activate the Si-H bonds in primary silanes across the Fe-amide bonds in a metal-ligand cooperative fashion. Upon treatment with excess silane, Si-Si dehydrogenative homocoupling is shown to occur across the Fe-Namide bond without concomitant oxidation and spin state changes at the Fe center.

One Bridge, Three Bonds: A Frontier in Multiple Bonding in Heterobimetallic Complexes.

A single bridging phosphinoamide ligand was shown to support a metal-metal triple bond in a Zr/Co heterobimetallic complex. The similarity of the bonding in this compound to previously synthesized Zr/Co species, and therefore the assignment of the Zr/Co triple bond, is supported by the structural parameters of the complex, the electronic structure predicted by density functional theory, and complete-active-space self-consistent-field (CASSCF) calculations. This demonstrates that metal-metal multiple bonds can be realized in heterobimetallic complexes without multiple bridging ligands to enforce the proximity of the two metals.

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.

Food and Drug Administration Approval of Artesunate for Severe Malaria: Enough to Achieve Best Practice?

Intravenous artesunate has been the global standard of care for severe malaria for over 2 decades. Yet, until recently, artesunate has only been available to patients through an expanded-access protocol from the Centers for Disease Control and Prevention. In May 2020, the Food and Drug Administration approved artesunate, allowing US hospitals to stock the drug and ensuring prompt treatment for this life-threatening infection. However, because of artesunate's high cost and the infrequency of severe malaria in the United States, hospitals may be reluctant to stock the drug. As US health systems weigh the decision to stock artesunate, we propose a hospital tier framework to inform this decision and support clinicians caring for patients who present with severe malaria.

Electronic and Structural Variations of a Nickel(0) N-Heterocyclic Phosphenium Complex in Comparison to Group 10 Analogues.

The bonding interactions and electronic structure of a diphosphine pincer ligand featuring an N-heterocyclic phosphenium/phosphido (NHP±) central moiety with nickel are explored. Treating Ni(COD)2 with the pincer ligand [PPP]Cl in the presence of a two-electron phosphine donor ligand PMe3 generates chlorophosphine complex (PPClP)Ni(PMe3) (2a). The cationic Ni complex [(PPP)Ni(PMe3)][BPh4] (3a) can be prepared by subsequent halide abstraction from 2a with NaBPh4. The assignment of 3a as a Ni0/NHP+ complex, based on analysis of structural parameters and computational investigations, lies in contrast to its previously reported group 10 MII/NHP- (M = Pd, Pt) analogues. The activation of O-H bonds across the Ni-PNHP bond is demonstrated by the addition of isopropanol to afford the metal hydride species [(PPOiPrP)Ni(PMe3)(H)][BPh4] (4). Notably, the installation of a P-H bond in the NHP unit by treatment of 2a with LiAlH4 yields (PPHP)Ni(PMe3) (6). The ambiphilic nature of the P-H bond was demonstrated through reactivity studies of P-H bond cleavage in comparison to a Pd analogue (PPHP)Pd(PPh3) (8).

Evaluation of a Geographic Screening Protocol for Chronic Parasitic Infections Before Kidney Transplant: An Institutional Experience in Minnesota.

Pretransplant recommendations advise risk-based screening for strongyloidiasis, schistosomiasis, and Chagas disease. We evaluated the implementation of a chronic parasite screening protocol at a health system in a nonendemic region serving a large foreign-born population. Candidates listed for kidney transplant at Hennepin Healthcare (Minneapolis, MN) between 2010 and 2020 were included. Country of birth and serologic screening for strongyloidiasis, schistosomiasis, and Chagas disease were retrospectively obtained from electronic medical records. Parasite screening frequency and seropositivity was assessed before and after implementation of a geographic risk factor-based screening protocol in 2014. Cost-efficiency of presumptive treatment was modeled. Of 907 kidney transplant candidates, 312 (34%) were born in the United States and 232 (26%) outside the United States, with the remainder missing country of birth information. The 447 (49%) candidates evaluated after implementation of the screening protocol had fewer unidentified countries of birth (53%-27%, P < 0.001) and were more frequently screened for strongyloidiasis, schistosomiasis, and Chagas disease (14%-44%, 8%-22%, and 1-14%, respectively, all Ps < 0.001). The number of identified seropositive candidates increased after protocol implementation from two to 14 for strongyloidiasis and from one to 11 for schistosomiasis, with none seropositive for Chagas disease. The cost-efficiency model favored presumptive ivermectin when strongyloidiasis prevalence reaches 30% of those screened. Implementing a geographic risk screening protocol before kidney transplant increases attention to infectious disease risk associated with country of birth and identification of chronic parasitic infections. In populations with higher strongyloidiasis prevalence or lower ivermectin costs, presumptive treatment may be cost-efficient.

"How can you advocate for something that is nonexistent?" (CM16-17) Power of community in a pandemic and the evolution of community-led response within a COVID-19 CICT and testing context.

Formal and informal bilingual/bicultural organizations and networks form the backbone of support for refugee, immigrant, and migrant (RIM) communities in the United States. They are pivotal in mitigating barriers and inequities in social and structural determinants of health. These organizations and networks are situated within the communities they serve, and often are established and run by members of a community, to serve the community. In the United States, the COVID-19 pandemic surfaced and widened existing health inequities for some racial and ethnic communities. Our primary objectives were to: (1) describe the processes that underpinned the pivotal role of immigrant-serving community structures in developing and implementing culturally sustaining programming in the context of pandemic response, and (2) amplify the voices of community experts, as they shared experiences and perspectives around these humanistic and community-centered approaches. We applied a community case study approach to a national sample of RIM-serving community structures representing broad country/region-of-origin, cultural, and linguistic identities. Community engagement strategies utilized in the project period included engaging community partners to identify and facilitate connections, and consult on analysis and dissemination. The project team conducted 20 in-depth, semi-structured interviews with a purposive sample of community experts/community organizations. Sampling strategy was further informed by immigrant identity (i.e., characterization of status) and geography (i.e., United States Department of Health & Human Services, Office of Intergovernmental and External Affairs Regions). Through thematic analysis, results identified key contextual, process-, and impact-oriented themes inherent to community-led COVID-19 responses, that were situated within and around the public and health system response to the pandemic. As public health and health systems scrambled to address acute and unprecedented barriers to access, distribution of COVID-19-related health resources and services, and disparate health outcomes, community structures diligently and intentionally reimagined and reconceptualized their response to COVID-19, frequently in the setting of scarce resources. The grassroots response evolved as a counter-narrative to top-down equity processes, historically defined by systems and applied to the community.

Hospital pharmacy acquisition of nonstocked antimicrobials-current processes and areas for improvement.

BACKGROUND: The delivery of prompt and appropriate antimicrobial therapy for life-threatening infections is an important antimicrobial stewardship measure and a priority for hospitals. OBJECTIVES: To better understand U.S. hospital pharmacy stocking processes and acquisition of nonstocked antimicrobials and to identify strategies for improving this process. METHODS: This mixed-methods study recruited infectious diseases and antimicrobial stewardship pharmacists. Semistructured interviews with pharmacists in Minnesota were conducted via video conferencing software from January 21, 2021, to March 17, 2021. Audio recordings of the interviews guided survey development and were also transcribed, coded, and qualitatively analyzed. Surveys were distributed throughout the United States via an e-mail listserv, and responses were collected between August 5, 2021, and September 15, 2021. RESULTS: Ten interviews and 78 surveys were included in the analysis. Formulary and stocking practices varied based on institution. Stocking decisions were most frequently based on the frequency of use, clinical utility, and cost of antimicrobials. Nonstocked antimicrobials were often ordered from the wholesale distributor but, if needed urgently, acquired from another local institution. Antibacterial agents were the most frequently needed nonstocked antimicrobials, especially those targeting multidrug-resistant gram-negative bacteria. When acquiring nonstocked antimicrobials, barriers include process inefficiencies, cost, availability, and safety concerns. Improved information sharing between local institutions may help improve this process. CONCLUSION: In this exploratory study, antimicrobial stocking practices varied within U.S. hospitals. Acquisition of nonstocked, urgently needed antimicrobials from neighboring hospitals may be common; however, this process lacks guidance and is often inefficient. Establishing better mechanisms for information sharing may improve this process and should be explored.

Antifungal drug price increases in the United States, 2000-2019.

BACKGROUND: Antifungal drugs treat a variety of conditions, ranging from localised dermatologic disease to life-threatening systemic infections. Some common antifungal drugs experienced large price increases in recent years, however, factors contributing to these price increases are poorly understood. We sought to examine trends in antifungal drug prices and determine underlying drivers of price changes. METHODS: Antifungal drug products in the United States were identified using the Food and Drug Administration (FDA) Label database. For each product, we determined the wholesale acquisition cost per unit over time between 2000 and 2019, adjusting for inflation, and examined variables that could impact price: route of administration, number of FDA indications, the quantity of professional guideline recommendations, use for prophylaxis, number of FDA-approved manufacturers, and whether it was compounded. Price trajectories were clustered into four groups: (1) stable, 2) moderate, (3) high, and (4) extreme price increases. RESULTS: Of 139 identified drug products, one outlier was removed due to exorbitant price increases. Cluster 1 (n = 31) demonstrated the most stable prices with a 25% mean price increase. Clusters 2 (n = 97), 3 (n = 7), and 4 (n = 3) demonstrated moderate, high, and extreme price increases with 52%, 318%, and 900% mean price increases, respectively. Atypical routes of administration and compounding were over-represented in clusters 3 and 4. There was no correlation between the number of manufacturers and price changes. CONCLUSIONS: Antifungal drugs exhibited large, inflation-adjusted price increases. Atypical routes of administration and compounding were over-represented within clusters exhibiting extraordinary price increases. Our data support policies aiming to curb large price increases for medically important drugs.

Impact of Simulation on Undergraduate Student Outcomes.

BACKGROUND: Clinical reasoning is a cognitive and metacognitive process that is essential for positive patient outcomes. Simulation experiences provide situations and reflection where students can build clinical reasoning. PURPOSE: This study examined the impact of a higher number of simulation experiences on undergraduate student outcomes. METHODS: A retrospective comparison study examined differences between group grade point average, Assessment Technologies Institute (ATI) predictor, and National Council Licensure Examination (NCLEX) scores ( P < .05). A sample of 395 students was included in data analysis. RESULTS: No differences were noted in grade point average or NCLEX pass rates. However, students who completed a simulation elective had significantly higher ATI predictor scores. Cohen's d (0.39) approached a medium effect size. CONCLUSIONS: Incorporating higher levels of in-person simulation through creative delivery models can improve student outcomes. Simulations may enhance students' clinical reasoning skills.