Evidence, Experience, Expertise, and the US Coronavirus Disease 2019 Public Health Response.

The U.S. Centers for Disease Control and Prevention (CDC), state, tribal, and local health departments assess available and promising interventions and individual and population health outcomes when crafting public health recommendations. This supplement provides a snapshot of some of the science, experience, and expertise supporting the COVID-19 response.

Death Certificate-Based ICD-10 Diagnosis Codes for COVID-19 Mortality Surveillance - United States, January-December 2020.

Approximately 375,000 deaths during 2020 were attributed to COVID-19 on death certificates reported to CDC (1). Concerns have been raised that some deaths are being improperly attributed to COVID-19 (2). Analysis of International Classification of Diseases, Tenth Revision (ICD-10) diagnoses on official death certificates might provide an expedient and efficient method to demonstrate whether reported COVID-19 deaths are being overestimated. CDC assessed documentation of diagnoses co-occurring with an ICD-10 code for COVID-19 (U07.1) on U.S. death certificates from 2020 that had been reported to CDC as of February 22, 2021. Among 378,048 death certificates listing U07.1, a total of 357,133 (94.5%) had at least one other ICD-10 code; 20,915 (5.5%) had only U07.1. Overall, 97.3% of 357,133 death certificates with at least one other diagnosis (91.9% of all 378,048 death certificates) were noted to have a co-occurring diagnosis that was a plausible chain-of-event condition (e.g., pneumonia or respiratory failure), a significant contributing condition (e.g., hypertension or diabetes), or both. Overall, 70%-80% of death certificates had both a chain-of-event condition and a significant contributing condition or a chain-of-event condition only; this was noted for adults aged 18-84 years, both males and females, persons of all races and ethnicities, those who died in inpatient and outpatient or emergency department settings, and those whose manner of death was listed as natural. These findings support the accuracy of COVID-19 mortality surveillance in the United States using official death certificates. High-quality documentation of co-occurring diagnoses on the death certificate is essential for a comprehensive and authoritative public record. Continued messaging and training (3) for professionals who complete death certificates remains important as the pandemic progresses. Accurate mortality surveillance is critical for understanding the impact of variants of SARS-CoV-2, the virus that causes COVID-19, and of COVID-19 vaccination and for guiding public health action.

Summary of Guidance for Public Health Strategies to Address High Levels of Community Transmission of SARS-CoV-2 and Related Deaths, December 2020.

In the 10 months since the first confirmed case of coronavirus disease 2019 (COVID-19) was reported in the United States on January 20, 2020 (1), approximately 13.8 million cases and 272,525 deaths have been reported in the United States. On October 30, the number of new cases reported in the United States in a single day exceeded 100,000 for the first time, and by December 2 had reached a daily high of 196,227.* With colder weather, more time spent indoors, the ongoing U.S. holiday season, and silent spread of disease, with approximately 50% of transmission from asymptomatic persons (2), the United States has entered a phase of high-level transmission where a multipronged approach to implementing all evidence-based public health strategies at both the individual and community levels is essential. This summary guidance highlights critical evidence-based CDC recommendations and sustainable strategies to reduce COVID-19 transmission. These strategies include 1) universal face mask use, 2) maintaining physical distance from other persons and limiting in-person contacts, 3) avoiding nonessential indoor spaces and crowded outdoor spaces, 4) increasing testing to rapidly identify and isolate infected persons, 5) promptly identifying, quarantining, and testing close contacts of persons with known COVID-19, 6) safeguarding persons most at risk for severe illness or death from infection with SARS-CoV-2, the virus that causes COVID-19, 7) protecting essential workers with provision of adequate personal protective equipment and safe work practices, 8) postponing travel, 9) increasing room air ventilation and enhancing hand hygiene and environmental disinfection, and 10) achieving widespread availability and high community coverage with effective COVID-19 vaccines. In combination, these strategies can reduce SARS-CoV-2 transmission, long-term sequelae or disability, and death, and mitigate the pandemic's economic impact. Consistent implementation of these strategies improves health equity, preserves health care capacity, maintains the function of essential businesses, and supports the availability of in-person instruction for kindergarten through grade 12 schools and preschool. Individual persons, households, and communities should take these actions now to reduce SARS-CoV-2 transmission from its current high level. These actions will provide a bridge to a future with wide availability and high community coverage of effective vaccines, when safe return to more everyday activities in a range of settings will be possible.

CDC Deployments to State, Tribal, Local, and Territorial Health Departments for COVID-19 Emergency Public Health Response - United States, January 21-July 25, 2020.

Coronavirus disease 2019 (COVID-19) is a viral respiratory illness caused by SARS-CoV-2. During January 21-July 25, 2020, in response to official requests for assistance with COVID-19 emergency public health response activities, CDC deployed 208 teams to assist 55 state, tribal, local, and territorial health departments. CDC deployment data were analyzed to summarize activities by deployed CDC teams in assisting state, tribal, local, and territorial health departments to identify and implement measures to contain SARS-CoV-2 transmission (1). Deployed teams assisted with the investigation of transmission in high-risk congregate settings, such as long-term care facilities (53 deployments; 26% of total), food processing facilities (24; 12%), correctional facilities (12; 6%), and settings that provide services to persons experiencing homelessness (10; 5%). Among the 208 deployed teams, 178 (85%) provided assistance to state health departments, 12 (6%) to tribal health departments, 10 (5%) to local health departments, and eight (4%) to territorial health departments. CDC collaborations with health departments have strengthened local capacity and provided outbreak response support. Collaborations focused attention on health equity issues among disproportionately affected populations (e.g., racial and ethnic minority populations, essential frontline workers, and persons experiencing homelessness) and through a place-based focus (e.g., persons living in rural or frontier areas). These collaborations also facilitated enhanced characterization of COVID-19 epidemiology, directly contributing to CDC data-informed guidance, including guidance for serial testing as a containment strategy in high-risk congregate settings, targeted interventions and prevention efforts among workers at food processing facilities, and social distancing.

COVID-19 Contact Tracing in Two Counties - North Carolina, June-July 2020.

Contact tracing is a strategy implemented to minimize the spread of communicable diseases (1,2). Prompt contact tracing, testing, and self-quarantine can reduce the transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (3,4). Community engagement is important to encourage participation in and cooperation with SARS-CoV-2 contact tracing (5). Substantial investments have been made to scale up contact tracing for COVID-19 in the United States. During June 1-July 12, 2020, the incidence of COVID-19 cases in North Carolina increased 183%, from seven to 19 per 100,000 persons per day* (6). To assess local COVID-19 contact tracing implementation, data from two counties in North Carolina were analyzed during a period of high incidence. Health department staff members investigated 5,514 (77%) persons with COVID-19 in Mecklenburg County and 584 (99%) in Randolph Counties. No contacts were reported for 48% of cases in Mecklenburg and for 35% in Randolph. Among contacts provided, 25% in Mecklenburg and 48% in Randolph could not be reached by telephone and were classified as nonresponsive after at least one attempt on 3 consecutive days of failed attempts. The median interval from specimen collection from the index patient to notification of identified contacts was 6 days in both counties. Despite aggressive efforts by health department staff members to perform case investigations and contact tracing, many persons with COVID-19 did not report contacts, and many contacts were not reached. These findings indicate that improved timeliness of contact tracing, community engagement, and increased use of community-wide mitigation are needed to interrupt SARS-CoV-2 transmission.

Trends in Number and Distribution of COVID-19 Hotspot Counties - United States, March 8-July 15, 2020.

The geographic areas in the United States most affected by the coronavirus disease 2019 (COVID-19) pandemic have changed over time. On May 7, 2020, CDC, with other federal agencies, began identifying counties with increasing COVID-19 incidence (hotspots) to better understand transmission dynamics and offer targeted support to health departments in affected communities. Data for January 22-July 15, 2020, were analyzed retrospectively (January 22-May 6) and prospectively (May 7-July 15) to detect hotspot counties. No counties met hotspot criteria during January 22-March 7, 2020. During March 8-July 15, 2020, 818 counties met hotspot criteria for ≥1 day; these counties included 80% of the U.S. population. The daily number of counties meeting hotspot criteria peaked in early April, decreased and stabilized during mid-April-early June, then increased again during late June-early July. The percentage of counties in the South and West Census regions* meeting hotspot criteria increased from 10% and 13%, respectively, during March-April to 28% and 22%, respectively, during June-July. Identification of community transmission as a contributing factor increased over time, whereas identification of outbreaks in long-term care facilities, food processing facilities, correctional facilities, or other workplaces as contributing factors decreased. Identification of hotspot counties and understanding how they change over time can help prioritize and target implementation of U.S. public health response activities.

Enhancing Surveillance and Diagnostics in Anthrax-Endemic Countries.

Naturally occurring anthrax disproportionately affects the health and economic welfare of poor, rural communities in anthrax-endemic countries. However, many of these countries have limited anthrax prevention and control programs. Effective prevention of anthrax outbreaks among humans is accomplished through routine livestock vaccination programs and prompt response to animal outbreaks. The Centers for Disease Control and Prevention uses a 2-phase framework when providing technical assistance to partners in anthrax-endemic countries. The first phase assesses and identifies areas for improvement in existing human and animal surveillance, laboratory diagnostics, and outbreak response. The second phase provides steps to implement improvements to these areas. We describe examples of implementing this framework in anthrax-endemic countries. These activities are at varying stages of completion; however, the public health impact of these initiatives has been encouraging. The anthrax framework can be extended to other zoonotic diseases to build on these efforts, improve human and animal health, and enhance global health security.

Update: Interim Guidance for Health Care Providers Caring for Pregnant Women with Possible Zika Virus Exposure - United States (Including U.S. Territories), July 2017.

CDC has updated the interim guidance for U.S. health care providers caring for pregnant women with possible Zika virus exposure in response to 1) declining prevalence of Zika virus disease in the World Health Organization's Region of the Americas (Americas) and 2) emerging evidence indicating prolonged detection of Zika virus immunoglobulin M (IgM) antibodies. Zika virus cases were first reported in the Americas during 2015-2016; however, the incidence of Zika virus disease has since declined. As the prevalence of Zika virus disease declines, the likelihood of false-positive test results increases. In addition, emerging epidemiologic and laboratory data indicate that, as is the case with other flaviviruses, Zika virus IgM antibodies can persist beyond 12 weeks after infection. Therefore, IgM test results cannot always reliably distinguish between an infection that occurred during the current pregnancy and one that occurred before the current pregnancy, particularly for women with possible Zika virus exposure before the current pregnancy. These limitations should be considered when counseling pregnant women about the risks and benefits of testing for Zika virus infection during pregnancy. This updated guidance emphasizes a shared decision-making model for testing and screening pregnant women, one in which patients and providers work together to make decisions about testing and care plans based on patient preferences and values, clinical judgment, and a balanced assessment of risks and expected outcomes.

Postexposure Prophylaxis After Possible Anthrax Exposure: Adherence and Adverse Events.

Anthrax postexposure prophylaxis (PEP) was recommended to 42 people after a laboratory incident that involved potential aerosolization of Bacillus anthracis spores in 2 laboratories at the Centers for Disease Control and Prevention in 2014. At least 31 (74%) individuals who initiated PEP did not complete either the recommended 60 days of antimicrobial therapy or the 3-dose vaccine regimen. Among the 29 that discontinued the antimicrobial component of PEP, most (38%) individuals discontinued PEP because of their low perceived risk of infection; 9 (31%) individuals discontinued prophylaxis due to PEP-related minor adverse events, and 10% cited both low risk and adverse events as their reason for discontinuation. Most minor adverse events reported were gastrointestinal complaints, and none required medical attention. Individuals taking ciprofloxacin were twice as likely (RR = 2.02, 95% CI = 1.1-3.6) to discontinue antimicrobial prophylaxis when compared to those taking doxycycline. In the event anthrax PEP is recommended, public health messages and patient education materials will need to address potential misconceptions regarding exposure risk and provide information about possible adverse events in order to promote PEP adherence.

A Review of Melioidosis Cases in the Americas.

Melioidosis is a bacterial infection caused by Burkholderia pseudomallei, a gram-negative saprophytic bacillus. Cases occur sporadically in the Americas with an increasing number of cases observed among people with no travel history to endemic countries. To better understand the incidence of the disease in the Americas, we reviewed the literature, including unpublished cases reported to the Centers for Disease Control and Prevention. Of 120 identified human cases, occurring between 1947 and June 2015, 95 cases (79%) were likely acquired in the Americas; the mortality rate was 39%. Burkholderia pseudomallei appears to be widespread in South, Central, and North America.

Melioidosis Cases and Selected Reports of Occupational Exposures to Burkholderia pseudomallei--United States, 2008-2013.

PROBLEM/CONDITION: Melioidosis is an infection caused by the Gram-negative bacillus Burkholderia pseudomallei, which is naturally found in water and soil in areas endemic for melioidosis. Infection can be severe and sometimes fatal. The federal select agent program designates B. pseudomallei as a Tier 1 overlap select agent, which can affect both humans and animals. Identification of B. pseudomallei and all occupational exposures must be reported to the Federal Select Agent Program immediately (i.e., within 24 hours), whereas states are not required to notify CDC's Bacterial Special Pathogens Branch (BSPB) of human infections. PERIOD COVERED: 2008-2013. DESCRIPTION OF SYSTEM: The passive surveillance system includes reports of suspected (human and animal) melioidosis cases and reports of incidents of possible occupational exposures. Reporting of suspected cases to BSPB is voluntary. BSPB receives reports of occupational exposure in the context of a request for technical consultation (so that the system does not include the full complement of the mandatory and confidential reporting to the Federal Select Agent Program). Reporting sources include state health departments, medical facilities, microbiologic laboratories, or research facilities. Melioidosis cases are classified using the standard case definition adopted by the Council of State and Territorial Epidemiologists in 2011. In follow up to reports of occupational exposures, CDC often provides technical assistance to state health departments to identify all persons with possible exposures, define level of risk, and provide recommendations for postexposure prophylaxis and health monitoring of exposed persons. RESULTS: During 2008-2013, BSPB provided technical assistance to 20 U.S. states and Puerto Rico involving 37 confirmed cases of melioidosis (34 human cases and three animal cases). Among those with documented travel history, the majority of reported cases (64%) occurred among persons with a documented travel history to areas endemic for melioidosis. Two persons did not report any travel outside of the United States. Separately, six incidents of possible occupational exposure involving research activities also were reported to BSPB, for which two incidents involved occupational exposures and no human infections occurred. Technical assistance was not required for these incidents because of risk-level (low or none) and appropriate onsite occupational safety response. Of the 261 persons at risk for occupational exposure to B. pseudomallei while performing laboratory diagnostics, 43 (16%) persons had high-risk exposures, 130 (50%) persons had low-risk exposures, and 88 (34%) persons were classified as having undetermined or unknown risk. INTERPRETATION: A small number of U.S. cases of melioidosis have been reported among persons with no travel history outside of the United States, whereas the majority of cases have occurred in persons with a travel history to areas endemic for melioidosis. If the number of travelers continues to increase in countries where the disease is endemic, the likelihood of identifying imported melioidosis cases in the United States might also increase. PUBLIC HEALTH ACTIONS: Reporting of melioidosis cases can improve the ability to monitor the incidence and prevalence of the disease in the United States. To improve prevention and control of melioidosis, CDC recommends that (1) physicians consider melioidosis in the differential diagnosis of patients with acute febrile illnesses, risk factors for melioidosis, and compatible travel or exposure history; (2) personnel at risk for occupational exposure (e.g., laboratory workers or researchers) follow proper safety practices, which includes using appropriate personal protective equipment when working with unknown pathogens; and (3) all possible occupational exposures to B. pseudomallei be reported voluntarily to BSPB.

Melioidosis diagnostic workshop, 2013.

Melioidosis is a severe disease that can be difficult to diagnose because of its diverse clinical manifestations and a lack of adequate diagnostic capabilities for suspected cases. There is broad interest in improving detection and diagnosis of this disease not only in melioidosis-endemic regions but also outside these regions because melioidosis may be underreported and poses a potential bioterrorism challenge for public health authorities. Therefore, a workshop of academic, government, and private sector personnel from around the world was convened to discuss the current state of melioidosis diagnostics, diagnostic needs, and future directions.

Contact investigation of melioidosis cases reveals regional endemicity in Puerto Rico.

BACKGROUND: Melioidosis results from infection with Burkholderia pseudomallei and is associated with case-fatality rates up to 40%. Early diagnosis and treatment with appropriate antimicrobials can improve survival rates. Fatal and nonfatal melioidosis cases were identified in Puerto Rico in 2010 and 2012, respectively, which prompted contact investigations to identify risk factors for infection and evaluate endemicity. METHODS: Questionnaires were administered and serum specimens were collected from coworkers, neighborhood contacts within 250 m of both patients' residences, and injection drug user (IDU) contacts of the 2012 patient. Serum specimens were tested for evidence of prior exposure to B. pseudomallei by indirect hemagglutination assay. Neighborhood seropositivity results guided soil sampling to isolate B. pseudomallei. RESULTS: Serum specimens were collected from contacts of the 2010 (n = 51) and 2012 (n = 60) patients, respectively. No coworkers had detectable anti-B. pseudomallei antibody, whereas seropositive results among neighborhood contacts was 5% (n = 2) for the 2010 patient and 23% (n = 12) for the 2012 patient, as well as 2 of 3 IDU contacts for the 2012 case. Factors significantly associated with seropositivity were having skin wounds, sores, or ulcers (odds ratio [OR], 4.6; 95% confidence interval [CI], 1.2-17.8) and IDU (OR, 18.0; 95% CI, 1.6-194.0). Burkholderia pseudomallei was isolated from soil collected in the neighborhood of the 2012 patient. CONCLUSIONS: Taken together, isolation of B. pseudomallei from a soil sample and high seropositivity among patient contacts suggest at least regional endemicity of melioidosis in Puerto Rico. Increased awareness of melioidosis is needed to enable early case identification and early initiation of appropriate antimicrobial therapy.

Fatal Burkholderia pseudomallei infection initially reported as a Bacillus species, Ohio, 2013.

A fatal case of melioidosis was diagnosed in Ohio one month after culture results were initially reported as a Bacillus species. To identify a source of infection and assess risk in patient contacts, we abstracted patient charts; interviewed physicians and contacts; genetically characterized the isolate; performed a Burkholderia pseudomallei antibody indirect hemagglutination assay on household contacts and pets to assess seropositivity; and collected household plant, soil, liquid, and insect samples for culturing and real-time polymerase chain reaction testing. Family members and pets tested were seronegative for B. pseudomallei. Environmental samples were negative by real-time polymerase chain reaction and culture. Although the patient never traveled internationally, the isolate genotype was consistent with an isolate that originated in Southeast Asia. This investigation identified the fifth reported locally acquired non-laboratory melioidosis case in the contiguous United States. Physicians and laboratories should be aware of this potentially emerging disease and refer positive cultures to a Laboratory Response Network laboratory.

A surveillance summary of smoking and review of tobacco control in Jordan.

The burden of smoking-related diseases in Jordan is increasingly evident. During 2006, chronic, noncommunicable diseases (NCDs) accounted for more than 50% of all deaths in Jordan. With this evidence in hand, we highlight the prevalence of smoking in Jordan among youth and adults and briefly review legislation that governs tobacco control in Jordan. The prevalence of smoking in Jordan remains unacceptably high with smoking and use of tobacco prevalences ranging from 15% to 30% among students aged 13-15 years and a current smoking prevalence near 50% among men. Opportunities exist to further reduce smoking among both youth and adults; however, combating tobacco use in Jordan will require partnerships and long-term commitments between both private and public institutions as well as within local communities.

Health related quality of life measures by demographics and common health risks, Jordan 2004.

OBJECTIVE: To measure health-related quality of life (HRQOL) in Jordan. METHODS: A multi-stage sampling design was used to select households where an adult 18 years of age or older, selected at random, was interviewed. Four HRQOL questions, initially developed by the U.S. CDC, related to mental and physical health were included in the questionnaire and overall unhealthy days were calculated. HRQOL measures were compared to selected chronic conditions and risk factors. RESULTS: Older adults (aged 65 and over), females, persons who were illiterate or with only primary education, and persons with monthly income less than $ 140 reported the highest percentage of fair or poor health and > or =14 overall unhealthy days compared to persons without these characteristics. A high percentage of persons with asthma (33 %), hypertension (37 %), high blood cholesterol (37 %), and diabetes (47 %) also reported fair and poor health. CONCLUSION: Demographic characteristics, the presence of a chronic condition or a chronic disease risk factor are important determinants of mental and physical well-being in Jordan and should be taken into account when planning public health interventions or prevention and promotion programs.

Replicating success: developing a standard FETP curriculum.

Field epidemiology training programs have been successful models to address a country's needs for a skilled public health workforce, partly due to their responsiveness to the countries' unique needs. The Centers for Disease Control and Prevention has partnered with ministries of health to strengthen their workforce through customized competency-based training programs. While desirable, emphasis on program flexibility can result in redundancy and inconsistency. To address this challenge, the ADDIE model (analysis, design, development, implementation, and evaluation) of instructional design was used by a cross-functional team to guide completion of a standard curriculum based on 15 competencies. The standard curriculum has supported the development and expansion of programs while still allowing for adaptation. This article describes the process that was used to develop the curriculum, which, together with needs assessment and evaluation, is crucial for successful training programs.