Cyclosporiasis Surveillance - United States, 2011-2015.

PROBLEM/CONDITION: Cyclosporiasis is an intestinal illness caused by the parasite Cyclospora cayetanensis, which is transmissible by ingestion of fecally contaminated food or water. Cyclosporiasis is most common in tropical and subtropical regions of the world. In the United States, foodborne outbreaks of cyclosporiasis have been linked to various types of imported fresh produce (e.g., basil, raspberries, and snow peas). Validated molecular typing tools, which could facilitate detection and investigation of outbreaks, are not yet available for C. cayetanensis. PERIOD COVERED: 2011-2015. DESCRIPTION OF SYSTEM: CDC has been conducting national surveillance for cyclosporiasis since it became a nationally notifiable disease in January 1999. As of 2015, cyclosporiasis was a reportable condition in 42 states, the District of Columbia, and New York City (NYC). Health departments voluntarily notify CDC of cases of cyclosporiasis through the National Notifiable Diseases Surveillance System and submit additional case information using the CDC cyclosporiasis case report form or the Cyclosporiasis National Hypothesis Generating Questionnaire (CNHGQ). RESULTS: For the 2011-2015 surveillance period, CDC was notified by 37 states and NYC of 2,207 cases of cyclosporiasis, including 1,988 confirmed cases (90.1%) and 219 probable cases (9.9%). The annual number of reported cases ranged from 130 in 2012 to 798 in 2013; the annual population-adjusted incidence rate ranged from 0.05 cases per 100,000 persons in 2012 to 0.29 in 2013. A total of 415 patients (18.8%) had a documented history of international travel during the 14 days before illness onset, 1,384 (62.7%) did not have a history of international travel, and 408 (18.5%) had an unknown travel history. Among the 1,359 domestically acquired cases with available information about illness onset, 1,263 (92.9%) occurred among persons who became ill during May-August. During 2011-2015, a total of 10 outbreaks of cyclosporiasis associated with 438 reported cases were investigated; a median of 21 cases were reported per outbreak (range: eight to 162). A food vehicle of infection (i.e., a food item or ingredient thereof) was identified (or suspected) for at least five of the 10 outbreaks; the food vehicles included a berry salad (one outbreak), cilantro imported from Mexico (at least three outbreaks), and a prepackaged salad mix from Mexico (one outbreak). INTERPRETATION: Cyclosporiasis continues to be a U.S. public health concern, with seasonal increases in reported cases during spring and summer months. The majority of cases reported for this 5-year surveillance period occurred among persons without a history of international travel who became ill during May-August. Many of the seemingly sporadic domestically acquired cases might have been associated with identified or unidentified outbreaks; however, those potential associations were not detected using the available epidemiologic information. Prevention of cases and outbreaks of cyclosporiasis in the United States depends on outbreak detection and investigation, including identification of food vehicles of infection and their sources, which could be facilitated by the availability of validated molecular typing tools. PUBLIC HEALTH ACTION: Surveillance for cases of cyclosporiasis and efforts to develop and validate molecular typing tools should remain U.S. public health priorities. During periods and seasons when increased numbers of domestically acquired cases are reported, the CNHGQ should be used to facilitate outbreak detection and hypothesis generation. Travelers to areas of known endemicity (e.g., in the tropics and subtropics) should follow food and water precautions similar to those for other enteric pathogens but should be advised that use of routine chemical disinfection or sanitizing methods is unlikely to kill C. cayetanensis. Health care providers should consider the possibility of Cyclospora infection in persons with persistent or remitting-relapsing diarrheal illness, especially for persons with a history of travel to areas of known endemicity or with symptom onset during spring or summer. If indicated, laboratory testing for Cyclospora should be explicitly requested because such testing is not typically part of routine examinations for ova and parasites and is not included in all gastrointestinal polymerase chain reaction panels. Newly identified cases of cyclosporiasis should be promptly reported to state or local public health authorities, who are encouraged to notify CDC of the cases.

Survey of Obstetrician-Gynecologists in the United States About Taeniasis and Cysticercosis.

An estimated 50 million persons worldwide are infected with cysticerci, the larval forms of the Taenia solium tapeworm. Neurocysticercosis can cause seizures, epilepsy, and hydrocephalus, and fatal cases have been reported in the United States in immigrants and in travelers returning from endemic countries. Pregnant women with symptomatic neurocysticercosis present treatment challenges, whereas those with the adult tapeworm infection (i.e., taeniasis) can put their infants and other family members, as well as obstetrician-gynecologists and their staff, at risk for cysticercosis. A questionnaire developed by the American College of Obstetricians and Gynecologists was sent to a representative sample of 1,000 physicians to assess their awareness of T. solium infection and the potential for it to be encountered in an obstetrics and gynecology setting. In total, 31.4% of respondents correctly answered that taeniasis is caused by eating undercooked pork containing T. solium cysts (95% confidence interval [CI] = 26.6-36.5). While only 14.5% (95% CI = 11.0-18.6) of respondents correctly answered that cysticercosis is acquired by ingesting tapeworm eggs shed in human stools, twice that number (30.3%; 95% CI = 25.5-35.3) correctly answered that a mother with taeniasis can cause cysticercosis in her infant. Practicing in a state in which cysticercosis was reportable at the time of the survey was not significantly associated with answering any of the 12 knowledge questions correctly. Overall, knowledge of T. solium infection among U.S. obstetricians-gynecologists is limited. This may result in missed opportunities to diagnose and treat pregnant women with taeniasis, which may put family members and obstetrics clinical staff at risk for cysticercosis.

Trichinellosis surveillance--United States, 2008-2012.

PROBLEM/CONDITION: Trichinellosis is a parasitic disease caused by nematodes in the genus Trichinella, which are among the most widespread zoonotic pathogens globally. Infection occurs following consumption of raw or undercooked meat infected with Trichinella larvae. Clinical manifestations of the disease range from asymptomatic infection to fatal disease; the common signs and symptoms include eosinophilia, fever, periorbital edema, and myalgia. Trichinellosis surveillance has documented a steady decline in the reported incidence of the disease in the United States. In recent years, proportionally fewer cases have been associated with consumption of commercial pork products, and more are associated with meat from wild game such as bear. PERIOD COVERED: 2008-2012. DESCRIPTION OF SYSTEM: Trichinellosis has been a nationally notifiable disease in the United States since 1966 and is reportable in 48 states, New York City, and the District of Columbia. The purpose of national surveillance is to estimate incidence of infection, detect outbreaks, and guide prevention efforts. Cases are defined by clinical characteristics and the results of laboratory testing for evidence of Trichinella infection. Food exposure histories are obtained at the local level either at the point of care or through health department interview. States notify CDC of cases electronically through the National Notifiable Disease Surveillance System (available at http://wwwn.cdc.gov/nndss). In addition, states are asked to submit a standardized supplementary case report form that captures the clinical and epidemiologic information needed to meet the surveillance case definition. Reported cases are summarized weekly and annually in MMWR. RESULTS: During 2008-2012, a total of 90 cases of trichinellosis were reported to CDC from 24 states and the District of Columbia. Six (7%) cases were excluded from analysis because a supplementary case report form was not submitted or the case did not meet the case definition. A total of 84 confirmed trichinellosis cases, including five outbreaks that comprised 40 cases, were analyzed and included in this report. During 2008-2012, the mean annual incidence of trichinellosis in the United States was 0.1 cases per 1 million population, with a median of 15 cases per year. Pork products were associated with 22 (26%) cases, including 10 (45%) that were linked with commercial pork products, six (27%) that were linked with wild boar, and one (5%) that was linked with home-raised swine; five (23%) were unspecified. Meats other than pork were associated with 45 (54%) cases, including 41 (91%) that were linked with bear meat, two (4%) that were linked with deer meat, and two (4%) that were linked with ground beef. The source for 17 (20%) cases was unknown. Of the 51 patients for whom information was reported on the manner in which the meat product was cooked, 24 (47%) reported eating raw or undercooked meat. INTERPRETATION: The risk for Trichinella infection associated with commercial pork has decreased substantially in the United States since the 1940s, when data collection on trichinellosis cases first began. However, the continued identification of cases related to both pork and nonpork sources indicates that public education about trichinellosis and the dangers of consuming raw or undercooked meat still is needed. PUBLIC HEALTH ACTIONS: Changes in domestic pork production and public health education regarding the safe preparation of pork have contributed to the reduction in the incidence of trichinellosis in the United States; however, consumption of wild game meat such as bear continues to be an important source of infection. Hunters and consumers of wild game meat should be educated about the risk associated with consumption of raw or undercooked meat.

Outbreak of Trichinella spiralis infections associated with a wild boar hunted at a game farm in Iowa.

BACKGROUND: Rates of trichinellosis have declined significantly in the United States due to improved pork production practices and public awareness of the danger of eating raw or undercooked pork. In April 2011, the Minnesota Department of Health received a report of presumptive trichinellosis in a 50-year-old man with a history of wild boar consumption. A public health investigation was initiated. METHODS: Medical record reviews and patient and family interviews were conducted. Trichinella species serology was performed on patient and family serum samples, and larval identification was attempted on clinical specimens and meat samples. RESULTS: The index patient harvested a wild boar from an Iowa game farm; he processed the meat after returning home and developed gastrointestinal symptoms 2 days later. Four days after his illness onset, all 5 family members consumed a roast from the boar. The index patient sought healthcare 4 times after illness onset before being definitively diagnosed with trichinellosis. Following initiation of albendazole therapy, the index patient developed atrial fibrillation. One additional family member who processed the raw meat was diagnosed with trichinellosis. Trichinella spiralis larvae were identified in wild boar meat samples. CONCLUSIONS: Trichinellosis has long been recognized as a potential hazard of consuming undercooked wild carnivore meat, and historically has been associated with consumption of pork from domestic swine, but may be unfamiliar to practicing clinicians in the United States. Education of hunters and the broader population on the potential for trichinellosis and the importance of proper handling and cooking meat from wild or free-range animals needs to be reinforced.

The effect of medical device dose-memory functions on patients' adherence to treatment, confidence, and disease self-management.

BACKGROUND: Adherence to treatment is an important issue in chronic disease management and an indicator of patients' ability to self-manage their condition and treatment. Some drug-dispensing and drug-delivery devices have been designed to support patients' medication-taking behavior by including dose-memory and combined dose-memory and dose-reminder functions, which electronically store, and visually display dose-history information, enabling the patient to review, monitor, and/or be actively reminded about their medication doses. PURPOSE: This literature review explored the role and impact of these devices on patients' treatment adherence, confidence with, and self-management of their condition and treatment. MATERIALS AND METHODS: A search of MEDLINE, Embase, and PsycINFO was performed to identify articles published in English from 2003-2013 that studied the effect of devices with dose-memory and combined dose-memory and dose-reminder functions on treatment adherence and users' (patients, health care professionals [HCPs], and caregivers) confidence, self-management behavior, and attitudes. RESULTS: The database searches yielded 940 abstracts from which 13 articles met the inclusion criteria and were retained. Devices with dose-memory and combined dose-memory and dose-reminder functions were found to improve self-reported and electronically monitored treatment adherence in chronic conditions such as asthma, diabetes, and HIV. The ability of the devices to provide dose-history information and active medication reminders was considered valuable in disease management by patients, caregivers, and HCPs. The devices were found to enhance patients' confidence in, and motivation to manage their medication and condition, and help reduce forgotten or incorrect medication dosing. CONCLUSION: The incorporation of dose-memory and combined dose-memory and dose-reminder functions in drug-delivery devices can improve patients' adherence, confidence, and self-management behavior. They can target non-intentional barriers to adherence and can provide a means of improving disease control and clinical outcomes, thereby offering clinical and economic value. This review highlights the importance of conducting further qualitative and quantitative research to further understand the value and impact of these types of devices on patients' long-term adherence to, and self-management of treatment.

Outbreak of human trichinellosis in Northern California caused by Trichinella murrelli.

In October of 2008, an outbreak of trichinellosis occurred in northern California that sickened 30 of 38 attendees of an event at which meat from a black bear was served. Morphologic and molecular testing of muscle from the leftover portion of bear meat revealed that the bear was infected with Trichinella murrelli, a sylvatic species of Trichinella found in temperate North America. Clinical records revealed a high attack rate for this outbreak: 78% for persons consuming any bear meat and 100% for persons consuming raw or undercooked bear meat. To our knowledge, this report is the first published report of a human trichinellosis outbreak in the United States attributed to T. murrelli, and it is the second such outbreak reported worldwide.

Population-based active surveillance for Cyclospora infection--United States, Foodborne Diseases Active Surveillance Network (FoodNet), 1997-2009.

BACKGROUND: Cyclosporiasis is an enteric disease caused by the parasite Cyclospora cayetanensis. Since the mid-1990 s, the Centers for Disease Control and Prevention has been notified of cases through various reporting and surveillance mechanisms. METHODS: We summarized data regarding laboratory-confirmed cases of Cyclospora infection reported during 1997-2009 via the Foodborne Diseases Active Surveillance Network (FoodNet), which gradually expanded to include 10 sites (Connecticut, Georgia, Maryland, Minnesota, New Mexico, Oregon, Tennessee, and selected counties in California, Colorado, and New York) that represent approximately 15% of the US population. Since 2004, the number of sites has remained constant and data on the international travel history and outbreak status of cases have been collected. RESULTS: A total of 370 cases were reported, 70.3% (260) of which were in residents of Connecticut (134 [36.2%]) and Georgia (126 [34.1%]), which on average during this 13-year period accounted for 29.0% of the total FoodNet population under surveillance. Positive stool specimens were collected in all months of the year, with a peak in June and July (208 cases [56.2%]). Approximately half (48.6%) of the 185 cases reported during 2004-2009 were associated with international travel, known outbreaks, or both. CONCLUSIONS: The reported cases were concentrated in time (spring and summer) and place (2 of 10 sites). The extent to which the geographic concentration reflects higher rates of testing, more sensitive testing methods, or higher exposure/infection rates is unknown. Clinicians should include Cyclospora infection in the differential diagnosis of prolonged or relapsing diarrheal illness and explicitly request stool examinations for this parasite.

Training speech-in-noise perception in mainstream school children.

OBJECTIVE: Auditory training has been advocated as a management strategy for children with hearing, listening or language difficulties. Because poor speech-in-noise perception is commonly reported, previous research has focused on the use of complex (word/sentence) stimuli as auditory training material to improve sentence-in-noise perception. However, some evidence suggests that engagement with the training stimuli is more important than the type of stimuli used for training. The aim of this experiment was to assess if sentence-in-noise perception could be improved using simpler auditory training stimuli. METHODS: We recruited 41 typically developing, normal-hearing children aged 8-10 years divided into four groups. Groups 1-3 trained over 4 weeks (12 × 30 min sessions) on either: (1) pure-tone frequency discrimination (FD), (2) FD in a modulated noise (FDN) or, (3) mono-syllabic words in a modulated noise (WN). Group 4 was an untrained Control. In the training tasks, either tone frequency (Group 1), or tone (Group 2) or speech (Group 3) level was varied adaptively. All children completed pre- and post-training tests of sentence perception in modulated (SMN) and unmodulated (SUN) noise and a probe measure of each training task. RESULTS: All trained groups improved significantly on the trained tasks. Transfer of training occurred between FDN training and FD, WN and SMN testing, and between WN training and SMN testing. A significant performance suppression on the SUN test resulted from FD and FDN training. CONCLUSION: The pattern of training-induced improvement, relative to Controls, suggests that transfer of training is more likely when some stimulus dimensions (tone frequency, speech, modulated noise) are shared between training tasks and outcomes. This and the finding of suppressed post-training performance, relative to Controls, between tasks not sharing a stimulus dimension both favour the use of outcome-specific material for auditory training.

Surveillance for laboratory-confirmed sporadic cases of cyclosporiasis--United States, 1997-2008.

PROBLEM/CONDITION: Cyclosporiasis is an enteric disease caused by the parasite Cyclospora cayetanensis. Cyclosporiasis is reported most commonly in tropical and subtropical regions. In the United States, outbreaks of cyclosporiasis associated with various types of imported fresh produce have been documented and described since the mid-1990s. No molecular tools are available for linking C. cayetanensis cases. National data regarding laboratory-confirmed sporadic cases (i.e., cases not linked to documented outbreaks) have not been summarized previously. REPORTING PERIOD: This summary includes laboratory-confirmed sporadic cases that occurred during 1997-2008 and were reported to CDC by 2009. DESCRIPTION OF SYSTEM: In January 1999, cyclosporiasis became a nationally notifiable disease, and, as of 2008, it was a reportable condition in 37 states, New York City (NYC), and the District of Columbia. For 1997-2008, CDC was notified of laboratory-confirmed cases via two active surveillance systems (the Cyclospora Sentinel Surveillance Network and the Foodborne Diseases Active Surveillance Network), two passive systems (the National Notifiable Diseases Surveillance System and the Public Health Laboratory Information System), and informal mechanisms (e.g., electronic mail). RESULTS: CDC was notified of 1,110 laboratory-confirmed sporadic cases of cyclosporiasis that occurred during 1997-2008. The overall population-adjusted incidence rates ranged from a low of 0.01 cases per 100,000 persons in 1997 to a high of 0.07 in 2002. Of the 1,110 cases, 849 (76.5%) were reported by seven states: 498 (44.9%) occurred in residents of Florida (228 cases), NYC (200 cases), and elsewhere in New York state (70 cases); and >50 cases were reported by each of five other states (Connecticut, Georgia, Massachusetts, New Jersey, and Pennsylvania). Overall, the case-patients' median age was 44 years (range: 3 months-96 years); 50.5% were female, 47.2% were male, and the sex was unknown for 2.3%. A total of 372 case-patients (33.5%) had a documented history of international travel during the 2-week period before symptom onset or diagnosis, 398 (35.9%) reported no international travel, and 340 (30.6%) had an unknown travel history. Some details about the travel were available for 317 (85.2%) of the case-patients with a known history of international travel; 142 (44.8%) had traveled to Mexico (60 persons), Guatemala (44 persons), or Peru (38 persons). Among the 398 case-patients classified as having domestically acquired cases, 124 persons (31.2%) lived in Florida, and 64 persons (16.1%) lived either in NYC (49 persons) or elsewhere in New York state (15 persons). The majority (278 [69.8%]) of onset or diagnosis dates for domestically acquired cases occurred during April-August. INTERPRETATION: Approximately one third of cases occurred in persons with a known history of international travel who might have become infected while traveling outside the continental United States. Domestically acquired cases were concentrated in time (spring and summer) and place (eastern and southeastern states): some of these cases probably were outbreak associated but were not linked to other cases, in part because of a lack of molecular tools. PUBLIC HEALTH ACTION: Surveillance for cases of cyclosporiasis and research to develop molecular methods for linking seemingly sporadic cases should remain U.S. public health priorities, in part to facilitate identification and investigation of outbreaks and to increase understanding of the biology of Cyclospora and the epidemiology of cyclosporiasis. Unidentified, uninvestigated cases and outbreaks represent missed opportunities to identify vehicles of infection, modes of contamination, and preventive measures. Travelers to known areas of endemicity should be advised that food and water precautions for Cyclospora are similar to those for other enteric pathogens, except that this parasite is unlikely to be killed by routine chemical disinfection or sanitizing methods. The diagnosis of cyclosporiasis should be considered for persons with persistent or remitting-relapsing diarrheal illness, and testing for Cyclospora should be requested explicitly.

Communication, listening, cognitive and speech perception skills in children with auditory processing disorder (APD) or Specific Language Impairment (SLI).

PURPOSE: Parental reports of communication, listening, and behavior in children receiving a clinical diagnosis of specific language impairment (SLI) or auditory processing disorder (APD) were compared with direct tests of intelligence, memory, language, phonology, literacy, and speech intelligibility. The primary aim was to identify whether there were differences between these characteristics in children with SLI or APD. METHOD: Normally hearing children who were clinically diagnosed with SLI (n = 22) or APD (n = 19), and a quasirandom sample of mainstream school (MS) children (n = 47) aged 6-13 years, underwent tests of verbal and nonverbal IQ, digit span, nonsense word repetition, Spoonerisms, reading, grammar, and sentence and VCV nonword intelligibility. Parents completed questionnaires on the children's communication, listening, and behavior. RESULTS: There was generally no difference between the performance of the children with SLI and the children with APD on the questionnaire and test measures, and both groups consistently and significantly underperformed compared with the children in the MS group. Speech intelligibility in both noise and quiet was unimpaired in the SLI and APD groups. CONCLUSION: Despite clinical diagnoses of SLI or APD, the 2 groups of children had very similar behavioral and parental report profiles, suggesting that the children were differentially diagnosed based on their referral route rather than on actual differences.

Trichinellosis surveillance - United States, 2002-2007.

PROBLEM/CONDITION: Trichinellosis is a parasitic disease caused by roundworms of the Trichinella genus. Humans are incidental hosts who become infected after ingestion of raw or undercooked meat containing encysted larvae of Trichinella spp. Common signs and symptoms of trichinellosis include eosinophilia, abdominal pain, fever, periorbital edema, and myalgia. National surveillance has documented a decline in the reported incidence of trichinellosis in the United States since 1947, the first year nationwide data were collected systematically. The decreased incidence of trichinellosis has mirrored the decrease of Trichinella in commercial pork products as a result of changes in pork industry management standards and government regulations. In addition, an overall decrease has occurred in the number of cases of trichinellosis related to pork consumption. During 1997-2001, meats other than pork were the most common source of infection, and more cases were associated with home-raised pork than with store-bought pork. REPORTING PERIOD COVERED: 2002-2007. DESCRIPTION OF SYSTEM: Trichinellosis is a reportable disease in 48 states and has been a nationally notifiable disease since 1966. Cases are defined by clinical characteristics and the results of laboratory testing for evidence of Trichinella infection. States report cases to CDC through the National Notifiable Diseases Surveillance System. Reported cases are summarized weekly and yearly in MMWR. In addition, states are asked to submit a standardized case report form with supplementary case data to CDC's Division of Parasitic Diseases. RESULTS: During 2002-2007, a total of 66 cases of trichinellosis were reported to CDC. Those cases for which a supplementary case report form was not submitted or that did not meet the case definition were excluded from analysis. Of the 66 cases reported during 2002-2007, a total of 12 (18%) cases were excluded from analysis. Associated meat products were classified as either pork or meat products other than pork and were identified for 43 (80%) cases. Meat products other than pork were associated with 27 (50%) cases: 21 with bear meat, one with either bear or deer meat, one with cougar meat, one with deer meat, one with walrus or seal meat, and two with commercial beef. Pork was associated with 10 (19%) cases: seven with commercial pork, two with noncommercial pork, and one with an unspecified type of pork. Of the seven cases associated with consumption of commercial pork, five were linked to U.S. commercial pork, and two were attributed to pork ingested during travel in Asia. The two cases associated with noncommercial pork were attributed to wild boar meat; one case involved wild boar meat from a farm and the other wild boar meat from a farmers' market. Six patients reported consuming both pork and meat products other than pork, but the infected meat product could not be identified. INTERPRETATION: The number of reported trichinellosis cases attributed to commercial pork consumption remains low. The greatest number of cases continues to be associated with consumption of meat other than pork, especially bear meat. PUBLIC HEALTH ACTION: For the incidence of trichinellosis in the United States to be reduced further, education regarding safe food preparation practices and prevention of trichinellosis should be targeted toward hunters and other consumers of wild game meat, especially bear.