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During November 19-21, 2021, an indoor convention (event) in New York City (NYC), was attended by approximately 53,000 persons from 52 U.S. jurisdictions and 30 foreign countries. In-person registration for the event began on November 18, 2021. The venue was equipped with high efficiency particulate air (HEPA) filtration, and attendees were required to wear a mask indoors and have documented receipt of at least 1 dose of a COVID-19 vaccine.* On December 2, 2021, the Minnesota Department of Health reported the first case of community-acquired COVID-19 in the United States caused by the SARS-CoV-2 B.1.1.529 (Omicron) variant in a person who had attended the event (1). CDC collaborated with state and local health departments to assess event-associated COVID-19 cases and potential exposures among U.S.-based attendees using data from COVID-19 surveillance systems and an anonymous online attendee survey. Among 34,541 attendees with available contact information, surveillance data identified test results for 4,560, including 119 (2.6%) persons from 16 jurisdictions with positive SARS-CoV-2 test results. Most (4,041 [95.2%]), survey respondents reported always wearing a mask while indoors at the event. Compared with test-negative respondents, test-positive respondents were more likely to report attending bars, karaoke, or nightclubs, and eating or drinking indoors near others for at least 15 minutes. Among 4,560 attendees who received testing, evidence of widespread transmission during the event was not identified. Genomic sequencing of 20 specimens identified the SARS-CoV-2 B.1.617.2 (Delta) variant (AY.25 and AY.103 sublineages) in 15 (75%) cases, and the Omicron variant (BA.1 sublineage) in five (25%) cases. These findings reinforce the importance of implementing multiple, simultaneous prevention measures, such as ensuring up-to-date vaccination, mask use, physical distancing, and improved ventilation in limiting SARS-CoV-2 transmission, during large, indoor events.

By November 30, 2021, approximately 130,781 COVID-19-associated deaths, one in six of all U.S. deaths from COVID-19, had occurred in California and New York.* COVID-19 vaccination protects against infection with SARS-CoV-2 (the virus that causes COVID-19), associated severe illness, and death (1,2); among those who survive, previous SARS-CoV-2 infection also confers protection against severe outcomes in the event of reinfection (3,4). The relative magnitude and duration of infection- and vaccine-derived protection, alone and together, can guide public health planning and epidemic forecasting. To examine the impact of primary COVID-19 vaccination and previous SARS-CoV-2 infection on COVID-19 incidence and hospitalization rates, statewide testing, surveillance, and COVID-19 immunization data from California and New York (which account for 18% of the U.S. population) were analyzed. Four cohorts of adults aged ≥18 years were considered: persons who were 1) unvaccinated with no previous laboratory-confirmed COVID-19 diagnosis, 2) vaccinated (14 days after completion of a primary COVID-19 vaccination series) with no previous COVID-19 diagnosis, 3) unvaccinated with a previous COVID-19 diagnosis, and 4) vaccinated with a previous COVID-19 diagnosis. Age-adjusted hazard rates of incident laboratory-confirmed COVID-19 cases in both states were compared among cohorts, and in California, hospitalizations during May 30-November 20, 2021, were also compared. During the study period, COVID-19 incidence in both states was highest among unvaccinated persons without a previous COVID-19 diagnosis compared with that among the other three groups. During the week beginning May 30, 2021, compared with COVID-19 case rates among unvaccinated persons without a previous COVID-19 diagnosis, COVID-19 case rates were 19.9-fold (California) and 18.4-fold (New York) lower among vaccinated persons without a previous diagnosis; 7.2-fold (California) and 9.9-fold lower (New York) among unvaccinated persons with a previous COVID-19 diagnosis; and 9.6-fold (California) and 8.5-fold lower (New York) among vaccinated persons with a previous COVID-19 diagnosis. During the same period, compared with hospitalization rates among unvaccinated persons without a previous COVID-19 diagnosis, hospitalization rates in California followed a similar pattern. These relationships changed after the SARS-CoV-2 Delta variant became predominant (i.e., accounted for50% of sequenced isolates) in late June and July. By the week beginning October 3, compared with COVID-19 cases rates among unvaccinated persons without a previous COVID-19 diagnosis, case rates among vaccinated persons without a previous COVID-19 diagnosis were 6.2-fold (California) and 4.5-fold (New York) lower; rates were substantially lower among both groups with previous COVID-19 diagnoses, including 29.0-fold (California) and 14.7-fold lower (New York) among unvaccinated persons with a previous diagnosis, and 32.5-fold (California) and 19.8-fold lower (New York) among vaccinated persons with a previous diagnosis of COVID-19. During the same period, compared with hospitalization rates among unvaccinated persons without a previous COVID-19 diagnosis, hospitalization rates in California followed a similar pattern. These results demonstrate that vaccination protects against COVID-19 and related hospitalization, and that surviving a previous infection protects against a reinfection and related hospitalization. Importantly, infection-derived protection was higher after the Delta variant became predominant, a time when vaccine-induced immunity for many persons declined because of immune evasion and immunologic waning (2,5,6). Similar cohort data accounting for booster doses needs to be assessed, as new variants, including Omicron, circulate. Although the epidemiology of COVID-19 might change with the emergence of new variants, vaccination remains the safest strategy to prevent SARS-CoV-2 infections and associated complications; all eligible persons should be up to date with COVID-19 vaccination. Additional recommendations for vaccine doses might be warranted in the future as the virus and immunity levels change.

Background Population-based data from the United States on the effectiveness of the three coronavirus disease 2019 (Covid-19) vaccines currently authorized by the Food and Drug Administration are limited. Whether declines in effectiveness are due to waning immunity, the B.1.617.2 (delta) variant of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), or other causes is unknown. Methods We used data for 8,690,825 adults in New York State to assess the effectiveness of the BNT162b2, mRNA-1273, and Ad26.COV2.S vaccines against laboratory-confirmed Covid-19 and hospitalization with Covid-19 (i.e., Covid-19 diagnosed at or after admission). We compared cohorts defined according to vaccine product received, age, and month of full vaccination with age-specific unvaccinated cohorts by linking statewide testing, hospital, and vaccine registry databases. We assessed vaccine effectiveness against Covid-19 from May 1 through September 3, 2021, and against hospitalization with Covid-19 from May 1 through August 31, 2021. Results There were 150,865 cases of Covid-19 and 14,477 hospitalizations with Covid-19. During the week of May 1, 2021, when the delta variant made up 1.8% of the circulating variants, the median vaccine effectiveness against Covid-19 was 91.3% (range, 84.1 to 97.0) for BNT162b2, 96.9% (range, 93.7 to 98.0) for mRNA-1273, and 86.6% (range, 77.8 to 89.7) for Ad26.COV2.S. Subsequently, effectiveness declined contemporaneously in all cohorts, from a median of 93.4% (range, 77.8 to 98.0) during the week of May 1 to a nadir of 73.5% (range, 13.8 to 90.0) around July 10, when the prevalence of the delta variant was 85.3%. By the week of August 28, when the prevalence of the delta variant was 99.6%, the effectiveness was 74.2% (range, 63.4 to 86.8). Effectiveness against hospitalization with Covid-19 among adults 18 to 64 years of age remained almost exclusively greater than 86%, with no apparent time trend. Effectiveness declined from May through August among persons 65 years of age or older who had received BNT162b2 (from 94.8 to 88.6%) or mRNA-1273 (from 97.1 to 93.7%). The effectiveness of Ad26.COV2.S was lower than that of the other vaccines, with no trend observed over time (range, 80.0 to 90.6%). Conclusions The effectiveness of the three vaccines against Covid-19 declined after the delta variant became predominant. The effectiveness against hospitalization remained high, with modest declines limited to BNT162b2 and mRNA-1273 recipients 65 years of age or older.

In July 2022, a case of paralytic poliomyelitis resulting from infection with vaccine-derived poliovirus (VDPV) type 2 (VDPV2)

Data from randomized clinical trials and real-world observational studies show that all three COVID-19 vaccines currently authorized for emergency use by the Food and Drug Administration* are safe and highly effective for preventing COVID-19-related serious illness, hospitalization, and death (1,2). Studies of vaccine effectiveness (VE) for preventing new infections and hospitalizations attributable to SARS-CoV-2, the virus that causes COVID-19), particularly as the B.1.617.2 (Delta) variant has become predominant, are limited in the United States (3). In this study, the New York State Department of Health linked statewide immunization, laboratory testing, and hospitalization databases for New York to estimate rates of new laboratory-confirmed COVID-19 cases and hospitalizations by vaccination status among adults, as well as corresponding VE for full vaccination in the population, across all three authorized vaccine products. During May 3-July 25, 2021, the overall age-adjusted VE against new COVID-19 cases for all adults declined from 91.7% to 79.8%. During the same period, the overall age-adjusted VE against hospitalization was relatively stable, ranging from 91.9% to 95.3%. Currently authorized vaccines have high effectiveness against COVID-19 hospitalization, but effectiveness against new cases appears to have declined in recent months, coinciding with the Delta variant's increase from2% to80% in the U.S. region that includes New York and relaxation of masking and physical distancing recommendations. To reduce new COVID-19 cases and hospitalizations, these findings support the implementation of a layered approach centered on vaccination, as well as other prevention strategies such as masking and physical distancing.

On July 18, 2022, the New York State Department of Health (NYSDOH) notified CDC of detection of poliovirus type 2 in stool specimens from an unvaccinated immunocompetent young adult from Rockland County, New York, who was experiencing acute flaccid weakness. The patient initially experienced fever, neck stiffness, gastrointestinal symptoms, and limb weakness. The patient was hospitalized with possible acute flaccid myelitis (AFM). Vaccine-derived poliovirus type 2 (VDPV2) was detected in stool specimens obtained on days 11 and 12 after initial symptom onset. To date, related Sabin-like type 2 polioviruses have been detected in wastewater* in the patient's county of residence and in neighboring Orange County up to 25 days before (from samples originally collected for SARS-CoV-2 wastewater monitoring) and 41 days after the patient's symptom onset. The last U.S. case of polio caused by wild poliovirus occurred in 1979, and the World Health Organization Region of the Americas was declared polio-free in 1994. This report describes the second identification of community transmission of poliovirus in the United States since 1979; the previous instance, in 2005, was a type 1 VDPV (1). The occurrence of this case, combined with the identification of poliovirus in wastewater in neighboring Orange County, underscores the importance of maintaining high vaccination coverage to prevent paralytic polio in persons of all ages.

Objective:To describe a pilot project infection prevention and control (IPC) assessment conducted in skilled nursing facilities (SNFs) in New York State (NYS) during a pivotal 2-week period when the region became the nation’s epicenter for coronavirus disease 2019 (COVID-19).Design:A telephone and video assessment of IPC measures in SNFs at high risk or experiencing COVID-19 activity.Participants:SNFs in 14 New York counties, including New York City.Intervention:A 3-component remote IPC assessment: (1) screening tool; (2) telephone IPC checklist; and (3) COVID-19 video IPC assessment (ie, “COVIDeo”).Results:In total, 92 SNFs completed the IPC screening tool and checklist: 52 (57%) were conducted as part COVID-19 investigations, and 40 (43%) were proactive prevention-based assessments. Among the 40 proactive assessments, 14 (35%) identified suspected or confirmed COVID-19 cases. COVIDeo was performed in 26 (28%) of 92 assessments and provided observations that other tools would have missed: personal protective equipment (PPE) that was not easily accessible, redundant, or improperly donned, doffed, or stored and specific challenges implementing IPC in specialty populations. The IPC assessments took ∼1 hour each and reached an estimated 4 times as many SNFs as on-site visits in a similar time frame.Conclusions:Remote IPC assessments by telephone and video were timely and feasible methods of assessing the extent to which IPC interventions had been implemented in a vulnerable setting and to disseminate real-time recommendations. Remote assessments are now being implemented across New York State and in various healthcare facility types. Similar methods have been adapted nationally by the Centers for Disease Control and Prevention.

This database study examines vaccination for COVID-19 among children in New York after the emergence of the Omicron variant, including analysis of case rates and hospitalizations for COVID-19 disease.

A total of 38 long-term care facilities within a region participated in a 3-month quality improvement initiative focused on environmental cleaning and disinfection. Significant improvements in daily and discharge cleaning were observed during the project period. Further study of the sustainability and clinical impact of this type of initiative is warranted.

About 55% of U.S. Candida auris clinical cases were reported from New York and New Jersey from 2016 through 2020. Nearly all New York-New Jersey clinical isolates (99.8%) were fluconazole resistant, and 50% were amphotericin B resistant. Echinocandin resistance increased from 0% to 4% and pan-resistance increased from 0 to C. auris clinical isolates but not for New Jersey, highlighting the regional differences.

ImportanceThere is limited evidence on the effectiveness of the BNT162b2 vaccine for children, particularly those 5-11 years and after the Omicron variant’s emergence.ObjectiveTo estimate BNT162b2 vaccine effectiveness against COVID cases and hospitalizations among children 5-11 years and 12-17 years during December, 2021 and January, 2022.DesignAnalyses of cohorts constructed from linked statewide immunization, laboratory testing, and hospitalization databases.Setting/ParticipantsNew York State children 5-17 years.Main outcomes/measuresNew laboratory-confirmed COVID-19 cases and hospitalizations. Comparisons were made using the incidence rate ratio (IRR), comparing outcomes by vaccination status, and estimated vaccine effectiveness (VE: 1-[1/IRR]).ResultsFrom December 13, 2021 to January 30, 2022, among 852,384 fully-vaccinated children 12-17 years and 365,502 children 5-11 years, VE against cases declined from 66% (95% CI: 64%, 67%) to 51% (95% CI: 48%, 54%) for those 12-17 years and from 68% (95% CI: 63%, 72%) to 12% (95% CI: 6%, 16%) for those 5-11 years. During the January 24-30 week, VE for children 11 years was 11% (95%CI -3%, 23%) and for those age 12 was 67% (95% CI: 62%, 71%). VE against hospitalization declined changed from 85% (95% CI: 63%, 95%) to 73% (95% CI: 53%, 87%) for children 12-17 years, and from 100% (95% CI: -189%, 100%) to 48% (95% CI: -12%, 75%) for those 5-11 years. Among children newly fully-vaccinated December 13, 2021 to January 2, 2022, VE against cases within two weeks of full vaccination for children 12-17 years was 76% (95% CI: 71%, 81%) and by 28-34 days it was 56% (95% CI: 43%, 63%). For children 5-11, VE against cases declined from 65% (95% CI: 62%, 68%) to 12% (95% CI: 8%, 16%) by 28-34 days.Conclusions and RelevanceIn the Omicron era, the effectiveness against cases of BNT162b2 declined rapidly for children, particularly those 5-11 years. However, vaccination of children 5-11 years was protective against severe disease and is recommended. These results highlight the potential need to study alternative vaccine dosing for children and the continued importance layered protections, including mask wearing, to prevent infection and transmission.

BackgroundUS population-based data on COVID-19 vaccine effectiveness (VE) for the 3 currently FDA-authorized products is limited. Whether declines in VE are due to waning immunity, the Delta variant, or other causes, is debated.MethodsWe conducted a prospective study of 8,834,604 New York adults, comparing vaccine cohorts defined by product, age, and month of full-vaccination to age-specific unvaccinated cohorts, by linking statewide testing, hospital, and vaccine registry databases. VE was estimated from May 1, 2021 for incident laboratory-confirmed COVID-19 cases (weekly life-table hazard rates through September 3) and hospitalizations (monthly incidence rates through August 31).Results155,092 COVID-19 cases and 14,862 hospitalizations occurred. Estimated VE for cases declined contemporaneously across age, products, and time-cohorts, from high levels beginning May 1 (1.8% Delta variant prevalence), to a nadir around July 10 (85.3% Delta), with limited changes thereafter (>95% Delta). Decreases were greatest for Pfizer-BioNTech (−24.6%, −19.1%, −14.1% for 18-49, 50-64 years, and ≥65 years, respectively), and similar for Moderna (−18.0%, −11.6%, −9.0%, respectively) and Janssen (−19.2%, −10.8, −10.9%, respectively). VE for hospitalization for adults 18-64 years was >86% across cohorts, without time trend. Among persons ≥65 years, VE declined from May to August for Pfizer-BioNTech (95.0% to 89.2%) and Moderna (97.2% to 94.1%). VE was lower for Janssen, without trend, ranging 85.5%-82.8%.ConclusionsDeclines in VE for cases may have been primarily driven by factors other than waning. VE for hospitalizations remained high, with modest declines limited to Pfizer-BioNTech and Moderna recipients ≥65 years, supporting targeted booster dosing recommendations.

BACKGROUND Candida auris (C. auris), an emerging multi-drug resistant fungus, was first detected in New York State (NYS) in 2016. A person can be colonized with C. auris for months, contributing to environmental surface contamination within healthcare facilities (HCF) and increasing the likelihood of transmission. We describe characteristics of C. auris-colonized individuals (“surveillance cases”) in NYS HCFs to help target infection prevention recommendations. METHODS NYSDOH investigated all individuals with suspected or confirmed C. auris and conducted case finding for colonized individuals in HCFs. Specimens were tested for C. auris by polymerase chain reaction and culture. Surveillance cases had positive C. auris cultures without evidence of clinical infection. Hospital patients and nursing home residents (“facility-based surveillance cases”) were included in the analysis of demographic and clinical data. RESULTS Between 10/5/2016 and 11/7/2017, 114 facility-based surveillance cases were identified. The median age was 74 years (range 23-100 years). Facility-based surveillance cases had a median of three HCF admissions in 90 days before first positive culture (range 0-8). Ninety-three percent were from facilities in Brooklyn or Queens. Fifty-four percent had diabetes. During the week before first positive culture, 81% received mechanical ventilation, 80% had tracheostomy, and 70% had a percutaneous feeding tube. Thirty-four percent had no prior indications for Contact Precautions at time of first positive culture. To date only 9% had serial negative C. auris surveillance cultures. Sixty-two percent were known to be deceased. CONCLUSIONS NYSDOH identified many previously-unrecognized C. auris-colonized individuals in HCFs. They had medical comorbidities requiring invasive care and moved between multiple HCFs before their C. auris identification. HCFs should consider C. auris in their risk assessments and have a high index of suspicion for C. auris colonization among patients who have these characteristics.

Candida auris is a globally emerging yeast that causes outbreaks in health care settings and is often resistant to one or more classes of antifungal medications (1). Cases of C. auris with resistance to all three classes of commonly prescribed antifungal drugs (pan-resistance) have been reported in multiple countries (1). C. auris has been identified in the United States since 2016; the largest number (427 of 911 [47%]) of confirmed clinical cases reported as of October 31, 2019, have been reported in New York, where C. auris was first detected in July 2016 (1,2). As of June 28, 2019, a total of 801 patients with C. auris were identified in New York, based on clinical cultures or swabs of skin or nares obtained to detect asymptomatic colonization (3). Among these patients, three were found to have pan-resistant C. auris that developed after receipt of antifungal medications, including echinocandins, a class of drugs that targets the fungal cell wall. All three patients had multiple comorbidities and no known recent domestic or foreign travel. Although extensive investigations failed to document transmission of pan-resistant isolates from the three patients to other patients or the environment, the emergence of pan-resistance is concerning. The occurrence of these cases underscores the public health importance of surveillance for C. auris, the need for prudent antifungal prescribing, and the importance of conducting susceptibility testing on all clinical isolates, including serial isolates from individual patients, especially those treated with echinocandin medications. This report summarizes investigations related to the three New York patients with pan-resistant infections and the subsequent actions conducted by the New York State Department of Health and hospital and long-term care facility partners.

Since implementation of Standard Precautions* for the prevention of bloodborne pathogen transmission in 1985, health care-associated transmission of human immunodeficiency virus (HIV) in the United States has been rare (1). In October 2017, the New York City Department of Health and Mental Hygiene (NYCDOHMH) and the New York State Department of Health (NYSDOH) were notified by a clinician of a diagnosis of acute HIV infection in a young adult male (patient A) without recognized risk factors (i.e., he was monogamous, had an HIV-negative partner, and had no injection drug use) who had recently been hospitalized for a chronic medical condition. The low risk coupled with the recent hospitalization and medical procedures prompted NYSDOH, NYCDOHMH, and CDC to investigate this case as possible health care-associated transmission of HIV. Among persons with known HIV infection who had hospitalization dates overlapping those of patient A, one person (patient B) had an HIV strain highly similar to patient A's strain by nucleotide sequence analysis. The sequence relatedness, combined with other investigation findings, indicated a likely health care-associated transmission. Nucleotide sequence analysis, which is increasingly used for detecting HIV clusters (i.e., persons with closely related HIV strains) and to inform public health response (2,3), might also be used to identify possible health care-associated transmission of HIV to someone with health care exposure and no known HIV risk factors (4).

Summary Background Transmission of multidrug-resistant Candida auris infection has been reported in the USA. To better understand its emergence and transmission dynamics and to guide clinical and public health responses, we did a molecular epidemiological investigation of C auris cases in the USA. Methods In this molecular epidemiological survey, we used whole-genome sequencing to assess the genetic similarity between isolates collected from patients in ten US states (California, Connecticut, Florida, Illinois, Indiana, Maryland, Massachusetts, New Jersey, New York, and Oklahoma) and those identified in several other countries (Colombia, India, Japan, Pakistan, South Africa, South Korea, and Venezuela). We worked with state health departments, who provided us with isolates for sequencing. These isolates of C auris were collected during the normal course of clinical care (clinical cases) or as part of contact investigations or point prevalence surveys (screening cases). We integrated data from standardised case report forms and contact investigations, including travel history and epidemiological links (ie, patients that had shared a room or ward with a patient with C auris ). Genetic diversity of C auris within a patient, a facility, and a state were evaluated by pairwise differences in single-nucleotide polymorphisms (SNPs). Findings From May 11, 2013, to Aug 31, 2017, isolates that corresponded to 133 cases (73 clinical cases and 60 screening cases) were collected. Of 73 clinical cases, 66 (90%) cases involved isolates related to south Asian isolates, five (7%) cases were related to South American isolates, one (1%) case to African isolates, and one (1%) case to east Asian isolates. Most (60 [82%]) clinical cases were identified in New York and New Jersey; these isolates, although related to south Asian isolates, were genetically distinct. Genomic data corroborated five (7%) clinical cases in which patients probably acquired C auris through health-care exposures abroad. Among clinical and screening cases, the genetic diversity of C auris isolates within a person was similar to that within a facility during an outbreak (median SNP difference three SNPs, range 0–12). Interpretation Isolates of C auris in the USA were genetically related to those from four global regions, suggesting that C auris was introduced into the USA several times. The five travel-related cases are examples of how introductions can occur. Genetic diversity among isolates from the same patients, health-care facilities, and states indicates that there is local and ongoing transmission. Funding US Centers for Disease Control and Prevention

Candida auris is an emerging yeast that causes healthcare-associated infections. It can be misidentified by laboratories and often is resistant to antifungal medications. We describe an outbreak of C. auris infections in healthcare facilities in New York City, New York, USA. The investigation included laboratory surveillance, record reviews, site visits, contact tracing with cultures, and environmental sampling. We identified 51 clinical case-patients and 61 screening case-patients. Epidemiologic links indicated a large, interconnected web of affected healthcare facilities throughout New York City. Of the 51 clinical case-patients, 23 (45%) died within 90 days and isolates were resistant to fluconazole for 50 (98%). Of screening cultures performed for 572 persons (1,136 total cultures), results were C. auris positive for 61 (11%) persons. Environmental cultures were positive for samples from 15 of 20 facilities. Colonization was frequently identified during contact investigations; environmental contamination was also common.

Candida auris is a multidrug-resistant yeast which has emerged in healthcare facilities worldwide, however little is known about identification methods, patient colonization, spread, environmental survival, and drug resistance. Colonization on both biotic and abiotic surfaces, along with travel, appear to be the major factors for the spread of this pathogen across the globe. In this investigation, we present laboratory findings from an ongoing C. auris outbreak in NY from August 2016 through 2018. A total of 540 clinical isolates, 11,035 patient surveillance specimens, and 3,672 environmental surveillance samples were analyzed. Laboratory methods included matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) for yeast isolate identification, real-time PCR for rapid surveillance sample screening, culture on selective/non-selective media for recovery of C. auris and other yeasts from surveillance samples, antifungal susceptibility testing to determine the C. auris resistance profile, and Sanger sequencing of ribosomal genes for C. auris genotyping. Results included: a) identification and confirmation of C. auris in 413 clinical isolates and 931 patient surveillance isolates, as well as identification of 277 clinical cases and 350 colonized cases from 151 healthcare facilities including 59 hospitals, 92 nursing homes, 1 long-term acute care hospital (LTACH), and 2 hospices, b) successful utilization of an in-house developed C. auris real-time PCR assay for the rapid screening of patient and environmental surveillance samples, c) demonstration of relatively heavier colonization of C. auris in nares compared to the axilla/groin, and d) predominance of the South Asia Clade I with intrinsic resistance to fluconazole and elevated minimum inhibitory concentration (MIC) to voriconazole (81%), amphotericin B (61%), 5-FC (3%) and echinocandins (1%). These findings reflect greater regional prevalence and incidence of C. auris and the deployment of better detection tools in an unprecedented outbreak.

BACKGROUND During 2009 and 2010, 2 clusters of organ transplant-transmitted Balamuthia mandrillaris, a free-living ameba, were detected by recognition of severe unexpected illness in multiple recipients from the same donor. METHODS We investigated all recipients and the 2 donors through interview, medical record review, and testing of available specimens retrospectively. Surviving recipients were tested and treated prospectively. RESULTS In the 2009 cluster of illness, 2 kidney recipients were infected and 1 died. The donor had Balamuthia encephalitis confirmed on autopsy. In the 2010 cluster, the liver and kidney-pancreas recipients developed Balamuthia encephalitis and died. The donor had a clinical syndrome consistent with Balamuthia infection and serologic evidence of infection. In both clusters, the 2 asymptomatic recipients were treated expectantly and survived; 1 asymptomatic recipient in each cluster had serologic evidence of exposure that decreased over time. Both donors had been presumptively diagnosed with other neurologic diseases prior to organ procurement. CONCLUSIONS Balamuthia can be transmitted through organ transplantation with an observed incubation time of 17-24 days. Clinicians should be aware of Balamuthia as a cause of encephalitis with high rate of fatality, and should notify public health departments and evaluate transplant recipients from donors with signs of possible encephalitis to facilitate early diagnosis and targeted treatment. Organ procurement organizations and transplant centers should be aware of the potential for Balamuthia infection in donors with possible encephalitis and also assess donors carefully for signs of neurologic infection that may have been misdiagnosed as stroke or as noninfectious forms of encephalitis.

Unsafe practices are an underestimated contributor to the disease burden of bloodborne viruses. Outbreaks associated with failures in basic infection prevention have been identified in nonhospital settings with increased frequency in the United States during the past 15 years, representing an alarming trend and indicating that the challenge of providing consistently safe care is not always met. As has been the case with most medical specialties, public health investigations by state and local health departments, and the Centers for Disease Control and Prevention, have identified some instances of unsafe practices that have placed podiatric medical patients at risk for viral, bacterial, and fungal infections. All health-care providers, including podiatric physicians, must make infection prevention a priority in any setting in which care is delivered.

Background Candida auris is an emerging multidrug-resistant yeast which can spread within healthcare facilities and is associated with significant morbidity. Over 160 clinical cases have been reported in NYS. This pilot aims to assess the feasibility of C. auris admission screening and to better understand its role in controlling spread of C. auris in an area where it has emerged. Methods One hospital and two nursing homes (NHs) with known prior cases participated (one NH and hospital are closely associated and are reported together). Patients were screened on admission to any of three hospital intensive care units (medical, cardiac, pulmonary) or to a ventilator unit in the NHs from November 2017 to April 2018. Screening consisted of bilateral nares and axilla/groin swabs sent to the NYS Department of Health Wadsworth Center (WC) for a WC-developed C. auris real-time polymerase chain reaction (rt-PCR) test. Specimens with detection of C. auris on rt-PCR underwent fungal culture. Facilities were alerted of positive results and infection control precautions were promptly initiated. Results To date, 575 patients (1,371 samples) were screened. Of patients not previously known to be colonized, 39 had C. auris detected on rt-PCR; 34 confirmed by C. auris culture at either site and one culture pending. Of these, 30 (88%) were detected and confirmed from the axilla/groin specimen (Figure 1). Mean age was 76 years and 59% were females. Patients had significant healthcare facility exposure (Figure 2). Eleven (32%) were from NH-A and 23 (68%) from the hospital/NH-B combined. Rates of positivity were 16.2% (11/68) for NH-A and 4.6% (23/498) for the hospital/NH-B. Conclusion C. auris rt-PCR is a useful tool within an admission screening program; however, more accessible and affordable rapid laboratory diagnostics are urgently needed. The axilla/groin site detected the majority of colonized individuals. Admission screening was feasible and increased facility knowledge of colonization status, which led to earlier implementation of infection control precautions potentially limiting spread. However, further study is needed to assess transmission dynamics and potential impact of admission screening on control of C. auris within an outbreak or endemic setting. Figure 1. Figure 2. Disclosures All authors: No reported disclosures.

Background New York State (NYS) is experiencing a continuing outbreak of Candida auris, first identified in 2016. Patients who are colonized asymptomatically with C. auris can progress to bloodstream infection (BSI). Methods Colonized patients with positive nares or axilla/groin C. auris cultures were followed prospectively. Laboratories, hospitals and skilled nursing facilities reported C. auris clinical infections to the NYS Department of Health. Patient demographics, clinical history, hospital admission, procedures, and outcomes data were obtained using a standardized case report form. Patient-days were determined from date of first positive colonization to date of first positive clinical isolate, death, or March 30, 2018, whichever was first. Results Between September 28, 2016 and March 30, 2018, 187 C. auris colonized patients were identified. Of these, seven progressed to BSI during at least 24,781 patient days of follow-up (median: 98 patient-days, range 0–548 days.) The median time from date of first colonization to date of BSI was 86 days (range 3–310 days). The median patient age at time of colonization was 71 years (range 57–89 years). Between colonization and BSI, patients had a median of five admissions in healthcare facilities (range 1–12). All patients had central neurologic disease, gastrostomy tubes, chronic wounds, and vascular lines at time of BSI. All patients had a positive culture for one or more other multi-drug resistant organism within 90 days of a positive C. auris culture, and all received antibiotics in the 30 days before BSI. Six (86%) patients received mechanical ventilation and had tracheostomies. Five (71%) patients had diabetes. Four (57%) had vascular lines replaced in the 30 days before BSI onset. Two (29%) cases had gastrostomy tube replacement between colonization and BSI. One patient died a week after C. auris BSI; a second died 4 months later. Conclusion In NYS, 4% of C. auris colonized patients developed BSI, a rate of 0.3 BSI per 1,000 patient-days. BSI patients have portals of entry such as indwelling medical devices and wounds. Neurologic disease and diabetes may be risk factors for BSI. Meticulous aseptic technique for invasive procedures, device and wound care may help prevent C. auris BSI in colonized patients. Disclosures All authors: No reported disclosures.

Background New York State Department of Health (NYSDOH) and Wadsworth Center (WC) participate in the Centers for Disease Control and Prevention’s Antibiotic Resistance Laboratory Network (AR Lab Network), including identification and characterization of specific bla genes in carbapenemase-producing organisms (CPO). Three investigations from November 2018–March 2019 illustrate the findings and challenges investigating CPO in a blaKPC endemic setting. Methods NYSDOH WC testing includes organism identification, drug susceptibility testing, detection of carbapenemase production, detection of carbapenemase genes, and whole-genome sequencing (WGS). NYSDOH epidemiologic (epi) investigations of novel resistance mechanisms review demographic and exposure data, conduct contact tracing with targeted rectal screening to identify colonized persons, and assess infection control (IC) and public health (PH) practices and provide recommendations. Results NYSDOH identified three nursing home residents infected with CPO with novel carbapenemase genes (Figure 1) with no travel history but multiple co-morbidities, including mechanical ventilation: blaOXA-48Klebsiella pneumoniae (KP) (Facility A), blaNDM KP (Facility B and C). Epi investigations identified CPO in 48 of 106 residents screened for rectal colonization; most isolates had genes other than the index gene. Facility A and Facility B each had no additional residents colonized with CPO with the index gene after screening; 14 and 10 residents, respectively from Facility A and B, had CPO with endemic blaKPC gene. WGS analysis identified 2 clusters of blaKPC KP within Facility A and no clusters of CPO were detected in Facility B. IC/PH recommendations were made after diagnosis at all 3 facilities; serial IC/PH assessments/recommendations and screening were needed to interrupt transmission at Facility C, where 24 residents were colonized with CPO, including 7 residents with CPO with the index gene (blaNDM), and a subset of the blaNDM isolates were related to the index case by both epi and WGS analysis. Conclusion Epi investigation and WGS were complementary to detect transmission, identify clusters within an endemic setting, and inform PH response and IC measures for these emerging CPO in NY Healthcare Facilities. Disclosures All authors: No reported disclosures.

Surveillance criteria for central line-associated bloodstream infections (CLABSIs) are continually being refined to more accurately reflect infections related to central lines. An audit of 567 medical records from adult, pediatric, and neonatal intensive care unit patients with a central line and a positive blood culture showed a 16% decrease in CLABSI rates after the 2013 National Healthcare Safety Network definitions compared with the 2012 definitions.

Objective.To assess the effect of multiple sources of bias on state- and hospital-specific National Healthcare Safety Network (NHSN) laboratory-identified Clostridium difficile infection (CDI) rates.Design.Sensitivity analysis.Setting.A total of 124 New York hospitals in 2010.Methods.New York NHSN CDI events from audited hospitals were matched to New York hospital discharge billing records to obtain additional information on patient age, length of stay, and previous hospital discharges. “Corrected” hospital-onset (HO) CDI rates were calculated after (1) correcting inaccurate case reporting found during audits, (2) incorporating knowledge of laboratory results from outside hospitals, (3) excluding days when patients were not at risk from the denominator of the rates, and (4) adjusting for patient age. Data sets were simulated with each of these sources of bias reintroduced individually and combined. The simulated rates were compared with the corrected rates. Performance (ie, better, worse, or average compared with the state average) was categorized, and misclassification compared with the corrected data set was measured.Results.Counting days patients were not at risk in the denominator reduced the state HO rate by 45% and resulted in 8% misclassification. Age adjustment and reporting errors also shifted rates (7% and 6% misclassification, respectively).Conclusions.Changing the NHSN protocol to require reporting of age-stratified patient-days and adjusting for patient-days at risk would improve comparability of rates across hospitals. Further research is needed to validate the risk-adjustment model before these data should be used as hospital performance measures.

Rubella was declared eliminated in the United States in 2004. During 2013-2015, 2 infants with congenital rubella syndrome (CRS) were born in New York State. Both mothers were foreign born and traveled to Yemen during their pregnancy. Delayed consideration of CRS led to preventable exposures and a substantial public health response.

An outbreak of typhoid fever in rural Malawi triggered an investigation by the Malawi Ministry of Health and the Centers for Disease Control and Prevention in July 2009. During the investigation, villagers were directly consuming washed, donated, pesticide-treated wheat seed meant for planting. The objective of this study was to evaluate the potential for pesticide exposure and health risk in the outbreak community. A sample of unwashed (1430 g) and washed (759 g) wheat seed donated for planting, but which would have been directly consumed, was tested for 365 pesticides. Results were compared with each other (percentage change), the US Environmental Protection Agency's (EPA) health guidance values and estimated daily exposures were compared with their Reference dose (RfD). Unwashed and washed seed samples contained, respectively: carboxin, 244 and 57 p.p.m.; pirimiphos methyl, 8.18 and 8.56 p.p.m.; total permethrin, 3.62 and 3.27 p.p.m.; and carbaryl, 0.057 and 0.025 p.p.m.. Percentage change calculations (unwashed to washed) were as follows: carboxin, -76.6%; pirimiphos methyl, +4.6%; total permethrin, -9.7%; and carbaryl -56.1%. Only carboxin and total permethrin concentration among washed seed samples exceeded US EPA health guidance values (285 × and seven times, respectively). Adult estimated exposure scenarios (1 kg seed) exceeded the RfD for carboxin (8 × ) and pirimiphos methyl (12 × ). Adult villagers weighing 70 kg would have to consume 0.123, 0.082, 1.06, and 280 kg of washed seed daily to exceed the RfD for carboxin, pirimiphos methyl, permethrins, and carbaryl, respectively. Carboxin, pirimiphos methyl, permethrins, and carbaryl were detected in both unwashed and washed samples of seed. Carboxin, total permethrin, and carbaryl concentration were partially reduced by washing. Health risks from chronic exposure to carboxin and pirimiphos methyl in these amounts are unclear. The extent of this practice among food insecure communities receiving relief seeds and resultant health impact needs further study.

Background Salmonella enterica serovar Typhi causes an estimated 22 million cases of typhoid fever and 216 000 deaths annually worldwide. We investigated an outbreak of unexplained febrile illnesses with neurologic findings, determined to be typhoid fever, along the Malawi-Mozambique border. Methods The investigation included active surveillance, interviews, examinations of ill and convalescent persons, medical chart reviews, and laboratory testing. Classification as a suspected case required fever and ≥1 other finding (eg, headache or abdominal pain); a probable case required fever and a positive rapid immunoglobulin M antibody test for typhoid (TUBEX TF); a confirmed case required isolation of Salmonella Typhi from blood or stool. Isolates underwent antimicrobial susceptibility testing and subtyping by pulsed-field gel electrophoresis (PFGE). Results We identified 303 cases from 18 villages with onset during March-November 2009; 214 were suspected, 43 were probable, and 46 were confirmed cases. Forty patients presented with focal neurologic abnormalities, including a constellation of upper motor neuron signs (n = 19), ataxia (n = 22), and parkinsonism (n = 8). Eleven patients died. All 42 isolates tested were resistant to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole; 4 were also resistant to nalidixic acid. Thirty-five of 42 isolates were indistinguishable by PFGE. Conclusions The unusual neurologic manifestations posed a diagnostic challenge that was resolved through rapid typhoid antibody testing in the field and subsequent blood culture confirmation in the Malawi national reference laboratory. Extending laboratory diagnostic capacity, including blood culture, to populations at risk for typhoid fever in Africa will improve outbreak detection, response, and clinical treatment.

Background Candida auris is an often multidrug-resistant yeast that causes invasive infections and, unlike most Candida species, spreads in healthcare facilities. CDC released a clinical alert in June 2016 requesting reporting of C. auris cases. We investigated cases to contain transmission and inform prevention measures for this novel organism. Methods Clinical cases were defined as C. auris from any clinical specimen from a patient in the United States. Response to cases included implementation of infection control measures, enhanced cleaning and disinfection, and testing of close contacts for C. auris colonisation (isolation from a person’s axilla or groin was defined as a screening case). Microbiology records were reviewed at reporting facilities for missed cases. All isolates were forwarded to CDC for confirmation, antifungal susceptibility testing, and whole-genome sequencing (WGS). Results As of April 13, 2017, 61 clinical cases of C. auris were reported from six states: New York (39), New Jersey (15), Illinois (4), Indiana (1), Maryland (1), and Massachusetts (1). All but two occurred since 2016 (Figure). An additional 32 screening cases were identified among contacts. Median age of clinical case-patients was 70 years (range 21–96); 56% were male. Nearly, all had underlying medical conditions and extensive exposure to healthcare facilities before infection. Most clinical isolates were from blood (38, 62%), followed by urine (8, 13%) and respiratory tract (5, 8%). Among the first 35 isolates, 30 (86%) were resistant to fluconazole, 15 (43%) to amphotericin B, and one (3%) to caspofungin. No isolate was resistant to all three. WGS revealed isolates from each state were highly related and different from other states, suggestive of transmission. Microbiology record reviews did not identify additional cases before 2016. Conclusion C. auris is an emerging pathogen, with similarities to multidrug-resistant bacteria, that has been transmitted in US healthcare settings. CDC and public health partners are committed to prompt and aggressive action through investigation of cases and heightened infection control practices to halt its spread. Disclosures All authors: No reported disclosures.

Background As of March 25 2018, 151 clinical cases of C. auris were diagnosed in NYS. We conducted point prevalence surveys (PPS) and environmental surveys (ES) to detect surveillance cases and assess the burden of environmental contamination in NYS healthcare facilities from September 12, 2016. Methods A PPS was defined as culturing ≥2 individuals at a healthcare facility that diagnosed, cared for, or was near a facility with a C. auris case. ES involved environmental swabbing in facilities where cases resided or were admitted. Cultures and polymerase chain reaction (PCR) were performed at the NYS Wadsworth Center. Results As of March 25, 2018, 81 PPS or ES had been conducted at 55 facilities. From these PPS, a total of 144 (6.1%) individuals were positive for C. auris by culture; 125 were PCR positive. The rates of culture positive C. auris identified patients varied by facility type: hospitals (38/767, 5.0%), long-term care facilities (LTCF) (88/1,404, 6.3%), long-term acute care (1/35, 2.9%), and co-located hospital and LTCF (17/138, 12.3%). The majority of the LTCF C. auris culture-positive cases (80/82) were identified in facilities that cared for ventilated patients. Rates in LTCF caring for ventilated patients were nearly 10 times as high as other LTCF [86/1,121 (7.7%) vs. 2/284 (0.7%)]. ES identified 86 (3.0%) samples positive by culture and 257 (8.9%) by PCR. Thirty-seven (67%) of the 55 facilities had at least one positive environmental sample by PCR or culture; many of these positive samples were from surfaces or equipment deemed to be “clean.” Over 1,900 person-hours were needed to conduct onsite PPS and ES that collected >4,200 human and >2,800 environmental samples and identified opportunities for improving basic infection prevention and environmental cleaning. Ten facilities, including the co-located hospital and LTCF, had multiple positive PPS or ES. Conclusion PPS conducted over 17 months detected many colonized individuals and C. auris in facility environments, likely indicating a silent reservoir for this organism beyond clinical cases, especially in LTCFs. Serial PPS and ES can help improve C. auris detection and inform subsequent infection prevention and control interventions. However, these efforts are resource intensive and can divert resources from other activities. Disclosures All authors: No reported disclosures.

A patient with no risk factors for malaria was hospitalized in New York City with Plasmodium falciparum infection. After investigating all potential sources of infection, we concluded the patient had been exposed to malaria while hospitalized less than 3 weeks earlier. Molecular genotyping implicated patient-to-patient transmission in a hospital setting.Infect. Control Hosp. Epidemiol. 2015;37(1):113–115

Background Carbapenem-resistant Enterobacteriaceae (CRE) are an urgent concern in health care in the United States because of high attributable mortality and versatile resistance mechanisms. CRE reporting was mandated in New York State (NYS) hospitals in July 2013. Methods Infection preventionists from the NYS Department of Health audited hospital-reported CRE data by comparing laboratory records with cases reported to the National Healthcare Safety Network (NHSN). Information regarding microbiology laboratory testing methodologies was obtained through a survey in October 2013. Results There were 1,151 CRE laboratory reports audited, with 13.6% determined not to have been reported to the NHSN when they should have been and 4.6% determined to be reported in error. There were a variety of errors, including lapses in surveillance and misinterpretation of the surveillance definition. Conclusion Educational initiatives that include microbiology laboratory staff, improvements in the use of laboratory information systems to communicate with infection prevention, and updated NHSN definitions should improve the accuracy and consistency of CRE reporting in NYS.

Unsafe practices are an underestimated contributor to the disease burden of bloodborne viruses. Outbreaks associated with failures in basic infection prevention have been identified in nonhospital settings with increased frequency in the United States during the past 15 years, representing an alarming trend and indicating that the challenge of providing consistently safe care is not always met. As has been the case with most medical specialties, there have been public health investigations by state and local health departments, and the Centers for Disease Control and Prevention have identified some instances of unsafe practices that have placed podiatric medical patients at risk for viral, bacterial, and fungal infections. All health-care providers, including podiatric physicians, must make infection prevention a priority in any setting in which care is delivered.

On December 23, 2014, the New York State Department of Health (NYSDOH) was notified of adverse health events in two patients who had been inadvertently administered nonsterile, simulation 0.9% sodium chloride intravenous (IV) fluids at an urgent care facility. Simulation saline is a nonsterile product not meant for human or animal use; it is intended for use by medical trainees practicing IV administration of saline on mannequins or other training devices. Both patients experienced a febrile illness during product administration and were hospitalized; one patient developed sepsis and disseminated intravascular coagulation. Neither patient died. Staff members at the clinic reported having ordered the product through their normal medical supply distributor and not recognizing during administration that it was not intended for human use.

Background Candida auris, an emerging yeast, has been detected in New York State (NYS). C. auris is often resistant to antifungal medications and has caused healthcare-associated outbreaks. We describe the emergence and spread of C. auris in NYS in multiple healthcare facilities. Methods C. auris cases were identified through active or passive surveillance. Isolates were identified using matrix-assisted laser desorption/ionization-time of flight mass spectrometry, and antifungal susceptibility testing was performed. Cases of C. auris were classified as clinical or screening depending on the reason for culture (diagnostic or surveillance). Invasive cases of Candida haemulonii were classified as probable if the yeast identification method used could not reliably identify C. auris and the isolate was not available. Surveillance methods included culturing contacts, conducting point prevalence surveys, and collecting environmental cultures. Facility site visits were conducted to review infection control practices when transmission was suspected. Results As of May 15, 2017, 53 clinical, 17 screening, and four probable cases had been reported. Twenty-three of the 53 clinical cases died. Clinical cases were identified in 18 hospitals, one long-term acute care hospital (LTACH), and one private medical office, but the cases passed through 24 hospitals, 24 long-term care facilities, and one LTACH in the 90 days before diagnosis through May 15, 2017. Although the facilities were located eight counties, 42 of 53 (79%) of the cases were residents in three downstate metropolitan counties. Site visits identified areas for improvement in infection control, including adherence to recommended hand hygiene practices, standard and contact precautions, and environmental cleaning practices. Isolates from 52 of 53 clinical cases were resistant to fluconazole. Amphotericin B susceptibility varied. Initial isolates from all clinical cases were susceptible to echinocandins; one case developed echinocandin resistance during treatment. Conclusion C. auris has emerged as a novel pathogen in NYS and has been detected in multiple healthcare facilities. The spread to many facilities likely reflects the challenges of detection and demonstrates the need for strict infection control practices. Disclosures All authors: No reported disclosures.

Objectives. Carbon monoxide (CO) poisoning is a leading cause of morbidity and mortality during natural disasters. On January 26–27, 2009, a severe ice storm occurred in Kentucky, causing widespread, extended power outages and disrupting transportation and communications. After the storm, CO poisonings were reported throughout the state. The objectives of this investigation were to determine the extent of the problem, identify sources of CO poisoning, characterize cases, make recommendations to reduce morbidity and mortality, and develop prevention strategies. Methods. We obtained data from the Kentucky Regional Poison Center (KRPC), hyperbaric oxygen treatment (HBOT) facilities, and coroners. Additionally, the Kentucky Department for Public Health provided statewide emergency department (ED) and hospitalization data. Results. During the two weeks after the storm, KRPC identified 144 cases of CO poisoning; exposure sources included kerosene heaters, generators, and propane heaters. Hospitals reported 202 ED visits and 26 admissions. Twenty-eight people received HBOT. Ten deaths were attributed to CO poisoning, eight of which were related to inappropriate generator location. Higher rates of CO poisoning were reported in areas with the most ice accumulation. Conclusions. Although CO poisonings are preventable, they continue to occur in postdisaster situations. Recommendations include encouraging use of CO alarms, exploring use of engineering controls on generators to decrease CO exposure, providing specific information regarding safe use and placement of CO-producing devices, and using multiple communication methods to reach people without electricity.

Summary Background Pandemic H1N1 2009 influenza virus has been identified as the cause of a widespread outbreak of febrile respiratory infection in the USA and worldwide. We summarised cases of infection with pandemic H1N1 virus in pregnant women identified in the USA during the first month of the present outbreak, and deaths associated with this virus during the first 2 months of the outbreak. Methods After initial reports of infection in pregnant women, the US Centers for Disease Control and Prevention (CDC) began systematically collecting additional information about cases and deaths in pregnant women in the USA with pandemic H1N1 virus infection as part of enhanced surveillance. A confirmed case was defined as an acute respiratory illness with laboratory-confirmed pandemic H1N1 virus infection by real-time reverse-transcriptase PCR or viral culture; a probable case was defined as a person with an acute febrile respiratory illness who was positive for influenza A, but negative for H1 and H3. We used population estimates derived from the 2007 census data to calculate rates of admission to hospital and illness. Findings From April 15 to May 18, 2009, 34 confirmed or probable cases of pandemic H1N1 in pregnant women were reported to CDC from 13 states. 11 (32%) women were admitted to hospital. The estimated rate of admission for pandemic H1N1 influenza virus infection in pregnant women during the first month of the outbreak was higher than it was in the general population (0·32 per 100 000 pregnant women, 95% CI 0·13–0·52 vs 0·076 per 100 000 population at risk, 95% CI 0·07–0·09). Between April 15 and June 16, 2009, six deaths in pregnant women were reported to the CDC; all were in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation. Interpretation Pregnant women might be at increased risk for complications from pandemic H1N1 virus infection. These data lend support to the present recommendation to promptly treat pregnant women with H1N1 influenza virus infection with anti-influenza drugs. Funding US CDC.

BACKGROUND: The bacterium Salmonella enterica serovar Typhi causes typhoid fever, which is typically associated with fever and abdominal pain. An outbreak of typhoid fever in Malawi-Mozambique in 2009 was notable for a high proportion of neurologic illness. OBJECTIVE: Describe neurologic features complicating typhoid fever during an outbreak in Malawi-Mozambique METHODS: Persons meeting a clinical case definition were identified through surveillance, with laboratory confirmation of typhoid by antibody testing or blood/stool culture. We gathered demographic and clinical information, examined patients, and evaluated a subset of patients 11 months after onset. A sample of persons with and without neurologic signs was tested for vitamin B6 and B12 levels and urinary thiocyanate. RESULTS: Between March - November 2009, 303 cases of typhoid fever were identified. Forty (13%) persons had objective neurologic findings, including 14 confirmed by culture/serology; 27 (68%) were hospitalized, and 5 (13%) died. Seventeen (43%) had a constellation of upper motor neuron findings, including hyperreflexia, spasticity, or sustained ankle clonus. Other neurologic features included ataxia (22, 55%), parkinsonism (8, 20%), and tremors (4, 10%). Brain MRI of 3 (ages 5, 7, and 18 years) demonstrated cerebral atrophy but no other abnormalities. Of 13 patients re-evaluated 11 months later, 11 recovered completely, and 2 had persistent hyperreflexia and ataxia. Vitamin B6 levels were markedly low in typhoid fever patients both with and without neurologic signs. CONCLUSIONS: Neurologic signs may complicate typhoid fever, and the diagnosis should be considered in persons with acute febrile neurologic illness in endemic areas.