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US-bound immigrants and refugees undergo a mandatory overseas medical examination that includes tuberculosis screening; this exam is not routinely required for temporary visitors applying for non-immigrant visas (NIV) to visit, work, or study in the United States. US health departments and foreign ministries of health report tuberculosis cases in travelers to Centers for Disease Control and Prevention Quarantine Stations. We reviewed cases reported to this passive surveillance system from January 2011 to June 2016. Of 1252 cases of tuberculosis in travelers reported to CDC, 114 occurred in travelers with a long-term NIV. Of these, 83 (73%) were infectious; 18 (16%) with multidrug-resistant tuberculosis (MDR TB) and one with extensively drug-resistant tuberculosis (XDR TB). We found evidence that NIV holders are diagnosed with tuberculosis disease in the United States. Given that long-term NIV holders were over-represented in this data set, despite the small proportion (4%) of overall non-immigrant admissions they represent, expanding the US overseas migration health screening program to this population might be an efficient intervention to further reduce tuberculosis in the United States., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

COVID-19 vaccines protect against severe COVID-19-associated outcomes, including hospitalization and death. As SARS-CoV-2 has evolved, and waning vaccine effectiveness has been noted, vaccine formulations and policies have been updated to provide continued protection against severe illness and death from COVID-19. Since September 2022, bivalent mRNA COVID-19 vaccines have been recommended in the United States, but the variants these vaccines protect against are no longer circulating widely. On September 11, 2023, the Food and Drug Administration (FDA) approved the updated (2023-2024 Formula) COVID-19 mRNA vaccines by Moderna and Pfizer-BioNTech for persons aged ≥12 years and authorized these vaccines for persons aged 6 months-11 years under Emergency Use Authorization (EUA). On October 3, 2023, FDA authorized the updated COVID-19 vaccine by Novavax for use in persons aged ≥12 years under EUA. The updated COVID-19 vaccines include a monovalent XBB.1.5 component, which is meant to broaden vaccine-induced immunity and provide protection against currently circulating SARS-CoV-2 XBB-sublineage variants including against severe COVID-19-associated illness and death. On September 12, 2023, the Advisory Committee on Immunization Practices recommended vaccination with updated COVID-19 vaccines for all persons aged ≥6 months. These recommendations will be reviewed as new evidence becomes available or new vaccines are approved and might be updated., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

An estimated 30 million passengers are transported on 272 cruise ships worldwide each year* (1). Cruise ships bring diverse populations into proximity for many days, facilitating transmission of respiratory illness (2). SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) was first identified in Wuhan, China, in December 2019 and has since spread worldwide to at least 187 countries and territories. Widespread COVID-19 transmission on cruise ships has been reported as well (3). Passengers on certain cruise ship voyages might be aged ≥65 years, which places them at greater risk for severe consequences of SARS-CoV-2 infection (4). During February-March 2020, COVID-19 outbreaks associated with three cruise ship voyages have caused more than 800 laboratory-confirmed cases among passengers and crew, including 10 deaths. Transmission occurred across multiple voyages of several ships. This report describes public health responses to COVID-19 outbreaks on these ships. COVID-19 on cruise ships poses a risk for rapid spread of disease, causing outbreaks in a vulnerable population, and aggressive efforts are required to contain spread. All persons should defer all cruise travel worldwide during the COVID-19 pandemic., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Background: Ships destined for, or departing from, U.S. ports of entry must report certain signs and symptoms of potentially communicable diseases of public health interest among travelers to the Division of Global Migration and Quarantine (DGMQ) at the Centers for Disease Control and Prevention., Methods: We reviewed ships' varicella case and outbreak reports from January 2010 through December 2015., Results: DGMQ received 967 reports of varicella and 13 reports of herpes zoster. Most varicella case-patients were 20-49 years of age (84.7%, 472/557) and were cruise ship crew members (78.4%, 758/967). Most often, cruise ship crew member case-patients were born in or held passports from Indonesia (21.7%, 80/369), Philippines (17.6%, 65/369), or India (17.3%, 64/369). Ninety-nine varicella outbreaks were reported, including 439 varicella cases and one herpes zoster case; 97 (98.0%) outbreaks occurred on cruise ships, and 90.2% of associated cases were among crew members (397/440). Most varicella cases were in crew members, who are adults often from tropical regions where varicella immunity is acquired later in childhood or young adulthood or without varicella vaccination programs., Conclusion: Varicella vaccination as appropriate for susceptible travelers, particularly crew members, before maritime travel may decrease risk of varicella infection and prevent outbreaks on ships., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

In 2014, the Centers for Disease Control and Prevention conducted conveyance contact investigations for 2 Middle East respiratory syndrome cases imported into the United States, comprising all passengers and crew on 4 international and domestic flights and 1 bus. Of 655 contacts, 78% were interviewed; 33% had serologic testing. No secondary cases were identified.

Background: Deaths and certain illnesses onboard ships arriving at US ports are required to be reported to the US Centers for Disease Control and Prevention (CDC), and notifications of certain illnesses are requested., Methods: We performed a descriptive analysis of required maritime illness and death reports of presumptive diagnoses and requested notifications to CDC's Division of Global Migration and Quarantine, which manages CDC's Quarantine Stations, from January 2010 to December 2014., Results: CDC Quarantine Stations received 2891 individual maritime case reports: 76.8% (2221/2891) illness reports, and 23.2% (670/2891) death reports. The most frequent individual illness reported was varicella (35.9%, 797/2221) and the most frequently reported causes of death were cardiovascular- or pulmonary-related conditions (79.6%, 533/670). There were 7695 cases of influenza-like illness received within aggregate notifications. CDC coordinated 63 contact investigations with partners to identify 972 contacts; 88.0% (855/972) were notified. There was documentation of 6.5% (19/293) receiving post-exposure prophylaxis. Three pertussis contacts were identified as secondary cases; and one tuberculosis contact was diagnosed with active tuberculosis., Conclusion: These data provide a picture of US maritime illness and death reporting and response. Varicella reports are the most frequent individual disease reports received. Contact investigations identified few cases of disease transmission., (Copyright © 2017. Published by Elsevier Ltd.)

Objective: CDC routinely conducts contact investigations involving travelers on commercial conveyances, such as aircrafts, cargo vessels, and cruise ships., Methods: The agency used established systems of communication and partnerships with other federal agencies to quickly provide accurate traveler contact information to states and jurisdictions to alert contacts of potential exposure to two travelers with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) who had entered the United States on commercial flights in April and May 2014., Results: Applying the same process used to trace and notify travelers during routine investigations, such as those for tuberculosis or measles, CDC was able to notify most travelers of their potential exposure to MERS-CoV during the first few days of each investigation., Conclusion: To prevent the introduction and spread of newly emerging infectious diseases, travelers need to be located and contacted quickly.

Rocky Mountain spotted fever (RMSF) is an emerging public health issue on some American Indian reservations in Arizona. RMSF causes an acute febrile illness that, if untreated, can cause severe illness, permanent sequelae requiring lifelong medical support, and death. We describe costs associated with medical care, loss of productivity, and death among cases of RMSF on two American Indian reservations (estimated population 20,000) between 2002 and 2011. Acute medical costs totaled more than $1.3 million. This study further estimated $181,100 in acute productivity lost due to illness, and $11.6 million in lifetime productivity lost from premature death. Aggregate costs of RMSF cases in Arizona 2002-2011 amounted to $13.2 million. We believe this to be a significant underestimate of the cost of the epidemic, but it underlines the severity of the disease and need for a more comprehensive study., (© The American Society of Tropical Medicine and Hygiene.)

Background: Rocky Mountain spotted fever (RMSF) is a disease that now causes significant morbidity and mortality on several American Indian reservations in Arizona. Although the disease is treatable, reported RMSF case fatality rates from this region are high (7%) compared to the rest of the nation (<1%), suggesting a need to identify clinical points for intervention., Methods: The first 205 cases from this region were reviewed and fatal RMSF cases were compared to nonfatal cases to determine clinical risk factors for fatal outcome., Results: Doxycycline was initiated significantly later in fatal cases (median, day 7) than nonfatal cases (median, day 3), although both groups of case patients presented for care early (median, day 2). Multiple factors increased the risk of doxycycline delay and fatal outcome, such as early symptoms of nausea and diarrhea, history of alcoholism or chronic lung disease, and abnormal laboratory results such as elevated liver aminotransferases. Rash, history of tick bite, thrombocytopenia, and hyponatremia were often absent at initial presentation., Conclusions: Earlier treatment with doxycycline can decrease morbidity and mortality from RMSF in this region. Recognition of risk factors associated with doxycycline delay and fatal outcome, such as early gastrointestinal symptoms and a history of alcoholism or chronic lung disease, may be useful in guiding early treatment decisions. Healthcare providers should have a low threshold for initiating doxycycline whenever treating febrile or potentially septic patients from tribal lands in Arizona, even if an alternative diagnosis seems more likely and classic findings of RMSF are absent., (Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Rocky Mountain spotted fever (RMSF) has emerged as a significant cause of morbidity and mortality since 2002 on tribal lands in Arizona. The explosive nature of this outbreak and the recognition of an unexpected tick vector, Rhipicephalus sanguineus, prompted an investigation to characterize RMSF in this unique setting and compare RMSF cases to similar illnesses., Methods: We compared medical records of 205 patients with RMSF and 175 with non-RMSF illnesses that prompted RMSF testing during 2002-2011 from 2 Indian reservations in Arizona., Results: RMSF cases in Arizona occurred year-round and peaked later (July-September) than RMSF cases reported from other US regions. Cases were younger (median age, 11 years) and reported fever and rash less frequently, compared to cases from other US regions. Fever was present in 81% of cases but not significantly different from that in patients with non-RMSF illnesses. Classic laboratory abnormalities such as low sodium and platelet counts had small and subtle differences between cases and patients with non-RMSF illnesses. Imaging studies reflected the variability and complexity of the illness but proved unhelpful in clarifying the early diagnosis., Conclusions: RMSF epidemiology in this region appears different than RMSF elsewhere in the United States. No specific pattern of signs, symptoms, or laboratory findings occurred with enough frequency to consistently differentiate RMSF from other illnesses. Due to the nonspecific and variable nature of RMSF presentations, clinicians in this region should aggressively treat febrile illnesses and sepsis with doxycycline for suspected RMSF., (Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objective: To evaluate whether cosmetically relevant dental effects occurred among children who had received doxycycline for treatment of suspected Rocky Mountain spotted fever (RMSF)., Study Design: Children who lived on an American Indian reservation with high incidence of RMSF were classified as exposed or unexposed to doxycycline, based on medical and pharmacy record abstraction. Licensed, trained dentists examined each child's teeth and evaluated visible staining patterns and enamel hypoplasia. Objective tooth color was evaluated with a spectrophotometer., Results: Fifty-eight children who received an average of 1.8 courses of doxycycline before 8 years of age and who now had exposed permanent teeth erupted were compared with 213 children who had never received doxycycline. No tetracycline-like staining was observed in any of the exposed children's teeth (0/58, 95% CI 0%-5%), and no significant difference in tooth shade (P=.20) or hypoplasia (P=1.0) was found between the 2 groups., Conclusions: This study failed to demonstrate dental staining, enamel hypoplasia, or tooth color differences among children who received short-term courses of doxycycline at <8 years of age. Healthcare provider confidence in use of doxycycline for suspected RMSF in children may be improved by modifying the drug's label., (Published by Elsevier Inc.)