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Salmonella is a public health concern, for which a complex interplay between host, agent, and environment exists. An improved understanding of causal processes can be used to better gauge the causes and trajectory of Salmonella in a changing environment. This would be useful in determining the impact of climate change on the New York State (NYS) environment, the effect of climate change on Salmonella in NYS, factors contributing to Salmonella vulnerability in humans, and aspects of climate change and Salmonella which necessitate further research. A systematic review was conducted to study associations between Salmonella and the environment. Using the search criteria, a total of 91 relevant articles were identified from four electronic databases. Key information was abstracted, organized, and synthesized to identify causal processes and linkages between climate change, the environment of NYS, and Salmonella-related outcomes, as well as risk factors to characterize Salmonella vulnerabilities. Three inter-related domains were identified for consideration and application to epidemiological research to confirm and extrapolate disease patterns using climate change scenarios: improved quantification of causal relationships, inclusion of factors linked to sectors not immediately associated with the exposure and outcome, and increased capacity to validate models in diverse settings. This article has been made Open Access thanks to the generous support of a global network of libraries as part of the Knowledge Unlatched Select initiative.

BACKGROUND. Following Haemophilus influenzae serotype b (Hib) conjugate vaccine introduction in the 1980s, Hib disease in young children dramatically decreased, and epidemiology of invasive H. influenzae changed. METHODS. Active surveillance for invasive H. influenzae disease was conducted through Active Bacterial Core surveillance sites. Incidence rates were directly standardized to the age and race distribution of the US population. RESULTS. During 2009–2015, the estimated mean annual incidence of invasive H. influenzae disease was 1.70 cases per 100 000 population. Incidence was highest among adults aged ≥65 years (6.30) and children aged

Background Influenza hospitalizations result in substantial morbidity and mortality each year. Little is known about the association between influenza hospitalization and census tract‐based socioeconomic determinants beyond the effect of individual factors. Objective To evaluate whether census tract‐based determinants such as poverty and household crowding would contribute significantly to the risk of influenza hospitalization above and beyond individual‐level determinants. Methods We analyzed 33 515 laboratory‐confirmed influenza‐associated hospitalizations that occurred during the 2009‐2010 through 2013‐2014 influenza seasons using a population‐based surveillance system at 14 sites across the United States. Results Using a multilevel regression model, we found that individual factors were associated with influenza hospitalization with the highest adjusted odds ratio (AOR) of 9.20 (95% CI 8.72‐9.70) for those ≥65 vs 5‐17 years old. African Americans had an AOR of 1.67 (95% CI 1.60‐1.73) compared to Whites, and Hispanics had an AOR of 1.21 (95% CI 1.16‐1.26) compared to non‐Hispanics. Among census tract‐based determinants, those living in a tract with ≥20% vs

Background Infants aged Methods We conducted a case-control evaluation among pertussis cases Results A total of 240 cases and 535 controls were included; 17 (7.1%) case mothers and 90 (16.8%) control mothers received Tdap during the third trimester of pregnancy. The multivariable VE estimate for Tdap administered during the third trimester of pregnancy was 77.7% (95% confidence interval [CI], 48.3%-90.4%); VE increased to 90.5% (95% CI, 65.2%-97.4%) against hospitalized cases. Conclusions Vaccination during pregnancy is an effective way to protect infants during the early months of life. With a continuing resurgence in pertussis, efforts should focus on maximizing Tdap uptake among pregnant women.

Introduction Previous FluSurv-NET studies found that adult females had a higher incidence of influenza-associated hospitalizations than males. To identify groups of women at higher risk than men, we analyzed data from 14 FluSurv-NET sites that conducted population-based surveillance for laboratory-confirmed influenza-associated hospitalizations among residents of 78 US counties. Methods We analyzed 6292 laboratory-confirmed, geocodable (96%) adult cases collected by FluSurv-NET during the 2010-12 influenza seasons. We used 2010 US Census and 2008-2012 American Community Survey data to calculate overall age-adjusted and age group-specific female:male incidence rate ratios (IRR) by race/ethnicity and census tract-level poverty. We used national 2010 pregnancy rates to estimate denominators for pregnant women aged 18-49. We calculated male:female IRRs excluding them and IRRs for pregnant:non-pregnant women. Results Overall, 55% of laboratory-confirmed influenza cases were female. Female:male IRRs were highest for females aged 18-49 of high neighborhood poverty (IRR 1.50, 95% CI 1.30-1.74) and of Hispanic ethnicity (IRR 1.70, 95% CI 1.34-2.17). These differences disappeared after excluding pregnant women. Overall, 26% of 1083 hospitalized females aged 18-49 were pregnant. Pregnant adult females were more likely to have influenza-associated hospitalizations than their non-pregnant counterparts (relative risk [RR] 5.86, 95% CI 5.12-6.71), but vaccination levels were similar (25.5% vs 27.8%). Conclusions Overall rates of influenza-associated hospitalization were not significantly different for men and women after excluding pregnant women. Among women aged 18-49, pregnancy increased the risk of influenza-associated hospitalization sixfold but did not increase the likelihood of vaccination. Improving vaccination rates in pregnant women should be an influenza vaccination priority.

Foodborne diseases represent a substantial public health concern in the United States. CDC's Foodborne Diseases Active Surveillance Network (FoodNet) monitors cases reported from 10 U.S. sites* of laboratory-diagnosed infections caused by nine enteric pathogens commonly transmitted through food. This report describes preliminary surveillance data for 2016 on the nine pathogens and changes in incidences compared with 2013-2015. In 2016, FoodNet identified 24,029 infections, 5,512 hospitalizations, and 98 deaths caused by these pathogens. The use of culture-independent diagnostic tests (CIDTs) by clinical laboratories to detect enteric pathogens has been steadily increasing since FoodNet began surveying clinical laboratories in 2010 (1). CIDTs complicate the interpretation of FoodNet surveillance data because pathogen detection could be affected by changes in health care provider behaviors or laboratory testing practices (2). Health care providers might be more likely to order CIDTs because these tests are quicker and easier to use than traditional culture methods, a circumstance that could increase pathogen detection (3). Similarly, pathogen detection could also be increasing as clinical laboratories adopt DNA-based syndromic panels, which include pathogens not often included in routine stool culture (4,5). In addition, CIDTs do not yield isolates, which public health officials rely on to distinguish pathogen subtypes, determine antimicrobial resistance, monitor trends, and detect outbreaks. To obtain isolates for infections identified by CIDTs, laboratories must perform reflex culture†; if clinical laboratories do not, the burden of culturing falls to state public health laboratories, which might not be able to absorb that burden as the adoption of these tests increases (2). Strategies are needed to preserve access to bacterial isolates for further characterization and to determine the effect of changing trends in testing practices on surveillance.

Using population-based surveillance data, we analyzed antiviral treatment among hospitalized patients with laboratory-confirmed influenza. Treatment increased after the influenza A(H1N1) 2009 pandemic from 72% in 2010–2011 to 89% in 2014–2015 (P < .001). Overall, treatment was higher in adults (86%) than in children (72%); only 56% of cases received antivirals on the day of admission.

BACKGROUND Sepsis is a serious and often fatal clinical syndrome, resulting from infection. Information on patient demographics, risk factors, and infections leading to sepsis is needed to integrate comprehensive sepsis prevention, early recognition, and treatment strategies. METHODS To describe characteristics of patients with sepsis, CDC and partners conducted a retrospective chart review in four New York hospitals. Random samples of medical records from adult and pediatric patients with administrative codes for severe sepsis or septic shock were reviewed. RESULTS Medical records of 246 adults and 79 children (aged birth to 17 years) were reviewed. Overall, 72% of patients had a health care factor during the 30 days before sepsis admission or a selected chronic condition likely to require frequent medical care. Pneumonia was the most common infection leading to sepsis. The most common pathogens isolated from blood cultures were Escherichia coli in adults aged ≥18 years, Klebsiella spp. in children aged ≥1 year, and Enterococcus spp. in infants aged

In 2010, 13-valent pneumococcal conjugate vaccine (PCV13) was introduced in the US for prevention of invasive pneumococcal disease in children. Individual-level socioeconomic status (SES) is a potential confounder of the estimated effectiveness of PCV13 and is often controlled for in observational studies using zip code as a proxy. We assessed the utility of zip code matching for control of SES in a post-licensure evaluation of the effectiveness of PCV13 (calculated as [1-matched odds ratio]*100). We used a directed acyclic graph to identify subsets of confounders and collected SES variables from birth certificates, geocoding, a parent interview, and follow-up with medical providers. Cases tended to be more affluent than eligible controls (for example, 48.3% of cases had private insurance vs. 44.6% of eligible controls), but less affluent than enrolled controls (52.9% of whom had private insurance). Control of confounding subsets, however, did not result in a meaningful change in estimated vaccine effectiveness (original estimate: 85.1%, 95% CI 74.8–91.9%; adjusted estimate: 82.5%, 95% CI 65.6–91.1%). In the context of a post-licensure vaccine effectiveness study, zip code appears to be an adequate, though not perfect, proxy for individual SES., Highlights • Socioeconomic status (SES) may impact enrollment in vaccine effectiveness studies. • We assessed zip code matching as a proxy for SES in a pneumococcal vaccine study. • After zip code matching, we found differences in SES between cases and controls. • Differences did not appear to substantially bias estimated vaccine effectiveness.

Objective. Transcripts from admission chest radiographs could aid in identification of pneumonia cases for public health surveillance. We assessed the reliability of radiographic data abstraction and performance of radiographic key terms to identify pneumonia in patients hospitalized with laboratory-confirmed influenza virus infection. Methods. We used data on patients hospitalized with laboratory-confirmed influenza virus infection from October 2008 through December 2009 from 10 geographically diverse U.S. study sites participating in the Influenza Hospitalization Surveillance Network (FluSurv-NET). Radiographic key terms (i.e., bronchopneumonia, consolidation, infiltrate, airspace density, and pleural effusion) were abstracted from final impressions of chest radiograph reports. We assessed the reliability of radiographic data abstraction by examining the percent agreement and Cohen's κ statistic between clinicians and surveillance staff members. Using a composite reference standard for presence or absence of pneumonia based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and discharge summary data, we calculated sensitivity, specificity, positive predictive value (PPV), and percent agreement for individual and combined radiographic key terms. Results. For each radiographic key term, the percent agreement between clinicians and surveillance staff members ranged from 89.4% to 98.6% and Cohen's κ ranged from 0.46 (moderate) to 0.84 (almost perfect). The combination of bronchopneumonia or consolidation or infiltrate or airspace density terms had sensitivity of 66.5%, specificity of 89.2%, PPV of 80.4%, and percent agreement of 80.1%. Adding pleural effusion did not result in significant changes in sensitivity, specificity, PPV, or percent agreement. Conclusion. Radiographic key terms abstracted by surveillance staff members from final impressions of chest radiograph reports had moderate to almost perfect reliability and could be used to identify pneumonia among patients hospitalized with laboratory-confirmed influenza virus infection. This method can inform pneumonia surveillance and aid in public health response.

BACKGROUND Invasive group A Streptococcus (GAS) infections are associated with significant morbidity and mortality rates. We report the epidemiology and trends of invasive GAS over 8 years of surveillance. METHODS From January 2005 through December 2012, we collected data from the Centers for Disease Control and Prevention's Active Bacterial Core surveillance, a population-based network of 10 geographically diverse US sites (2012 population, 32.8 million). We defined invasive GAS as isolation of GAS from a normally sterile site or from a wound in a patient with necrotizing fasciitis (NF) or streptococcal toxic shock syndrome (STSS). Available isolates were emm typed. We calculated rates and made age- and race-adjusted national projections using census data. RESULTS We identified 9557 cases (3.8 cases per 100 000 persons per year) with 1116 deaths (case-fatality rate, 11.7%). The case-fatality rates for septic shock, STSS, and NF were 45%, 38%, and 29%, respectively. The annual incidence was highest among persons aged ≥65 years (9.4/100 000) or

To evaluate progress toward prevention of enteric and foodborne illnesses in the United States, the Foodborne Diseases Active Surveillance Network (FoodNet) monitors the incidence of laboratory-confirmed infections caused by nine pathogens transmitted commonly through food in 10 U.S. sites. This report summarizes preliminary 2015 data and describes trends since 2012. In 2015, FoodNet reported 20,107 confirmed cases (defined as culture-confirmed bacterial infections and laboratory-confirmed parasitic infections), 4,531 hospitalizations, and 77 deaths. FoodNet also received reports of 3,112 positive culture-independent diagnostic tests (CIDTs) without culture-confirmation, a number that has markedly increased since 2012. Diagnostic testing practices for enteric pathogens are rapidly moving away from culture-based methods. The continued shift from culture-based methods to CIDTs that do not produce the isolates needed to distinguish between strains and subtypes affects the interpretation of public health surveillance data and ability to monitor progress toward prevention efforts. Expanded case definitions and strategies for obtaining bacterial isolates are crucial during this transition period.

Background Timing of influenza spread across the United States is dependent on factors including local and national travel patterns and climate. Local epidemic intensity may be influenced by social, economic and demographic patterns. Data are needed to better explain how local socioeconomic factors influence both the timing and intensity of influenza seasons to result in national patterns. Methods To determine the spatial and temporal impacts of socioeconomics on influenza hospitalization burden and timing, we used population-based laboratory-confirmed influenza hospitalization surveillance data from the CDC-sponsored Influenza Hospitalization Surveillance Network (FluSurv-NET) at up to 14 sites from the 2009/2010 through 2013/2014 seasons (n = 35,493 hospitalizations). We used a spatial scan statistic and spatiotemporal wavelet analysis, to compare temporal patterns of influenza spread between counties and across the country. Results There were 56 spatial clusters identified in the unadjusted scan statistic analysis using data from the 2010/2011 through the 2013/2014 seasons, with relative risks (RRs) ranging from 0.09 to 4.20. After adjustment for socioeconomic factors, there were five clusters identified with RRs ranging from 0.21 to 1.20. In the wavelet analysis, most sites were in phase synchrony with one another for most years, except for the H1N1 pandemic year (2009–2010), wherein most sites had differential epidemic timing from the referent site in Georgia. Conclusions Socioeconomic factors strongly impact local influenza hospitalization burden. Influenza phase synchrony varies by year and by socioeconomics, but is less influenced by socioeconomics than is disease burden.

IMPORTANCE: Group B Streptococcus (GBS) is an important cause of invasive bacterial disease. Previous studies have shown a substantial and increasing burden of GBS infections among nonpregnant adults, particularly older adults and those with underlying medical conditions. OBJECTIVE: To update trends of invasive GBS disease among US adults using population-based surveillance data. DESIGN, SETTING, AND PARTICIPANTS: In this population-based surveillance study, a case was defined as isolation of GBS from a sterile site between January 1, 2008, and December 31, 2016. Demographic and clinical data were abstracted from medical records. Rates were calculated using US Census data. Antimicrobial susceptibility testing and serotyping were performed on a subset of isolates. Case patients were residents of 1 of 10 catchment areas of the Active Bacterial Core surveillance (ABCs) network, representing approximately 11.5% of the US adult population. Patients were included in the study if they were nonpregnant, were 18 years or older, were residents of an ABCs catchment site, and had a positive GBS culture from a normally sterile body site. MAIN OUTCOMES AND MEASURES: Trends in GBS cases overall and by demographic characteristics (sex, age, and race), underlying clinical conditions of patients, and isolate characteristics are described. RESULTS: The ABCs network detected 21 250 patients with invasive GBS among nonpregnant adults from 2008 through 2016. The GBS incidence in this population increased from 8.1 cases per 100 000 population in 2008 to 10.9 in 2016 (P = .002 for trend). There were 3146 cases reported in 2016 (59% male; median age, 64 years; age range, 18-103 years). The GBS incidence was higher among men than women and among blacks than whites and increased with age. Projected to the US population, an estimated 27 729 cases of invasive disease and 1541 deaths occurred in the United States in 2016. Ninety-five percent of cases in 2016 occurred in someone with at least 1 underlying condition, most commonly obesity (53.9%) and diabetes (53.4%). Resistance to clindamycin increased from 37.0% of isolates in 2011 to 43.2% in 2016 (P = .02). Serotypes Ia, Ib, II, III, and V accounted for 86.4% of isolates in 2016; serotype IV increased from 4.7% in 2008 to 11.3% in 2016 (P

Annual influenza vaccine is recommended for all persons aged ≥6 months in the United States, with recognition that some persons are at risk for more severe disease (1). However, there might be previously unrecognized demographic groups that also experience higher rates of serious influenza-related disease that could benefit from enhanced vaccination efforts. Socioeconomic status (SES) measures that are area-based can be used to define demographic groups when individual SES data are not available (2). Previous surveillance data analyses in limited geographic areas indicated that influenza-related hospitalization incidence was higher for persons residing in census tracts that included a higher percentage of persons living below the federal poverty level (3-5). To determine whether this association occurs elsewhere, influenza hospitalization data collected in 14 FluSurv-NET sites covering 27 million persons during the 2010-11 and 2011-12 influenza seasons were analyzed. The age-adjusted incidence of influenza-related hospitalizations per 100,000 person-years in high poverty (≥20% of persons living below the federal poverty level) census tracts was 21.5 (95% confidence interval [CI]: 20.7-22.4), nearly twice the incidence in low poverty (

Background We describe the impact of early initiation of influenza antiviral treatment among pregnant women hospitalized with laboratory-confirmed influenza during the 2010-2014 influenza seasons. Methods Severe influenza was defined as illness with ≥1 of the following: intensive care unit admission, need for mechanical ventilation, respiratory failure, pulmonary embolism, sepsis, or death. Within severity stratum, we used parametric survival analysis to compare length of stay by timing of antiviral treatment, adjusting for underlying conditions, influenza vaccination, and pregnancy trimester. Results Among 865 pregnant women, the median age was 27 years (interquartile range [IQR], 23-31 years). Most (68%) were healthy, and 85% received antiviral treatment. Sixty-three women (7%) had severe influenza, and 4 died. Severity was associated with preterm delivery and fetal loss. Women with severe influenza were less likely to be vaccinated than those without severe influenza (14% vs 26%; P = .03). Among women treated with antivirals ≤2 days versus those treated >2 days from illness onset, the median length of stay was 2.2 days (interquartile range [IQR], 0.9-5.8 days; n = 8) versus 7.8 days (IQR, 3.0-20.6 days; n = 7), respectively, for severe influenza (P = .03) and 2.4 days (IQR, 2.3-2.5 days; n = 153) versus 3.1 days (IQR, 2.8-3.5 days; n = 62), respectively, for nonsevere influenza (P Conclusions Early initiation of influenza antiviral treatment to pregnant women hospitalized with influenza may reduce the length of stay, especially among those with severe influenza. Influenza during pregnancy is associated with maternal and infant morbidity, and annual influenza vaccination is warranted.

BACKGROUND: Pertussis is poorly controlled, with the highest rates of morbidity and mortality among infants. Although the source of infant pertussis is often unknown, when identified, mothers have historically been the most common reservoir of transmission. Despite high vaccination coverage, disease incidence has been increasing. We examined whether infant source of infection (SOI) has changed in the United States in light of the changing epidemiology. METHODS: Cases RESULTS: A total of 1306 infant cases were identified; 24.2% were CONCLUSIONS: In contrast to previous studies, our data suggest that the most common source of transmission to infants is now siblings. While continued monitoring of SOIs will optimize pertussis prevention strategies, recommendations for vaccination during pregnancy should directly increase protection of infants, regardless of SOI.

Background Patients hospitalized with influenza may require extended care on discharge. We aimed to explore predictors for extended care needs and the potential mitigating effect of antiviral treatment among community-dwelling adults aged ≥ 65 years hospitalized with influenza. Methods We used laboratory-confirmed influenza hospitalizations from 3 influenza seasons. Extended care was defined as new placement in a skilled nursing home/long-term/rehabilitation facility on hospital discharge. We focused on those treated with antiviral agents to explore the effect of early treatment on extended care and hospital length of stay using logistic regression and competing risk survival analysis, accounting for time from illness onset to hospitalization. Treatment was categorized as early (≤ 4 days) or late (>4 days) in reference to date of illness onset. Results Among 6593 community-dwelling adults aged ≥ 65 years hospitalized for influenza, 18% required extended care at discharge. The need for care increased with age and neurologic disorders, intensive care unit admission, and pneumonia were predictors of care needs. Early treatment reduced the odds of extended care after hospital discharge for those hospitalized ≤ 2 or >2 days from illness onset (adjusted odds ratio, 0.38 [95% confidence interval {CI}, .17-.85] and 0.75 [.56-.97], respectively). Early treatment was also independently associated with reduction in length of stay for those hospitalized ≤ 2 days from illness onset (adjusted hazard ratio, 1.81; 95% CI, 1.43-2.30) or >2 days (1.30; 1.20-1.40). Conclusions Prompt antiviral treatment decreases the impact of influenza on older adults through shorten hospitalization and reduced extended care needs.

Adjusting for diagnostic test sensitivity enables more accurate and timely comparisons over time., Diagnostic test sensitivity affects rate estimates for laboratory-confirmed influenza–associated hospitalizations. We used data from FluSurv-NET, a national population-based surveillance system for laboratory-confirmed influenza hospitalizations, to capture diagnostic test type by patient age and influenza season. We calculated observed rates by age group and adjusted rates by test sensitivity. Test sensitivity was lowest in adults >65 years of age. For all ages, reverse transcription PCR was the most sensitive test, and use increased from 65 years. After 2009, hospitalization rates adjusted by test sensitivity were ≈15% higher for children 65 years of age. Test sensitivity adjustments improve the accuracy of hospitalization rate estimates.

Background We investigated the effect of influenza vaccination on disease severity in adults hospitalized with laboratory-confirmed influenza during 2013-14, a season in which vaccine viruses were antigenically similar to those circulating. Methods We analyzed data from the 2013-14 influenza season and used propensity score matching to account for the probability of vaccination within age strata (18-49, 50-64, and ≥65 years). Death, intensive care unit (ICU) admission, and hospital and ICU lengths of stay (LOS) were outcome measures for severity. Multivariable logistic regression and competing risk models were used to compare disease severity between vaccinated and unvaccinated patients, adjusting for timing of antiviral treatment and time from illness onset to hospitalization. Results Influenza vaccination was associated with a reduction in the odds of in-hospital death among patients aged 18-49 years (adjusted odds ratios [aOR] = 0.21; 95% confidence interval [CI], 0.05 to 0.97), 50-64 years (aOR = 0.48; 95% CI, 0.24 to 0.97), and ≥65 years (aOR = 0.39; 95% CI, 0.17 to 0.66). Vaccination also reduced ICU admission among patients aged 18-49 years (aOR = 0.63; 95% CI, 0.42 to 0.93) and ≥65 years (aOR = 0.63; 95% CI, 0.48 to 0.81), and shortened ICU LOS among those 50-64 years (adjusted relative hazards [aRH] = 1.36; 95% CI, 1.06 to 1.74) and ≥65 years (aRH = 1.34; 95% CI, 1.06 to 1.73), and hospital LOS among 50-64 years (aRH = 1.13; 95% CI, 1.02 to 1.26) and ≥65 years (aRH = 1.24; 95% CI, 1.13 to 1.37). Conclusions Influenza vaccination during 2013-14 influenza season attenuated adverse outcome among adults that were hospitalized with laboratory-confirmed influenza.

Background In 2012, >48000 pertussis cases were reported in the United States. Many cases occurred in vaccinated persons, showing that pertussis vaccination does not prevent all pertussis cases. However, pertussis vaccination may have an impact on disease severity. Methods We analyzed data on probable and confirmed pertussis cases reported through Enhanced Pertussis Surveillance (Emerging Infections Program Network) between 2010 and 2012. Surveillance data were collected through physician and patient interview and vaccine registries. We assessed whether having received an age-appropriate number of pertussis vaccines (AAV) (for persons aged ≥3 months) was associated with reduced odds of posttussive vomiting, a marker of more clinically significant illness, or of severe pertussis (seizure, encephalopathy, pneumonia, and/or hospitalization). Adjusted odds ratios were calculated using multivariable logistic regression. Results Among 9801 pertussis patients aged ≥3 months, 77.6% were AAV. AAV status was associated with a 60% reduction in odds of severe disease in children aged 7 months-6 years in multivariable logistic regression and a 30% reduction in odds of posttussive vomiting in persons aged 19 months-64 years. Conclusions Serious pertussis symptoms and complications are less common among AAV pertussis patients, demonstrating that the positive impact of pertussis vaccination extends beyond decreasing risk of disease.

ObjectivesExternal validity, or generalisability, is the measure of how well results from a study pertain to individuals in the target population. We assessed generalisability, with respect to socioeconomic status, of estimates from a matched case–control study of 13-valent pneumococcal conjugate vaccine effectiveness for the prevention of invasive pneumococcal disease in children in the USA.DesignMatched case–control study.SettingThirteen active surveillance sites for invasive pneumococcal disease in the USA.ParticipantsCases were identified from active surveillance and controls were age and zip code matched.Outcome measuresSocioeconomic status was assessed at the individual level via parent interview (for enrolled individuals only) and birth certificate data (for both enrolled and unenrolled individuals) and at the neighbourhood level by geocoding to the census tract (for both enrolled and unenrolled individuals). Prediction models were used to determine if socioeconomic status was associated with enrolment.ResultsWe enrolled 54.6% of 1211 eligible cases and found a trend toward enrolled cases being more affluent than unenrolled cases. Enrolled cases were slightly more likely to have private insurance at birth (p=0.08) and have mothers with at least some college education (pConclusionsWe conclude that although enrolled cases are somewhat more affluent than unenrolled cases, our estimates are externally valid with respect to socioeconomic status. Our analysis provides evidence that this study design can yield valid estimates and the assessing generalisability of observational data is feasible, even when unenrolled individuals cannot be contacted.

Context In 2011, the Food Safety and Modernization Act established Integrated Food Safety Centers of Excellence across the United States to train, educate, and enhance the skill of foodborne illness outbreak investigation teams. To target regional training efforts, the New York Integrated Food Safety Center of Excellence (NYCoE) identified training needs in food safety and foodborne illness investigations among public heath staff in 11 states and 1 large metropolitan area in the Northeast. Objective To identify topics so as to develop training materials relevant to food safety and foodborne disease outbreaks in order to improve and impact foodborne outbreak investigations regionally and nationally. Design Cross-sectional, paper-based survey conducted in January-February 2016. Setting Eleven Northeast and Mid-Atlantic states, and 1 large metropolitan area. Participants Foodborne illness outbreak investigators in the NYCoE region. Main outcome measures Identification of training needs, as self-reported by participants, regarding general foodborne outbreak investigation needs and those specific to epidemiologists, environmental health specialists, and laboratorians. Topics included basic food safety/processing knowledge, communication and metrics, and training formats. Information regarding demographics, utility of the NYCoE, and certificate programs was also collected. Results Surveys returned from 33 respondents (from 10 states and 1 metropolitan area) identified metrics (100%), increasing use of culture-independent diagnostic tests (85%), and guidance on implementation of the Council to Improve Foodborne Outbreak Response (guidelines (89%) as the top training needs. By field, epidemiologists cited training in applying whole genome sequencing (100%), environmental health specialists cited training on the National Outbreak Reporting System (67%), and laboratorians cited training on whole genome sequencing (91%) as important. Short, online, or in-person, 1- to 2-day trainings were the preferred training formats (≥91%). Respondents wanted certificate programs in food safety (73%). Conclusion New diagnostic and molecular techniques are highly desirable topics for trainings, as is understanding national guidelines and outcome measures. Shorter and hands-on training formats, as well as certificate programs, are desirable. The NYCoE used the results of this survey to (i) select training topics for a Food Safety symposium conducted in July 2016 and to (ii) drive other activities.

In 2009, in the Active Bacterial Core surveillance sites, penicillin was not commonly used to treat meningococcal disease. This is likely because of inconsistent availability of antimicrobial susceptibility testing and ease of use of third-generation cephalosporins. Consideration of current practices may inform future meningococcal disease management guidelines.

Background In February 2010, PCV13 was introduced for routine use among children aged < 5 years. In June 2012, PCV13 was recommended for use in series with 23-valent polysaccharide vaccine (PPSV23) for adults ≥19 years with select medical conditions, and in August 2014, for all adults ≥65 years. We evaluated the direct and indirect effects of PCV13 6 years post-introduction on invasive pneumococcal disease (IPD). Methods IPD cases (isolation of pneumococcus from sterile sites) were identified among residents of Active Bacterial Core surveillance (ABCs) sites during July 2007–June 2016. Isolates were serotyped by Quellung, PCR, or whole genome sequencing and classified as PCV13 or non-vaccine type (NVT). Incidence changes were estimated as percent changes (one minus rate ratio) and 95% confidence intervals (95% CI) between pre-PCV13 (2007–2009) and two post-PCV13 periods (July 2014–June 2015 and July 2015–June 2016). Results ABCs identified 31,190 IPD cases between 2007 and 2015, with 2,750 cases among children Conclusion IPD incidence declined among children and adults in the U.S. following PCV13 introduction among children. The lack of difference in PCV13 rates between 2014–2015 and 2015–2016 suggests no measurable early impact of PCV13 introduction among adults ≥65 years. To date, we found no evidence of significant replacement disease with non-PCV13 types. Further work is needed to explain reductions in non-vaccine type disease observed in the post-PCV13 era. Disclosures W. Schaffner, Pfizer: Scientific Advisor, Consulting fee; Merck: Scientific Advisor, Consulting fee; Novavax: Consultant, Consulting fee; Dynavax: Consultant, Consulting fee; Sanofi-pasteur: Consultant, Consulting fee; GSK: Consultant, Consulting fee; Seqirus: Consultant, Consulting fee; L. Harrison, GSK: Scientific Advisor, Consulting fee

BACKGROUND Older adults are at increased risk of influenza-associated complications, including hospitalization, but influenza vaccine effectiveness (VE) data are limited for this population. We conducted a case-control study to estimate VE to prevent laboratory-confirmed influenza hospitalizations among adults aged ≥50 years in 11 US Emerging Infections Program hospitalization surveillance sites. METHODS Cases were influenza infections (confirmed by reverse-transcription polymerase chain reaction) in adults aged ≥50 years hospitalized during the 2010-2011 influenza season, identified through Emerging Infections Program surveillance. Community controls, identified through home telephone lists, were matched by age group (±5 years), county, and month of hospitalization for case patients. Vaccination status was determined by self-report (with location and date) or medical records. Conditional logistic regression models were used to calculate adjusted VE (aVE) estimates (100 × [1 - adjusted odds ratio]), adjusting for sex, race, socioeconomic factors, smoking, chronic medical conditions, recent hospitalization for a respiratory condition, and functional status. RESULTS Among case patients, 205 of 368 (55%) were vaccinated, compared with 489 of 773 controls (63%). Case patients were more likely to be of nonwhite race and more likely to have ≥2 chronic health conditions, a recent hospitalization for a respiratory condition, an income

Summary Background In 2010, 13-valent pneumococcal conjugate vaccine (PCV13) was licensed and recommended in the USA for prevention of invasive pneumococcal disease in children. Licensure was based on immunogenicity data comparing PCV13 with the earlier seven-valent formulation. Because clinical endpoints were not assessed for the new antigens, we did a postlicensure matched case-control study to assess vaccine effectiveness. Methods Cases in children aged 2–59 months were identified through active surveillance in 13 sites. Controls were identified via birth registries and matched to cases by age and postal (zip) code. The primary objective was the vaccine effectiveness of at least one dose against the 13 serotypes included in PCV13. Secondary objectives included vaccine effectiveness against all-cause invasive pneumococcal disease, against antibiotic non-susceptible invasive pneumococcal disease, and among children with and without underlying conditions. Vaccine effectiveness was calculated as (1 – matched odds ratio) × 100%. Findings We enrolled 722 children with invasive pneumococcal disease and 2991 controls; PCV13 serotype cases (217 [30%]) included most commonly serotypes 19A (128 [18%]), 7F (32 [4%]), and 3 (43 [6%]). Vaccine effectiveness against PCV13 serotypes was 86·0% (95% CI 75·5 to 92·3), driven by serotypes 19A and 7F, for which vaccine effectiveness was 85·6% (95% CI 70·6 to 93·5) and 96·5% (82·7 to 100), respectively. We also identified statistically significant effectiveness against serotype 3 (79·5%, 95% CI 30·3 to 94·8) and against antibiotic non-susceptible invasive pneumococcal disease (65·6%, 44·9 to 78·7). Vaccine effectiveness against all-cause invasive pneumococcal disease was 60·2% (95% CI 46·8 to 70·3). Vaccine effectiveness was similar among children with (81·4%, 95% CI 45·4 to 93·6) and without (85·8%, 74·9 to 91·9) underlying conditions. Interpretation PCV13 appears highly effective against invasive pneumococcal disease among children in the USA in the context of routine and catch-up schedules, although some new vaccine antigens could not be assessed. PCV13 immunisation provides a robust strategy for combating pneumococcal antimicrobial resistance. Funding Centers for Disease Control and Prevention.

During 2000–2011, passive surveillance for legionellosis in the United States demonstrated a 249% increase in crude incidence, although little was known about the clinical course and method of diagnosis. In 2011, a system of active, population-based surveillance for legionellosis was instituted through CDC’s Active Bacterial Core surveillance (ABCs) program. Overall disease rates were similar in both the passive and active systems, but more complete demographic information and additional clinical and laboratory data were only available from ABCs. ABCs data during 2011–2013 showed that approximately 44% of patients with legionellosis required intensive care, and 9% died. Disease incidence was higher among blacks than whites and was 10 times higher in New York than California. Laboratory data indicated a reliance on urinary antigen testing, which only detects Legionella pneumophila serogroup 1 (Lp1). ABCs data highlight the severity of the disease, the need to better understand racial and regional differences, and the need for better diagnostic testing to detect infections.

Background. Some studies suggest that influenza vaccination might be protective against severe influenza outcomes in vaccinated persons who become infected. We used data from a large surveillance network to further investigate the effect of influenza vaccination on influenza severity in adults aged ≥50 years who were hospitalized with laboratory-confirmed influenza. Methods. We analyzed influenza vaccination and influenza severity using Influenza Hospitalization Surveillance Network (FluSurv-NET) data for the 2012−2013 influenza season. Intensive care unit (ICU) admission, death, diagnosis of pneumonia, and hospital and ICU lengths of stay served as measures of disease severity. Data were analyzed by multivariable logistic regression, parametric survival models, and propensity score matching (PSM). Results. Overall, no differences in severity were observed in the multivariable logistic regression model. Using PSM, adults aged 50−64 years (but not other age groups) who were vaccinated against influenza had a shorter length of ICU stay than those who were unvaccinated (hazard ratio for discharge, 1.84; 95% confidence interval, 1.12−3.01). Conclusions. Our findings show a modest effect of influenza vaccination on disease severity. Analysis of data from seasons with different predominant strains and higher estimates of vaccine effectiveness are needed.

Background Influenza and pneumonia combined are the leading causes of death due to infectious diseases in the United States. We describe factors associated with pneumonia among adults hospitalized with influenza. Methods Through the Emerging Infections Program, we identified adults ≥ 18 years, who were hospitalized with laboratory-confirmed influenza during October 2005 through April 2008, and had a chest radiograph (CXR) performed. Pneumonia was defined as the presence of a CXR infiltrate and either an ICD-9-CM code or discharge summary diagnosis of pneumonia. Results Among 4,765 adults hospitalized with influenza, 1392 (29 %) had pneumonia. In multivariable analysis, factors associated with pneumonia included: age ≥ 75 years, adjusted odds ratio (AOR) 1.27 (95 % confidence interval 1.10–1.46), white race AOR 1.24 (1.03–1.49), nursing home residence AOR 1.37 (1.14–1.66), chronic lung disease AOR 1.37 (1.18–1.59), immunosuppression AOR 1.45 (1.19–1.78), and asthma AOR 0.76 (0.62–0.92). Patients with pneumonia were significantly more likely to require intensive care unit (ICU) admission (27 % vs. 10 %), mechanical ventilation (18 % vs. 5 %), and to die (9 % vs. 2 %). Conclusions Pneumonia was present in nearly one-third of adults hospitalized with influenza and was associated with ICU admission and death. Among patients hospitalized with influenza, older patients and those with certain underlying conditions are more likely to have pneumonia. Pneumonia is common among adults hospitalized with influenza and should be evaluated and treated promptly. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1004-y) contains supplementary material, which is available to authorized users.

Background Influenza results in an estimated 12,000–56,000 deaths annually in the USA. While in-hospital deaths are well characterized, less is known about deaths that occur after discharge among those hospitalized with influenza. Methods We identified patients hospitalized with laboratory-confirmed influenza who died during hospitalization or within 30 days after discharge during the 2014–2015 influenza season for 11 Influenza Hospitalization Surveillance Network sites. We matched cases to the National Center for Health Statistics Electronic Death Registration System and abstracted cause and location of death from death certificates. We compared clinical characteristics between those who died during hospitalization and those who died after hospital discharge using χ2 tests. Results Among 795 patients with laboratory-confirmed influenza who died, 370 (47%) died during hospitalization, and 425 (53%) died within 30 days after discharge. Eighteen (2%) were 0–17 years and 652 (82%) were ≥65 years. Common causes of death listed in any position on the death certificate included influenza (35%), other respiratory causes (50%), cardiovascular disease (37%), and sepsis (15%). Among those who died after discharge, 207 (49%) died within 7 days, 86 (20%) within 8–14 days, and 132 (31%) within 15–30 days post discharge. Patients who died after discharge were more likely to be ≥65 years (88 vs. 74%) or admitted from a nursing home (48 vs. 36%), but were less likely to be admitted to an intensive care unit (30 vs. 68%) or receive a pneumonia diagnosis (46 vs. 62%) than patients who died during hospitalization (all P Conclusion Over half of deaths among patients hospitalized with laboratory-confirmed influenza occurred after discharge. Patients who died after discharge were older and less likely to have influenza listed as a cause of death. Deaths that occur after an influenza-related hospitalization represent an important and under-characterized contribution to the burden of seasonal influenza. Disclosures E. J. Anderson, AbbVie: Consultant, Consulting fee; NovaVax: Research Contractor, Research support; Regeneron: Research Contractor, Research grant; MedImmune: Research Contractor, Research grant and Research support. W. Schaffner, Pfizer: Scientific Advisor, Consulting fee; Merck: Scientific Advisor, Consulting fee; Novavax: Consultant, Consulting fee; Dynavax: Consultant, Consulting fee; Sanofi-pasteur: Consultant, Consulting fee; GSK: Consultant, Consulting fee; Seqirus: Consultant, Consulting fee